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Abstract Background People bypass primary healthcare (PHC) institutions to seek expensive healthcare at high-level hospitals, leading to escalating medical costs and inefficient use of resources. In 2009, China launched nationwide synergic policies on primary care strengthening, to tackle access to healthcare and financial protection. This study aimed to assess the impact of the two policy areas, health insurance and health workforce, on healthcare seeking behavior. Methods Drawing on national survey data before (2008) and after (2013) the policies, we linked individual-level data on healthcare-seeking behavior with county-level data on health workforce and health insurance. We constructed a multilevel zero-inflated negative binomial regression to examine the impacts of average reimbursement rate (ARR) of health insurance and the density of registered physicians on outpatient/inpatient visits, and multilevel multinomial logistic regression for the impacts on choice of outpatient/inpatient care providers. Results Although the increase in health insurance ARR and physician density have positive impacts on individuals’ healthcare use, their impacts might be weakened during 2008 and 2013, and the negative impacts of investment of those in PHC institutions on likelihood of visiting hospitals was larger. The negative impacts of ARR at PHC institutions on likelihood of visiting county-, municipal- and higher-level hospitals in 2013 was 28 percentage points, 66 percentage points and 33 percentage points larger than these in 2008. Conclusions Primary care strengthening requires synergic policies. Effective mechanisms for coordination across multisectoral actions are necessities for deepening those policies to ensure efficient delivery of healthcare without experiencing financial risks.

Abstract Background Sierra Leone, a fragile country, is facing an increasingly significant burden of non-communicable diseases (NCDs). Facilitated by an international partnership, a project was developed to adapt and pilot desktop guidelines and other clinical support tools to strengthen primary care-based hypertension and diabetes diagnosis and management in Bombali district, Sierra Leone between 2018 and 2019. This study assesses the feasibility of the project through analysis of the processes of intervention adaptation and development, delivery of training and implementation of a care improvement package and preliminary outcomes of the intervention. Methods A mixed-method approach was used for the assessment, including 51 semi-structured interviews, review of routine treatment cards (retrieved for newly registered hypertensive and diabetic patients from June 2018 to March 2019 followed up for three months) and mentoring data, and observation of training. Thematic analysis was used for qualitative data and descriptive trend analysis and t-test was used for quantitative data, wherever appropriate. Results A Technical Working Group, established at district and national level, helped to adapt and develop the context-specific desktop guidelines for clinical management and lifestyle interventions and associated training curriculum and modules for community health officers (CHOs). Following a four-day training of CHOs, focusing on communication skills, diagnosis and management of hypertension and diabetes, and thanks to a CHO-based mentorship strategy, there was observed improvement of NCD knowledge and care processes regarding diagnosis, treatment, lifestyle education and follow up. The intervention significantly improved the average diastolic blood pressure of hypertensive patients (n = 50) three months into treatment (98 mmHg at baseline vs. 86 mmHg in Month 3, P = 0.001). However, health systems barriers typical of fragile settings, such as cost of transport and medication for patients and lack of supply of medications and treatment equipment in facilities, hindered the optimal delivery of care for hypertensive and diabetic patients. Conclusion Our study suggests the potential feasibility of this approach to strengthening primary care delivery of NCDs in fragile contexts. However, the approach needs to be built into routine supervision and pre-service training to be sustained. Key barriers in the health system and at community level also need to be addressed.

Background: Sierra Leone, a fragile country, is facing an increasingly significant burden of non-communicable diseases (NCDs). Facilitated by an international partnership, a project was developed to adapt and pilot desktop guidelines and other clinical support tools to strengthen primary care-based hypertension and diabetes diagnosis and management in Bombali district, Sierra Leone between 2018 and 2019. This study assesses the feasibility of the project through analysis of the processes of intervention adaptation and development, delivery of training and implementation of a care improvement package and preliminary outcomes of the intervention.Methods: A mixed-method approach was used for the assessment, including 51 semi-structured interviews, review of routine treatment cards (retrieved for newly registered hypertensive and diabetic patients from June 2018 to March 2019 followed up for three months) and mentoring data, and observation of training. Thematic analysis was used for qualitative data and descriptive trend analysis and t-test was used for quantitative data, wherever appropriate.Results: A Technical Working Group, established at district and national level, helped to adapt and develop the context-specific desktop guidelines for clinical management and lifestyle interventions and associated training curriculum and modules for community health officers (CHOs). Following a four-day training of CHOs, focusing on communication skills, diagnosis and management of hypertension and diabetes, and thanks to a CHO-based mentorship strategy, there was observed improvement of NCD knowledge and care processes regarding diagnosis, treatment, lifestyle education and follow up. The intervention significantly improved the average diastolic blood pressure of hypertensive patients (n = 50) three months into treatment (98 mmHg at baseline vs. 86 mmHg in Month 3, P = 0.001). However, health systems barriers typical of fragile settings, such as cost of transport and medication for patients and lack of supply of medications and treatment equipment in facilities, hindered the optimal delivery of care for hypertensive and diabetic patients.Conclusion: Our study suggests the potential feasibility of this approach to strengthening primary care delivery of NCDs in fragile contexts. However, the approach needs to be built into routine supervision and pre-service training to be sustained. Key barriers in the health system and at community level also need to be addressed. [ABSTRACT FROM AUTHOR]

Stronger primary care has been associated with important contributions to health system performance, yet countries struggle to resource it adequately, given competing demands from hospitals. Although historically China has originated influential models of primary health care, it has an enduring problem with hospital dominance in health service delivery. This paper is a historical analysis of the co-evolution of hospitals and primary care providers in China from 1835 (the year when the first hospital was built in mainland China) to 1949 (the year when the People's Republic of China was founded), which aims to shed light on approaches to primary care strengthening. We develop and use a path dependence analytic framework, specifying the critical juncture, conjuncture and post-juncture development of the institutions shaping the balance between hospitals and primary care providers in China. We find that China had historically formed the hospital-centric model involving four sets of regenerating and mutually reinforcing institutions: 1) financial resources were being disproportionally distributed to hospitals; 2) high-quality medical professionals were largely concentrated in hospitals; 3) large outpatient departments were incorporated in hospitals, which functioned as a first point of care for many patients; 4) hospitals answered primarily to the demand of the more privileged social group. The early institutionalization of a hospital-centric model of Western medicine in China from 1835 became resistant to change, and efforts to strengthen primary care eventually took a divergent low-cost and de-professionalized developmental path towards 1949. As China still has a hospital-centric health system seeded in the nineteenth century, these findings can inform the framing of contemporary options for primary care strengthening. Without addressing these deep regenerating causes using a whole-system approach, China is unlikely to achieve a primary care orientation for health system development., (Copyright © 2019 Elsevier Ltd. All rights reserved.)