What should the government do regarding health policy-making to develop community health care in Shanghai?

BACKGROUND: The traditional three-stratum healthcare system, within which municipal, district and community hospitals all paid great attention to improving medical treatment service by developing medical technology, is no longer able to meet the current health needs in Shanghai. In 1997, the Chinese government called for the development of community health services to serve as a basic platform to provide public health service and basic medical cure. However, because the market-oriented economic reform was based on a fee-for-service mechanism (without a strict monitoring system), most community health centers (CHCs) still put great effort into developing medical services geared to profit, rather than to provide proper medical service for all and a "quality" public health service. To try to solve the problem, some government-controlled payment (GCP) system has been implemented in CHCs gradually in districts of Shanghai. The study intended to evaluate the impact of GCP solutions already implemented, as well as the impact of the standardized GCP system with supplementary solutions, in enabling CHCs to focus on providing quality public health services and appropriate medical treatment, rather than focusing on profit and loss, in order to meet the health needs aroused by major socioeconomic transition in Shanghai.

METHOD: In order to make a systematic assessment, a standardized form of GCP was piloted for 6 months in Changning, Zhabei, and Songjiang districts, representing rich urban, poor urban and rich rural districts, respectively. We employed an evaluation index system with 26 indicators, based on a systematic review of literature and two rounds of Delphi consultation. The evaluation index system investigates four main themes of the reform: the government's role, the reform measures, the performance of CHC services and satisfaction with CHC services. We conducted an evaluation of the impact of both various types of GCP implemented in recent years and the standardized GCP system used during the more recent pilot project conducted across districts with different socioeconomic profiles. Cross-sectional comparisons between the pilot districts and control districts with similar socioeconomic context were also carried out to observe further the impact of the GCP system.

RESULT: Various GCP systems were implemented in 2006 in Changning and Songjiang district and in 2007 in Zhabei district. These GCP systems were standardized in April 2009 and piloted for 6 months on this new basis in these three districts (Changning, Songjiang and Zhabei). The overall "outcome" scores based on an evaluation index applied to Changning, Zhabei, and Songjiang districts have been generally improving from 2004 to 2009. The improvements in outcome were significant after the districts had implemented various GCP solutions and increased further, albeit to a lesser extent, in the three pilot districts from April 2009 to September 2009, when the GCP systems were standardized by the implementation of some supplementary solutions. Cross-sectional comparisons between the pilot districts and control districts also indicated that CHC performance was consistently better in the pilot districts after the pilot period than in that of some other "control" districts.

CONCLUSION: Although there have been other policies interacting with the impact of GCP, GCP reforms implemented in the pilot districts at different times (as well as the later, standardized GCP system) have been effective in enabling CHCs to focus on providing quality public health services and appropriate medical treatment, rather than concentrating upon profit and loss. The impact of the standardized GCP system was further confirmed by cross-sectional comparisons of some broad indicators, in terms of medical cost, quality of medical service, and coverage of public health service, between the pilot districts and control districts. However, uncertainties exit when looking at individual indicators. Some indicators (see pp. 11-13 and Table 5), such as the service contracting rate with CHCs and the proportion of residents with health records set up, were not sufficient to allow for reasonable estimation of the impact of the GCP. In part this was due to inconsistent data collections. Some indicators, on the other hand, such as the standard management rate of residents with hypertension, were usually affected by the changing government's role over the period. Meanwhile, variations among the three pilot districts with different socioeconomic profiles were observed by several individual indicators within the evaluation index. Further research is needed to investigate the impact of other solutions--such as user fee removal and "zero margin profit" of medicine in CHCs--in order to coordinate other policies with the GCP to improve CHCs more effectively. Longer term observation of impact of the standardized GCP system, as well as other influencing factors in Shanghai based on quality data collected on a standard basis, may help improve policy. Moreover, variations in residents' expectations of barriers in access to CHC services and in healthcare-seeking behavior need to be taken into consideration when designing GCP systems for areas with different socioeconomic profiles in order to meet the different health needs which are a consequence of the major socioeconomic changes in Shanghai (and China in general, it could be agreed).