Madhurima Nundy, Associate Fellow, Institute of Chinese Studies.
One of the major programme priorities of China’s health care reforms that was announced in 2009 was strengthening of primary level services and the development of general practice in order to improve accessibility. China recently announced that it plans to expand the family physician services to all its citizens by 2020. The family physician or the general physician (GP) as the gatekeeper to the health service system is the hallmark of the National Health Service (NHS) in the UK where every citizen is assigned a GP. In India, where medical care is highly privatised and unregulated, the GP is a dying breed and is no longer able to stand up to a system now increasingly dominated by specialists. There is no regulated referral system that ensures rational distribution of services and market forces have put demands for more number of specialists thus creating a top-heavy system.
There are several aspects to the idea of a comprehensive referral system in medical care. This also builds in the idea of gatekeeping. Logically, the primary level of care is where the patient first seeks care and if further treatment and investigations are needed, there is referral to the next level. The primary contact for a person seeking care in a strictly enforced referral system is generally known as the gatekeeper who is the family physician. As part of general practice, the role of the GP is of extreme importance. General practice is founded on the basic knowledge and skills of all specialised disciplines and a GP has to have these skills that no other specialist will have. Therefore, the GP will have to go through intensive training to be able to skilfully sieve cases that will be treated at the primary level and those that will need referral.
With adept physicians at the primary level and a well-regulated system, gatekeeping helps distribute the load of patients seeking medical care. Large proportion of people seeking care and treatment generally do not need to go beyond the primary level as treatment at this level can resolve the symptoms they come with. This minimises irrational use of services and overmedicalisation. Such a system keeps overall cost of health care low. There is an equitable distribution of resources and this system is able to adequately guide people through a complex health service system which would otherwise be difficult to navigate. The effectiveness of gatekeeping depends on the context of the health care system. If we see the difference in the gatekeeping system in the UK and US, there are quite a few. The UK system is government regulated and funded. It focuses on strict gatekeeping rules hence protecting patients from unnecessary use of services. In the US, since the health system is privatised and dominated by specialists, medical decisions are influenced by financial considerations. Many a times, people are directly able to access specialist services or family physicians are likely to refer to specialists more often than in the UK. The UK system is far more equitable than the US.
Interestingly, China is now expanding the family physician services to all its citizens. The physician will function as the gatekeeper. During the earlier phase of reforms in the 1980s and 90s, China witnessed the dismantling of its three-tier referral system that created an inequitable and inaccessible health service system. The focus of the initial phase of reforms was on the secondary and tertiary level hospitals. Due to the breakdown of primary level services, the load of patients shifted to the tertiary level, thus resulting in an inefficient and a top-heavy system. As part of its new phase of reforms in health sector in 2009, China attempted to address the inequities in access by announcing systemic corrections. The strengthening of primary level services and introducing the family physician model was one of them.
The piloting of the family physician services started being implemented in few districts of Shanghai in 2011. This was revealed during our interactions with public health scholars from Fudan and policy makers at the Shanghai Municipal Health Bureau. Since the pilot started in 2011, 40 per cent of Shanghai’s population has contracted services with the family physician, as well as with a secondary and a tertiary hospital in the district, thus, completing the referral. The doctor-patient ratio is 1:2000. In Shanghai, people do not have to pay out-of-pocket as this is covered by the insurance and doctors are being paid a base salary but receive an additional amount depending on the load of work. The team and services include – the GP, a nurse and a public health practitioner providing preventive health services. Medical records of all those who have contracted services with the doctor are filed systematically. Families who contract with a family physician are ensured convenient services. They receive priority treatment and also a discount if they go through the proper referral channel.[i]
Several ministries and commissions have jointly brought out guidelines on contracting services with family physicians. In 2016, the 200 cities that are piloting public hospital reforms will introduce the family doctor contract services for their population. By 2017, they will attempt to contract services to 30 per cent of the population in these cities and 60 percent of the priority groups will be covered. The priority group includes – elderly, pregnant women, children, disabled persons, and people with chronic diseases.
The important question that arises is how will China redistribute physicians and specialists across provinces? There are several challenges to universalising this model. China faces a dearth of health personnel and the system is also dominated by specialists as in India. Family physicians have a low social status and hence have low salaries even though they have a more comprehensive understanding of the discipline. China has brought out guidelines to increase the number of family physicians to 300,000 by 2020. This would mean reorienting medical education to emphasise on general practice; medical colleges all around will have to serve as training bases for family physicians; provincial governments have to work towards increasing salaries and create specific posts. At present the plan is to train 10 per cent of the fresh graduates who have to go through a three year internship programme as GPs. To reach the adequate number in the pilot cities, on-the-job specialists will be given additional continuous education and will be provided GP training.[ii] It would be interesting to see how this model unfolds in China in the next few years and the lessons we could learn.
[i] Interview with Deputy Director, Shanghai Municipal Health Bureau, May 2014.
[ii] Correspondence with Chief Advisor, Shanghai Health Development Research Centre, June 2016.