The effect of pairing assistance under medical alliance policy
on healthcare utilization for patients with chronic diseases in rural
China
Abstract
Pairing assistance (PA) of health professionals between county hospitals
and township health centers is one of the key components of the reform
of medical alliances in China to strengthen the development of health
workforce in primary health care (PHC). This study aims to examine the
effect of PA on healthcare utilization for patients with chronic
diseases in rural areas. Two waves of National Health Services Survey
(2013 and 2018) were used. A total of 13893 and 22725 rural residents
with chronic diseases were included in the 2013 and 2018 waves,
respectively. Multiple logistic regressions were used to examine the
associations between PA and outpatient and inpatient service utilization
in PHC. Chow test was used to examine the difference between PA in two
models. Among rural patients with chronic diseases,
two-week
outpatient visits increased from 22.69% to 27.54%, and annual
hospitalization admission increased from 20.72% in 2013 to 25.44%. PA
was associated with a significant decrease in outpatient visits
(p<0.001) in 2018 after controlling for individual and county
characteristics. Patients in PA counties were 1.45 times (95% CI
1.10-1.90) more likely to use PHC outpatient care in 2013, but the
difference disappeared in 2018 (OR=0.85, 95% CI 0.71-1.01). PA did not
reverse the downward trend in the share of PHC outpatient visits. PA
under medical alliances in China provides a potential model for building
integrated people-centered health systems for other low- and
middle-income countries.
Key words: pairing assistance, medical alliance, health care
utilization, chronic disease
Introduction
Primary health care (PHC) is the cornerstone of any health system and a
catalyst for achieving Sustainable Development Goals (SDGs) and
Universal Health Coverage (UHC)1 2.
The availability of qualified primary care healthcare workers is a key
step in improving PHC. Many countries have implemented interventions to
address the lack of health workers in primary care settings, especially
in rural and remote areas 3. China’s reform of the
health system continued to invest efforts in PHC (in 2009, China
launched a huge and complex health reform to provide equal access and
eliminate financial risk for all residents) 4.
However, challenges remain for PHC. The share of outpatient visits in
PHC facilities decreased from 71% in 2005 to 57% in 20185.
To enhance the capacity of PHC facilities in rural areas and respond to
fragmentation of care throughout the health system, China issued
guidelines for building a hierarchical health system in which different
levels of hospitals would provide care according to designated scopes in
2015 and the government encouraged counties to explore medical alliances
in various forms 6. Pairing up physicians to PHC
facilities (mainly township health centers) is one of the major and
common strategies in different medical alliances to provide care and
guide PHC doctors to improve their ability 7. The
pairing of doctors has been a strategy for staffing the health workforce
in rural areas 3, 8. Currently, pairing doctors is
given priority in salary and promotion as incentives9. Medical alliances are the most important initiative
to operationalize a hierarchical health delivery system so that PHC
facilities can be supported and improved and care across levels of
hospitals can be coordinated and integrated. Currently, a tight medical
alliance that shares unified responsibilities, resources, risks, and
economic interests has become the policy direction. Under the medical
alliance, township health centers and village clinics can pair up with
county hospitals and receive support and training. To date, progress in
promoting unified administrative management, such as drugs and
consumables, procurement, and payment, still varies greatly in different
regions10.
Pairing up with county hospitals is expected to improve PHC facilities
and benefit patients through several channels. First, pairing assistance
can increase the supply of rural health workers, which could temporarily
relieve the shortage of rural health workers 11.
Second, the pairing assistance can improve the capacity of the rural
health workforce, which will improve PHC in the long run and increase
the utilization of PHC 12. Third, for patients,
pairing assistance can help them enjoy high-quality care in PHC
facilities, shorter travel costs, and fewer payments.
Despite the nationwide implementation of medical alliances, little is
known about the actual effect of pairing up with county hospitals to
rural PHC facilities. This study aims to examine the effect of
partnership with county hospitals on the utilization of healthcare for
chronic disease patients in rural areas in the context of the
construction of medical alliances throughout the country.
Materials and methods