The Shanghai case: a qualitative evaluation of community health ...

international journal of health planning and management Int J Health Plann Mgmt 2005; 20: 269–286. Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/hpm.814

The Shanghai case: A qualitative evaluation of community health reform in response to the challenge of population ageing Xiaolin Wei1*, David Zakus2, Hong Liang3 and Xiaoming Sun4 1 Centre for International Health, Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Rm. 2260, MSB, 1 King’s College Circle, Toronto, ON, Canada, M5S 1A8 2 Centre for International Health and Department of Health Policy, Management and Evaluation, and Department of Public Health, Faculty of Medicine, University of Toronto 3 Institute of Population Study, Fudan University, Shanghai, Fudan University, Shanghai 220, Han Dan Road. Shanghai, China. 200433 4 Department of Community Health & Women and Children’s Health, Shanghai Municipal Health Bureau Rm. 235, 223 Han Kou Road, Shanghai, China, 200002

SUMMARY Shanghai’s health care system is facing a serious challenge of an ageing population, as 14% of its 17 million residents are 65 or older. In 2000, a community health reform was implemented to provide comprehensive and continuous primary care to community residents with a focus on seniors. The study employed the theoretical framework of examining primary care in terms of the constellation of its four unique elements (first contact, comprehensiveness, longitudinality and coordination) and three healthcare components (structure, process and outcome). The study aimed to evaluate the extent to which the reform has achieved its process goals and how the organizational context influenced the level of implementation. In-depth interviews with 25 health providers, 15 seniors and four community leaders were carried out. The study found that the Shanghai community health reform has improved the structure and process of primary care regarding first contact, comprehensiveness and longitunality. However, the reform is constrained by structural barriers on seniors’ financial access to resources and the capacity of primary care providers. The previous organization system also constrains the reform in CHCs financing and administration. The Shanghai case illustrates that a broad societal view has to be taken when analysing health reforms, which requires the involvement of multiple sectors including the government, health providers and health consumers. Copyright # 2005 John Wiley & Sons, Ltd. key words: primary care; health reform; ageing; China

* Correspondence to: Dr X. Wei, Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Rm. 2260, MSB, 1 King’s College Circle, Toronto, ON, Canada, M5S 1A8. E-mail: [email protected]

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BACKGROUND Population ageing continues to be of great concern in both the developing and the developed countries. Shanghai, which is the largest and a fast developing city in China, was recommended as an example of promoting primary care to face this ageing challenge in a recent World Health Organization meeting (Zuo, 2001). Shanghai’s economy has been accelerating at an annual rate of 12% since 1992, reaching USD 5000 per capita GDP in 2002 (Shanghai Municipal Government, 2004). Shanghai is also experiencing rapid population ageing. The number of years a region takes to increase the proportion of its seniors (i.e. those 65 years or older) from 7% to 14% is considered a marker of the speed for societal ageing. Sweden, formerly the fastest ageing country in the world, took 85 years; France took 115 years; while it only took Shanghai 23 years to reach 14% in 2001 (Liang, 2002). Shanghai’s senior population increased by 50.3% in the past 10 years, but the total population only increased by 2.1% in the same period (National Bureau of Statistics China, 2001). In 2002, nearly 17% of Shanghai’s 17 million inhabitants were 65 years or older (Shanghai Statistics Bureau, 2002). However, Shanghai, in this transitional and developing era, is far less prepared for this ‘silver tide’ than its developed peers. Community health reform Hospitals in Shanghai are classified into three levels: municipal (tertiary), district (secondary) and street (primary). Large hospitals (tertiary and secondary) have the mandate to treat serious cases referred from lower level hospitals and to provide technical supervision. Street-level hospitals are responsible for prevention, common diseases and simple injuries. However, during the transition to an market oriented economy instigated in 1979, the street hospitals began to compete with large hospitals on specialty care to attract more patients, while failing to provide adequate health prevention (Sun and Liang, 2003). In 1997, community health care was introduced as the strategic direction for urban health reform in China by the national Ministry of Health (Shanghai Municipal Health Bureau, 2002). Shanghai’s community health reform was officially launched in 2000 to face the challenge of an ageing population with a number of strategies: (1) transforming street hospitals into Community Health Centres (CHCs); (2) clarifying the aspects of primary care to be provided in CHCs; (3) strengthening local government’s leadership in community health; (4) securing government funds for CHCs; and (5) promoting collaboration between CHCs and community organizations. The major goal of the community health care reform was to provide convenient, comprehensive and continuous care for community residents with a focus on seniors. The second goal of the reform aimed at re-organizing street hospitals into key primary care providers. According to ‘The Main Contents of Community Health Services in Shanghai’ CHCs have the mandate to provide comprehensive care including: basic acute care, general preventive care, rehabilitation, chronic disease management, health education and promotion, and technical support for family planning. Furthermore, it Copyright # 2005 John Wiley & Sons, Ltd.

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COMMUNITY HEALTH REFORM SHANGHAI Community Health Centre Director

Community Service Department

Medical Service Department

Logistic Department

Administrative Office

Archive Management

Human Resources

Financial Department

General Logistic Support

Clinical Services

In-patient Service and Nursing

Chronic Diseases Management

Maternal and Child Health

Immunization

Figure 1. General administrative structure of community health centres in Shanghai

stressed that CHCs should ‘take families as a unit and set priorities for the health needs of seniors, women, children and the disabled in the community’ (Shanghai Municipal Health Bureau, 2002, p 51). More specifically, this document defined the scope of illnesses that CHCs have responsibility for: common acute care, small surgeries and diagnosed chronic diseases. In addition, CHCs are to focus on preventive care and are not encouraged to provide specialty care. It is recommended that chronic diseases including hypertension, cancer, diabetes and chronic pulmonary diseases be managed at the community level. In 2002, all 132 CHCs in Shanghai had been transformed with a new structure of ‘three departments plus one office’ (Figure 1) to focus on providing preventive care. There are usually 80 health professionals in a CHC with doctors outnumbering nurses. The Government of the Shanghai Municipality also invested in establishing satellite health stations in communities where it takes more than 15 min walk to a CHC within its catchment area. A variety of training programme were also set up to train CHC doctors and nurses to be general practitioners (GPs) and community nurses. Moreover, the municipal government secured funds for preventive activities at RMB 8 (USD 1) per capita in 1998, which was increased to RMB 15 in 2002. Health insurance reform Urban China previously had two work-unit based health insurance systems: the Government Insurance System that covered all public servants of the government or the Communist Party; and the Labour Insurance System that included all employees in state-owned enterprises. Employers paid their employees’ health care Copyright # 2005 John Wiley & Sons, Ltd.


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expenses directly to appointed hospitals. In return, individuals were highly tied to their ‘work-unit’ and were inhibited from moving to new jobs. The health insurance systems caused systematic inequity in the society, because government departments were financed through taxation for the medical expenses and state-owned enterprises had to pay health bills from their own budgets. Many state-owned enterprises with large numbers of retirees were heavily burdened, and people who were selfemployed and in private enterprises were uninsured. The situation became worse after the economic reform began, when many state-owned enterprises went bankrupt and their employees had to pay for health care out of their own pockets. In April 2001, the Shanghai government introduced a new health insurance system, the Urban Employee Basic Health Insurance (UEBHI), which is funded from both public and private resources and managed by a new government agency, the Shanghai Health Insurance Bureau. It covers both government and enterprise employees with the same co-insurance rates, and extends coverage to all seniors who are retired or have a retired spouse. The new insurance has a cost-sharing feature, consisting of a personal account collected from the individual’s salaries and a social risk pool made up of monthly contributions from the employer. Fees for hospitalization and home beds (i.e. physicians and nurses providing care to patients at their homes) are paid directly through the risk pool. Co-payment levels range from 10% to 50% according to a complex system based on the insured’s age, length of employment and rank. Seniors over 60 years have the most favourable co-payment rate. There is a co-payment differentiation in the three tiers of hospitals to encourage the use of primary care with co-payment rates for the CHC, district and municipal hospital outpatient services set at 10%, 15% and 20%, respectively.

DESIGN AND METHODS This study was proposed by the Shanghai Municipal Health Bureau (SMHB) to evaluate the effects of the reform on primary care for seniors. A multi-disciplinary team was established with external researchers from Fudan University and the University of Toronto, combining expertise in health system analysis, primary care evaluation, community participation and population studies. Qualitative methods with case studies were employed because of their usefulness in obtaining information on the level of reform implementation and opinions of different stakeholders (Posavac and Carey, 1997). Theoretical framework and research questions The theoretical framework of this study (Figure 2) is based on Starfield’s (1998a) structure-process approach of measuring the attainment of primary care: first contact, comprehensiveness, longitudinality and coordination. Health care can be classified into three components: structure, which denotes the capacity and settings of health care; process, which denotes the performance in health care delivery; and outcome, which denotes the effects of care on health status (Donabedian, 1988). First contact and comprehensiveness combine elements both from the structure Copyright # 2005 John Wiley & Sons, Ltd.


COMMUNITY HEALTH REFORM SHANGHAI

Structure

Process

273

Outcome

First Contact

Comprehensiveness

Primary

Care

Longitudinality Coordination

Figure 2. Theoretical framework of measuring the four components of primary care, Adapted from Starfield (1998a) and Donabedian (1988)

and process components, while longitudinality and coordination reflect the process component. First contact requires accessibility (structure) and use (process) of services for most of the health care problems that arise in the community. Comprehensiveness demands the availability of health professionals (structure regarding training) who can provide an array of services (e.g. acute care, home care, preventive care and health promotion; i.e. process). Longitudinality presupposes the existence of a regular source of care and its use over time, where patient centred care (Stewart, 2001) acts as an important tool to establish a longitudinal patient– physician relationship. Coordination requires the availability of information about prior health problems during the treatment process by providers in CHCs and other speciality care settings (Starfield, 1998a). These four essential elements describe the uniqueness of primary care that focuses on people’s health in the constellation of bio, social and psychological environments. Primary care aims to provide care at an appropriate level with efficient use of health resources (Starfield, 1998b). These four elements are also inter-related; e.g. first contact will become merely administrative without the presence of a longitudinal patient–doctor relationship; comprehensive care needs a high level of coordination; and first contact with family doctors is successful only if the care is coordinated with specialties. Achievement of the four elements is believed to lead to better population health outcomes (Starfield, 1998b). A qualitative evaluation was conducted to explore the experiences, perceptions and attitudes from a variety of stakeholders. The study investigated the following research questions: To what extent has community health reform in the case study areas been implemented to provide primary care to seniors regarding the four elements? How do health providers, seniors and communities evaluate the achievements of primary care in terms of their met or unmet needs? Copyright # 2005 John Wiley & Sons, Ltd.


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How does the organizational context of the old system influence the implementation of the reform?

Selection of cases and interviewers Three districts in Shanghai: Pudong, Yangpu and Jing’an were selected to reflect a spread of neighbourhood wealth. Yangpu is a relatively poor area with many unemployed workers from bankrupt state-owned factories. Jing’an is a downtown district traditionally with business activities and better-off residents. Pudoing is a newly developed area across Huangpu River, where most of its residents reflect an average level of wealth in Shanghai. Each district has around 12 CHCs. All investigated districts have a high proportion of seniors in the communities (2–22%). One regular CHC, with a catchment population around 60 000, was randomly identified in each district. Semi-structured interviews were conducted with seniors, primary care doctors, nurses, CHC directors and community leaders in each CHC. Interviews with CHC doctors and nurses included questions on the history of the CHC, experiences in community health and their training, communication with seniors, health education, cooperation with the community and large hospitals, and implementation barriers. Seniors were interviewed about their experiences and perceptions of care received from the CHC. Residents’ Committee (RC) directors were interviewed for information on community participation and its effects on community seniors. An RC is a self-elected community organization covering a community around 5000 residents, and it is responsible for public health, security and welfare issues of their residents. Convenience sampling was employed to select interviewees to represent a variety of interests in the community and CHCs, and interviews stopped when redundant information was repeatedly obtained in two consecutive interviews (Jackson, 1999). In each CHC, three to four doctors and nurses were selected and interviewed in their offices. RC staff helped identify seniors using inclusion criteria: (1) men and women 65 or older who have lived in the community for more than 5 years; and (2) those with confirmed diagnosis of certain types of chronic diseases: diabetes, hypertension, cardiovascular or cerebrovascular diseases. Seniors who were permanently institutionalized, or with severe complications, mental illness and end stage cancer were excluded. In the end, about five seniors were interviewed in each CHC. In total, 44 in-depth interviews were conducted (Table 1). All interviews were conducted in July and August 2002 in Chinese by the first author and his assistant. An invitation letter was sent to all interviewees 2 weeks before and then they were visited based on appointments. Informed consent forms were collected before the interviews. In order to protect the confidentiality of participants, all names of CHCs and interviewees were masked. Only district names were used to identify different CHCs. Interviews were audiotaped and noted at the same time, and then were transcribed. All transcripts were translated into English for analysis. After an extensive discussion among the research team, a coding system was developed with a list of key words and themes for analysis. Copyright # 2005 John Wiley & Sons, Ltd.


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Table 1. Number of interviews in the study of community health centres in Shanghai Persons interviewed

Yangpu

Jing’an

Pudong

Total

CHCs staff Directors Doctors Nurses Seniors Community leaders Total

1 3 4 4 2 14

1 4 4 5 1 15

2 3 3 6 1 15

4 10 11 15 4 44

FINDINGS First contact First contact means that patients visit the primary care doctor first and are then referred to a specialist if necessary (Starfield, 1998b). The geographical, financial and temporal accessibility were explored first as a precondition for first contact. The SMHB standard, that a CHC or health station is within a 15 min walk, is adequately achieved in all investigated CHCs except Yangpu which serves a larger population where seniors in one community have to walk up to 40 min to reach a nearby health station. Geographical accessibility was achieved as most seniors reported a 5–10 min walk from their homes to the CHC or health station. More than 95% of seniors in the communities are covered by the UEBHI. Reasons for some seniors being uninsured are: (1) neither of the couple had a job when they were young; and (2) they immigrated to Shanghai with relatives. Their children and children’s employers often share medical expenses to some extent (e.g. 50%), however, reimbursement is sporadic. Uninsured seniors reported lower health care use than those insured. Seniors enjoy a favourable co-payment rate, but the costsharing feature of UEBHI still poses a financial threat to low income seniors. Most seniors live on pensions ranging from RMB 500 to 1200 per month with only a few enjoying cash contributions from their children. Seniors who have monthly pensions less than RMB 800 often have to spend more than a third of their income on medication. Two patients complained that they could not break even. Doctors reported that they prefer to prescribe cheaper medication to seniors if substitutes are available. CHCs only provide health care during regular hours, and many health stations only open half a day, thereby allowing doctors to work for two stations. Seniors reported that they have to store some medications in case of emergency. Private clinics are not widely available and their services are not covered by the UEBHI; therefore, seniors do not use them often. Another challenge to temporal accessibility is the waiting time. Patients do not need a doctor’s appointment but have to endure five line-ups for an outpatient visit in CHCs: registration, physician contact, pricing, payment and receiving medications. Ironically, the line-ups take up to 1 h but the treatment is only 10 min. Line-ups in CHCs, though, are much shorter compared Copyright # 2005 John Wiley & Sons, Ltd.


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with large hospitals. Patients usually do not need to wait in health stations because they have fewer patients and no registration is required. One of the major goals of community health services in Shanghai is to set CHCs as the entry point for health care. Most interviewed seniors, regardless of their economic status reported that they often visited a CHC or health station for common health problems. CHCs or health stations are described as ‘cheaper and convenient with considerate doctors’. However, when asked about having serious diseases, seniors reported that they would choose large hospitals because they are concerned that CHC doctors might delay the diagnosis and/or treatment. Comprehensiveness Comprehensiveness requires that primary care providers adequately recognize the full range of patient health needs and take appropriate actions (Starfield, 1998b), which demand a higher capacity of both curative and preventive care. Health providers in CHCs generally have lower levels of initial medical training compared with their peers in large hospitals. Most CHC doctors either receive a 4-year medical training programme after Grade 9, or have 3 years of college training after Grade 12. Only a few are more qualified with 5 years medical doctor training in universities. Nurses are usually trained in a 4-year programme after Grade 9. Training of general practitioners and nurses was the first step in this reform, with different levels ranging from 1 year on-the-job training to 4 years university residency. For example, Fudan University’s full-time GP training contains 1 year of lectures on campus, 1-year rotation in a teaching hospital, plus 2 years of selective rotations in the Shanghai Centre for Diseases Control (CDC) and other CHCs. District health bureaus (DHB) partner with district nursing schools to provide on-the-job training of 2 days a week to local CHCs for 1 year. Most doctors and nurses participate in the DHB programme because it is affordable, with the exception that a few doctors in the Jing’an CHC joined the Fudan 4-year programme. New knowledge such as medical techniques, psychology, prevention and health statistics are learned. A nurse stated, ‘I learned some skills that I did not know before, such as nasal feed and urine conduction; more importantly, I learned how to communicate with patients.’ However, nearly all interviewees complained that the part-time training programmes contained too much passive lecturing and were far from efficient. Dr M said, ‘We spent too much time on theoretical knowledge inapplicable to our daily life. For example, English occupies nearly one-quarter of the training, but I never use it in my clinical work. We want more practical training.’ After the training, doctors and nurses come back to work in an environment which has not changed much. Dr Y, a CHC director, said, ‘Our doctors are trained as general practitioners. However, the CHC is still fragmented into various specialties under the medical service department, such as Copyright # 2005 John Wiley & Sons, Ltd.



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internal medicine, surgery and etc. It is hard for them to remember what they learned.’ Currently, there is no degree or professional accreditation offered for part-time GP training in Shanghai. The challenge of comprehensiveness in primary care is to recognize situations in which actions are needed and justified according to available resources. Innovative provision of different pathways of treatment, such as home visits and other efforts of health care, are often required as part of comprehensive care (Starfield, 1998b). The investigated CHCs provide acute care, chronic disease management, home care and prevention. Although providing acute care continues to be the major function and revenue generator, CHCs have begun to pay more attention to other services because of regulations from health authorities. Home care, including home visits and home beds, is widely provided in CHCs. Home visits have doctors or nurses visiting patient homes for medical treatment. Home beds are managed at patient homes with the same standards of patient wards in hospitals. Home beds cost much less than hospitalization. Dr R reported, ‘Normally, a two-week hospitalization for stroke costs RMB 5000. It only costs RMB 400 if the same medications are administered at home.’ Also, home care provides greater convenience to seniors with disabilities and their families. However, because health authorities priced home care lower than its actual cost and because it needs more logistic support, CHCs do not have the capacity and motivation to expand this programme. To limit applications, SMHB requires that home care patients must be over 80 or disabled; have a clear diagnosis; and be in stable situation. All seniors said they expected more home care, and the CHC directors hoped health authorities would allow private financing for this service. Secondary and tertiary preventions for chronic disease are observed in investigated CHCs. For example, hypertension management has been widely established because it is the most common chronic disease in Shanghai (Zhang et al., 2002). All patients over 35 are required to have their blood pressure tested when they first see a doctor. Once hypertension is diagnosed, patients enter a three-stage hypertension management programme depending on the level of severity. Blood pressure checks are carried out regularly with behaviour change and treatment regiments provided. The Pudong CHC implemented this programme in 1999 and has reported positive health outcomes (Jiang and Meng, 2002). Dr L. said, ‘After three years, hypertensive patients have better blood pressure maintenance compared with their original situation. Patients are now accustomed to visiting the CHC for regular blood pressure checks’. A self-managed diabetes programme to promote continuity of care was designed recently in the Jing’an CHC. CHCs also provide health education and counselling. All investigated CHCs distribute printed pamphlets on hypertension, diabetes and osteoporosis to patients Copyright # 2005 John Wiley & Sons, Ltd.


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during their visits. CHC doctors give health education sessions on topics of chronic diseases management once or twice a month. Doctors reported that they provide more health education than before and consider patient’s contextual factors in their visits. Dr M said, ‘When I have time, I prefer to chat with patients, which also helps my understanding of them. I often tell hypertensive patients that you should not eat too much salt and sugar. It is very hard to change one’s habits, especially for seniors, who have had them for decades. I often give explicit examples and use simple words that seniors can understand.’ CHCs also organize health promotion sessions to the general public with topics of tobacco control, HIV, etc. However, no primary community-based health promotion for the general population was observed. RCs are indispensable partners of CHCs in providing comprehensive care in the community, especially with regard to health promotion and education. Several RCs provided free office space to health stations in their communities and others charged a subsidized rent. As one RC director said, ‘The CHC takes care of our health, so we should do whatever we can help.’ RCs collaborate intensively with CHCs in selecting topics, informing community residents, collecting patient feedback and providing classrooms. In addition, every RC has a public health education blackboard designed and maintained by RC staff. Mrs X said, ‘Our residents pay more attention to healthy life style as their economic condition betters. Seniors begin to understand the importance of preventing chronic diseases. Therefore, those health activities associated with the CHC are quite popular’. Another RC director, Mrs Z, added, ‘We have health education sessions on hypertension and diabetes once a month. We collect patient feedback to help the CHC design the next course’. Longitudinality Longitudinality refers to the long-term relationship between practitioners and patients, in which patient centeredness is an important implementation strategy (Starfield, 1998b). Patient centeredness is: (1) exploring the experience of disease and illness though patients’ ideas, feelings and expectations; (2) understanding the patient as a whole person, including their emotions and contexts; and (3) strengthening the patient-doctor relationship (Little et al., 2001; Stewart et al., 1995). Patient centeredness is addressed in all three investigated CHCs. ‘Patient centeredness is an important tool in our management. We require doctors to communicate more with patients. For example, doctors should explain Copyright # 2005 John Wiley & Sons, Ltd.



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to patients why these laboratory tests and medications are prescribed. Our CHC doctors are in the community and can understand the contextual information of our patients’ (CHC Director). Doctors in health stations reported a more patient focused approach compared with their peers in the CHC. Dr C. said, ‘Seniors usually live in a lonely situation, and it is worse when they are widowed. They generally have few persons to talk with. They are not as swift as younger persons. But we should not discriminate against them. I often ask doctors and nurses in my station to treat seniors well, speak with them often, and be considerate. We get lots of good feedback from our patients’. Several doctors mentioned the psychological effects on senior’s health, and one illustrated: ‘We try to track down senior’s behaviours and psychological problems. Sometimes patient symptoms can only be understood when you know their situation. For example, a regular patient of mine reported chest depression for a month. She did all the tests but found nothing wrong. Then I began to ask her about her life. She told me that her son died in a car accident in Japan recently. So I could recommend her some stress relief activities’. Consideration is also cherished in nurses, as Ms L. reported, ‘Most seniors are garrulous, but you have to understand they are lonely. They just want to talk with somebody’. Seniors also reported a good relationship with their providers, as Mrs M. said, ‘Because I have eye problems, Nurse C always walks me home after my treatment’. Another person said, ‘I am very grateful to the CHC for setting up this health station in our community. Doctors now spend more time telling me about why I get premature beat and how important it is to keep calm. After knowing this, I am not afraid of the disease’. Seniors reported that they were satisfied with improvements in the process of care. Most seniors reported frequent use of CHCs and health stations (2–6 times per month) because of their convenient and friendly service. About half of them said they always visit the same doctor for common illness, whom they can name in the CHC or health station, while the other half reported they usually visit the health station in their community where the same group of doctors (2–3) provides services. Copyright # 2005 John Wiley & Sons, Ltd.


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The length of relationship with a certain primary doctor or a group of doctor varied from 4 months to 5 years. However, in certain arenas primary care is still managed in a way that runs counter to the concept of ‘patient centeredness’. For example, the health insurance bureau imposes a ceiling of total cost per prescription, disregarding the situation of seniors with multiple diseases who need large amounts of medications. An extreme case was found in one old lady, Mrs Q, who has heart disease, hepatitis, cholangitis and diabetes. She has to visit the doctor every other day to renew her prescription to meet the prescription limits. Coordination Coordination is defined as the availability and recognition of patient information about prior problems and services that could be applied to current care (Starfield, 1998b). In Shanghai coordination requires communication among primary care providers in the CHC and between primary care providers and specialists. Coordination within the CHC has not been dramatically improved since the reform began. Doctors and nurses in CHCs are still fragmented in different specialties without good communication. However, a positive trend in coordination is reported in the newly established health stations. For example, traditional Chinese medicine doctors cooperate with family doctors trained in western medicine to optimize prescription and treatment for chronic diseases. CHCs also have a problem with managing patient information. In 2000, all CHCs launched a baseline household survey to collect demographic and epidemiological information of community residents using a SMHB designed household questionnaire. However, the survey was not completed due to a lack of surveyors, bad training and poor design. CHCs only carried this out because it was mandated by the SMHB and never analysed the data they collected. All CHC directors regarded it as a huge waste. There is only uni-directional referral from the CHC to large hospitals. CHCs refer serious patients to large hospitals with their records, but CHCs can only suggest a hospital as patients have the freedom to chose a hospital under the current health insurance scheme. CHC doctors are usually not involved in their patient’s treatment in hospitals. Large hospitals face the pressure of reducing the length of stay in order to admit new patients, therefore, patients without serious conditions are discharged to CHCs. However, no guideline regulates the transfer and large hospitals do not provide any clinical information to CHCs. CHC doctors complained that they have to ask patients about their hospitalization, rather than being given direct feedback. Dr X said, ‘The two-way referral mechanism is still vague. We do our job, but receive nothing from large hospitals. What’s their role?’ DISCUSSION The main achievement of the community health care reform in Shanghai is the increase in the geographical accessibility for seniors. The opening of health stations Copyright # 2005 John Wiley & Sons, Ltd.



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has improved seniors’ access to health care. Most seniors reported they could walk to a health care facility in less than 15 min. In addition, more seniors are covered under the new health insurance system and enjoy a favourable co-payment rate compared with other age groups. Care is cheaper in CHCs and health stations compared with large hospitals. Better accessibility of primary care is associated with a higher likelihood of first contact and a longitudinal relationship (Forrest and Starfield, 1998). CHCs are transforming primary care doctors into ‘gatekeepers’. Seniors reported that they often visit the CHC for common health problems, but they prefer large hospitals for serious health problems as they still worry about the quality of CHC doctors. Most seniors could name one primary care doctor or several doctors in the health station as their regular provider of care. Longitudinal relationships are being developed. Provision of first contact and longitudinal care in primary care settings can reduce costs, facilitate better understanding of problems, and reduce emergency care and hospitalization (Forrest and Starfield, 1996; Parchman and Culler, 1994). Resource availability, organization structure and community needs have to be taken into consideration in answering whether a specific service should be included in the comprehensive package (Rivo et al., 1994; Schorr and Nutting, 1977; Starfield, 1998b). Although primary care in Shanghai is not based on community needs, CHCs provide a much broader range of services under the current organizational and resource constraints. Doctors and nurses in the CHC do not remain in their office; they provide home care to seniors and the disabled in their communities, which has the potential to reduce the cost of care. Acute care remains the most important aspect, consisting of basic surgery and internal medicine for common diseases. All investigated CHCs provide preventive care, such as hypertension management, health education and counselling; however, all of them are secondary and tertiary preventions. Only sporadic health promotion activities for the general public were observed. Coordination among providers in health stations has been witnessed, but it still needs substantial improvement. Although CHCs have been reorganized, there is no real internal change from the previous organizational structure of street hospitals. We did, though, observe the coordination between doctors from different disciplines working together in health stations. More importantly, CHCs still fall short on the coordination between primary care providers and specialists, which has been proven to be necessary for primary care to achieve its full benefits for patients (Long, 1991; Starfield, 1998b; Williams, 1994). This needs more organizational attention from the health authorities to develop specific guidelines and balance the need for information on administrative and professional use (Basinski and Naylor, 1992). Another interesting finding is the level of community participation observed between the CHC and the RC. A mutually beneficial relationship between the two organizations was established to facilitate health education and health promotion sessions. The RC, as a community organization, provides office space and connects community residents with CHC’s health education sessions. However, community participation in Shanghai is at the ‘utilitarian’ level because CHCs cooperate with the community only to facilitate the care provision and offset the cost. It has not reached the ‘empowerment’ level as the community does not take a lead Copyright # 2005 John Wiley & Sons, Ltd.


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in designing health activities (Morgan, 2001; Zakus, 1998). Getting health volunteers involved can be considered as a good strategy, because they can provide pairs of hands to the CHC and enhance the community’s ownership of health activities (Zakus and Lysack, 1998). Barriers This study identified two structural barriers in the Shanghai community health reform: financial accessibility for seniors and the capacity of primary care providers. Although seniors enjoy a low co-payment rate in the new insurance scheme, we found medical costs still consume more than one third of the income of poor seniors. Gao and colleagues found that the cost-sharing feature of China’s health insurance reform may eventually increase the financial burden on low income groups (Gao et al., 2002). On the other hand, filial piety is fast diminishing in China’s transitional society, which poses another financial threat because more seniors no longer receive cash contributions from their adult children. Unless welfare authorities are involved in reducing insurance deductibles and provide effective health aid programmes for poor seniors, equality in access to primary care will be hard to achieve (Sun, et al., 2002). A competent team of primary care providers is crucial for CHCs to be the first contact for common health problems and to provide comprehensive care. However, capacity building is a long process because most primary doctors and nurses have low initial medical training, which is also the main reason that seniors prefer to visit large hospitals directly if they consider their illness to be serious. However, current training programmes for doctors and nurses are not adequate to fill this gap. Our interviews constantly reflected the idea that training should be specifically geared towards primary care needs, and more practice should be involved. The Canadian experience of family physician training could be useful to Shanghai, where the College of Family Physicians of Canada (a physician organization) plays an important role in organizing, regulating, evaluating and accrediting family physician training programmes. Organizational influences In a transitional society, previous organizational systems inevitably have a substantial influence on the process of reform (Gilson et al., 2003). The Shanghai case is more challenging because health care reforms all over China are engaged in a decentralization process that is associated with market economies (Fitzner et al., 2000; Peabody et al., 1995). The organizational influences of the previous system were examined in the context of three relationships: between the CHC and health authorities; within the CHC itself; and between CHC and seniors. In the process of health decentralization, administrative and financing tensions exist between the local organizations and central powers (Bossert et al., 2000). CHCs in Shanghai are under the administration of the DHB, and they are also under the technical guidance of CDCs and large hospitals. Under the community health reform, the government significantly reduces its funding to CHCs and offers more Copyright # 2005 John Wiley & Sons, Ltd.



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power to the CHC director to earn profits from acute care. But the DHB retains the power to appoint CHC directors and to supervise CHC performance. In some cases, the DHB even intervenes in the process of recruiting CHC employees. CHC directors complained that such excessive and fragmented supervision overburdened them. One CHC director said, ‘Although we provide comprehensive care, we have to prepare for supervision from upper level health authorities for specific diseases. Each level of health institution has the right to ‘supervise’ us. For example, today it is from the DHB for mental care and the CDC will come tomorrow for cancer management. We have to hire a full time preventive doctor to prepare different files.’ CHC directors reported that their CHCs are under-funded for public preventive service. Government has substantially reduced their funds to CHCs, and only provides minimal prevention funds on a per capita basis. The proportion of government funding has been reduced to less than 3% of CHC’s total revenue in 2002. CHCs reported that they spend more to fulfil the DHB’s order on preventive care than what they got from the government (Jiang and Meng, 2002). It is hard for CHCs to generate any motivation in providing high quality health prevention. Preventive care is essential to social welfare, and is a crucial part in the comprehensive package of primary care. In common with other researchers we argue that the government needs to take a leading role in financing public health services (Liu and Mills, 2002; Miller and Sartorius, 1979). The recent SARS epidemic helped raise this awareness. Although the internal structure of the CHC has been reformed as the ‘three departments and one office’, the internal management style has not changed. The medical service department, the largest of the four, is divided into a number of sub-specialty divisions as before, where doctors and nurses are working in isolation from specialty care. No action has been taken to enhance coordination within the CHC. Health professionals are still compensated based on the number of years worked in a specialty area, and the GP training programmes are not yet accredited. CHC directors are often waiting for instruction from higher health authorities rather than analysing their own problems. The relationship between health providers and seniors is still imbalanced and determined by health providers. As a top-down reform community health care in Shanghai is not designed and operationalized according to community needs, but by decisions from the government. The implementation of patient centeredness is confined by structural and managerial problems; e.g. CHCs do not have enough financial resources to provide services out-of-hours or have sufficient funds for home care; and the health insurance caps the cost of prescriptions. Besides, CHCs do not have any concrete plan to solve the problem of waiting times. Solving the structural barriers and organizational problems of the previous system needs efforts from various partners in the heath system; e.g. large hospitals have to be involved to establish an effective two-way referral system. However, most problems have to be discussed within broader sectors of society, including government sectors from health insurance, social welfare and health care financing. A more Copyright # 2005 John Wiley & Sons, Ltd.


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democratic involvement of seniors, the community and health providers is also important in the community health reform.

CONCLUSION The Shanghai case presented here illustrates how primary care reform is trying to become an effective and efficient tool to face the challenge of population ageing. This qualitative evaluation found that the reform has improved the structural and process components of primary care regarding first contact, comprehensiveness and longitudinality. However, the reform is confined by the structural barriers of senior’s financial resources and provider capacity. Previous organizational structure also constrains the reform in the financing and administration of CHCs. The reform needs a more fundamental change of the CHC’s internal organization and their administrative relationship with health authorities, plus sufficient government funding for preventive care. Empowerment type involvement of the community, especially seniors, is important for CHCs to gear their programmes to community health needs. The Shanghai case demonstrates that a broad societal view has to be considered in analysing health reforms, which requires the involvement of multiple sectors including the government, health providers and health care consumers.

ACKNOWLEDGEMENTS The study was supported by the Centre for International Health, Faculty of Medicine at the University of Toronto and the Shanghai Municipal Health Bureau. However, opinions in this paper reflect only those of the authors. The authors would also like to thank the anonymous reviewers for their comments.

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