Background
Many countries have identified the primary health care system as a priority for reform [
1‐
3]. Primary care (PC) was identified by the Alma-Ata declaration as the foundation for integrating all health and social services to improve health outcomes, and the key to sustainable, accessible, and equitable health systems [
4]. In China, a new health care reform was initiated in 2009, focusing on primary care (e.g., instituting universal health insurance coverage, a basic public health service program, and a national essential drug system) [
5]. In 2014, the government implemented a hierarchical medical system (involving primary diagnoses at primary health care institutions and two-way referrals among different levels of hospitals), to strengthen the service capabilities of primary health care and increase reliance upon primary health care services [
6].
Evidence from previous studies using administrative data has indicated a significant impact on primary care services since the 2009 reform, e.g., minimum subsidies per capita for basic public health service tripled from 2009 to 2016 [
7], and an overall reduction in average prescription costs for patients [
8]. However, the government’s efforts were not completely successful. People still seek care at relatively high-level hospitals for treatment, which leads to overcrowding in large hospitals and high healthcare expenditures [
9,
10]. Therefore, there is a pressing need to comprehensively evaluate the impact of the 2009 reform on primary health care services in China.
The strength of a country’s primary care system depends on multiple dimensions of primary care impacts in the context of its health care system [
11]. Previous Chinese studies mainly evaluated the primary care service on one dimension, such as equity [
12], satisfaction [
13] and continuity [
14]. Some comprehensive primary care studies have been performed, for example, using surveys such as the Primary Care Assessment Tool (PCAT) [
15,
16]. However, these assessments mainly focused on the perceptions of patients, and there is limited research exploring other perspectives, especially primary care physicians. Based on stakeholder theory, evaluating primary care should consider the perspectives of: patients (service users), health care professionals (service providers), and administrators (managers) [
17,
18]. It is important to survey primary care physicians because they are the main providers of care in this reform [
19]. Furthermore, evaluating primary care from multiple levels better reveals the relationships between the different levels of and provides insight into various stakeholder viewpoints.
The Quality and Costs of Primary Care (QUALICOPC) is an international study of primary care systems designed to understand how patients perceive the quality of primary care, how providers provide services, and overall health outcomes of primary care in 34 countries worldwide [
20]. QUALICOPC questionnaires are developed to make a comprehensive analysis of primary care (PC). Evaluation of the service capacity of the PC system includes three levels: structural level (governance, economic conditions, and workforce development), process level (access, continuity of care, coordination of care, and comprehensiveness of care) and outcome level (quality of care, efficiency of care, and equity in health) [
18,
19].
The aim of our study was to comprehensively evaluate the primary health care service capacity in China by investigating primary care physicians’ and their patients’ perceptions using the European QUALICOPC protocol. We compared and analyzed similarities and differences between the perspectives of physicians and their patients. Our goal is to contribute evidence for the improvement of Chinese health policy.
Discussion
To the best of our knowledge, this is the first study to measure the primary care service delivery using the QUALICOPC survey in China, and this is also the first study to compare both the perspectives of physicians and patients by QUALICOPC in the world. Our study showed differences and similarities in the core dimensions of the primary care service capacity between physicians and patients in west China.
Firstly, the perception of the best dimension was different among the physicians and the patients. From the point of view of PC physicians, equity of care scored the best. One explanation for such a finding could be that most PC physicians treated their patients fairly, e.g., had no restrictions to accepting new patients, and prescribed the cheapest equivalent medicine to reduce financial obstacles to disadvantaged patients. An alternative explanation for this finding is that the insurance coverage expansion promoted equity in economic access to primary care [
26]. In our study, only a few patients (29, 4.5%) postponed or abstained from a visit to a physician because of lack of insurance. Previous studies revealed that medical insurance may have played an important role in health equity [
27,
28]. Quality of service ranks highest among the dimensions in the perspective of patients. This is inconsistent with a previous study that found the Chinese primary health care system is poor in quality [
5]. This difference in findings is probably because the other study focused on outcome measures, while the variables in our study are mainly process measures (e.g., communication, careful treatment).
In addition, physicians had higher perceptions of accessibility, while patients’ experiences with accessibility seemed to be relatively worse. In general, accessibility was perceived well in terms of access to services, e.g., making an appointment for a visit and waiting time for consultation in primary care. Our finding that there was a barrier to spatial accessibility of primary care is consistent with literature on this topic [
29]. Poor accessibility scores for patients also may relate to the practice characteristics; for example, few primary care institutions outside provided clear information on when open and how to get out-of-hours care.
Lastly, coordination ranked the lowest among the core dimensions from the perspective of both physicians and patients. Similarly, Polish GPs and patients had lower perceptions of coordination [
17,
25]. The lack of efficient information flow could be the explanation of worse evaluation of coordination of care. The results showed that medical records were seldomly provided by the previous doctor and results after treatment were often not known when patients transferred. Findings of recent studies indicated that the coordination dimension was more related to the dissemination of information among family physicians or between family physicians and specialists (primary and secondary care) [
25,
30]. Small private practices which may lead to “a culture of individualism” could also impede coordination of care [
31]. An alternative interpretation is that the coordination of care is relevant to planners of PC and the opportunities offered by health managers in the local community [
32].
In China, poor coordination may be explained by “isolated” and “fragmented” healthcare services, for example, primary healthcare centers and hospitals operate independently and compete for patients [
33,
34]. Integrated care has been suggested as one strategy for promoting coordinated healthcare delivery. In 2016, the report on the Deepening Health Reform in China proposed a hierarchical medical system in accordance with a people-centered integrated care model for strengthening health care [
35]. However, the implementation of this policy has not brought about as many improvements as expected. The referral rate in China was far lower than the general referral rate (20–30%) published by the World Health Organization [
36]. The previous studies indicated that this may relate to the lack of coordination and continuity between hospitals at the different levels [
6,
37,
38]. We suggest that policy makers should focus more on the coordination dimension of primary care when enacting heath policy reforms. Sharing medical information (e.g., electronic medical records), shared management (e.g., collaboration skills), and payment stimulus could be the suggestions to promote the coordination [
39‐
41].
Our study has several limitations. Although the questionnaires were designed and validated for an international study and our material allows for international comparisons, the questions were not specifically designed to map the context of China. Thus, for Chinese circumstances, we removed or added some items, and made some adaptations in the original questionnaires. These may lead to a bias in the comparability of our findings with international results. Another limitation is that all information was based on the physician and patient self-reported data. Answers are subjective and could be under- or over-reported, and, therefore, could be inaccurate. Recall bias may also apply. Due to limited clinical knowledge, it is not possible to assess certain aspects of technical quality from the patient’s perception. In addition, further research needs to expand the sample size to more primary care settings or regions in China to increase generalizability of findings.
Acknowledgements
The authors thank all the teachers, students and the research participants who took part in the data collection. We thank the China Scholarship Council for supporting the first author’s visit to the Department of Health Policy and Management at University of California, Los Angeles (CSC Number: 201806240304). We would also like to acknowledge Dr. Gerald F. Kominski and Dr. Zhuyue Li for their assistance in making this a better article.