Patients’ Experiences in Different Models of Community Health Centers in Southern China

INTRODUCTION

International experiences have shown that countries with a strong primary care–led health system have better population health and are able to achieve more equitable distribution of health.¹ In the last 2 decades, the Chinese government has begun the process of establishing a community health service to achieve better population health.^2–5 In 2009, a health care reform plan was officially announced⁶ with a key component being the expansion of community health service facilities to serve as the first contact of care and gatekeepers to the entire health system.⁷ In urban areas, these facilities are organized around community health centers (CHCs)^8,9 and adhere to the national guidelines on the standard service provision set by the Ministry of Health.¹⁰

Health care staff in all CHCs are paid a fixed salary, plus a floating salary that is largely determined by the total income of the center.¹¹ Preregistration is not necessary, and any patient can walk in to see a doctor after paying a fixed one-off registration fee set by the provincial Health Bureau. The payment for 1 visit also includes fees for examination, treatment, and the drug expenditure. For medically insured patients, the payment is shared between the government and the individuals.^12,13 All CHCs are required to have clinical physicians, public health doctors, and managerial and assistant health care staff. They also have on-site nurses, telephone access, and evening and weekend clinics. Most health care staff at CHCs regulated by the National Labour Act have similar working hours.¹⁴ Western and traditional Chinese medicine services are available in most CHCs.⁸

Because of the socioeconomic variations in different urban regions, the local implementation of CHC-based primary care networks has led to the emergence of 3 categories of CHC models of ownership and management: (1) government-owned and -managed CHCs (G-CHCs), (2) government-owned and hospital-managed CHCs (H-CHCs), and (3) privately owned and managed CHCs (P-CHCs). In 2008, 36.5% of the CHCs were G-CHCs, 35.7% were H-CHCs, and 27.8% were P-CHCs.⁵

G-CHCs, which are independent of the public hospital system, are part of the government sector and directly managed by the local government as nonprofit health care facilities.¹⁵ The typical G-CHC is subject to the Separation of Revenue and Expenditure policy, ie, revenue generated by the G-CHC (including fees generated from medical treatment and drug sales) goes to the local government, and costs incurred by the G-CHC (including premises, equipment, facilities, and staff remuneration) are paid by the local government.

H-CHCs are owned by the government but managed by the host hospital. They are not part of the government sector and are allowed to make a profit as financially self-sufficient institutions. The H-CHC is usually regarded as a department within the hospital and typically functions as an outreach clinic. H-CHCs receive limited subsidies from the government through the host hospital, which further allocates funding to the H-CHC.

P-CHCs are owned and managed by private organizations and are independent of the government and hospital sectors. They do receive limited government subsidies, but they are financially self-sufficient. P-CHCs provide primary care services in accordance with industry regulations⁸ (Figure 1).

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Figure 1

Three Emerging CHC Models for Primary Care Delivery in Urban Areas in China

CHC = community health center; G-CHC = government-owned and -managed CHC; H-CHC = government-owned and hospital-managed CHC; P-CHC = privately owned and managed CHC.

One policy aspect relevant to government policy makers is the relationship between the ownership and management models of CHCs and the quality of care provided¹⁶ based on the key attributes of primary care. China’s health care system is similar to that of the United States in that the system has been market-driven; the result has been high overall health care spending without commensurately improved health outcomes. In China fragmentation of care is common. Preventive, primary, and tertiary care are provided separately, leading to wastage of health care services. Coordination of care is often lacking among different health care providers, which compete for patients and hold onto them when they should be referred elsewhere.¹⁷ Our study examined the effect of various models of ownership and management on patients’ experiences, especially in the primary care setting, in the anticipation that our findings would inform policy makers in both China and the United States.

METHODS

RESULTS

A total of 1,659 primary care patients were approached for study inclusion, and 1,440 patients responded to the PCAT questionnaire. Excellent inter-rater reliability was achieved among the 5 interviewers (Fleiss’ generalized κ = 0.81; 95% CI, 0.78–0.87; P <.001). The overall response rate was 86.1%. No significant differences existed in the response rates at each site (P = .419) and between respondents and nonrespondents in terms of age, sex, and medical insurance coverage. Patients differed by educational and income level in the 3 cities; however, there were no significant differences in terms of medical insurance coverage, chronic condition, self-perceived health problems, marital status, and sex distribution (Table 1).

After adjustments were made for sociodemographic characteristics, health care characteristics, and health utilization covariates, results showed that G-CHC respondents had the highest PCAT total scores when compared with H-CHC (95.18 vs 90.81; P = .005) and P-CHC (95.18 vs 90.69; P = .007) respondents. When the individual domain scores of PCAT were compared among the 3 models of primary care service provision, G-CHC respondents reported significantly higher PCAT scores for the first-contact (utilization) and coordination domains. The P-CHC respondents had the highest PCAT scores for the first-contact (accessibility) domain; however, P-CHC respondents had relatively lower PCAT scores in nearly all other individual scales, especially for the first-contact (utilization) and coordination domains (Table 2).

Further analyses were conducted to explore the differences in PCAT scores based on medical insurance and chronic disease within each CHC model. We found that uninsured H-CHC respondents had lower PCAT scores overall, suggesting a different primary care experience with this model (Table 3). Respondents who were chronically ill had significantly higher overall PCAT scores under G-CHCs (96.17 vs 92.17; P = .043) and H-CHCs (94.06 vs 88.59; P =.010) when compared with those who did not have chronic medical conditions. Respondents with chronic diseases under P-CHCs had significantly lower PCAT scores in terms of comprehensive service availability (11.34 vs 12.49; P = .002) when compared with those who did not have chronic diseases in the same ownership and management model (Table 4).

There were no interaction effects found between CHC models and health utilization factors or socioeconomic factors, including income and educational level. Factors significantly associated with higher overall PCAT scores included a government-owned and -managed CHC (P = .028 for H-CHC; P = .009 for P-CHC), regularly attending a CHC (P <.001), a most familiar doctor or nurse at the CHC (P <.001); medical insurance (P = .006), a chronic medical condition (P = .001), and good self-reported health status (P <.001) (Table 5).

DISCUSSION

This study is the first to evaluate the relationship between organizational and ownership models of CHCs and patients’ experiences of primary care using an internationally developed and cross-culturally adapted tool in southern China. The PCAT, which focuses on patients’ experience of, rather than satisfaction with, health care delivery, minimizes subjective bias that is due to sociodemographic variations and patient expectation. Previous studies have used PCAT to assess primary care under different health care systems and types of providers for patients with different sociodemographic attributes.^{19,20,24–34} This study adds to the evidence suggesting that the quality of primary care measured by patient experience is related to the ownership and management model of the CHCs.

The respondents gave G-CHCs higher overall PCAT scores as a result of better first-contact care (better first-contact utilization) and coordination of care. The higher score for first-contact utilization suggests that the better gatekeeping performance might be due to the more effective implementation of the reimbursement policy, which stipulates that patients shall be reimbursed only for health care expenditures occurring at a predesignated G-CHC, close to their living areas,³⁵ thereby possibly reducing doctor shopping. The higher score of G-CHCs in the coordination domain could be explained by the community-wide multisectoral initiatives and joint efforts made at different governmental levels to integrate health service connections under the government’s strategic plan.³⁶ The results also showed that a higher proportion of all respondents had follow-up visits at hospitals and they gave better overall PCAT scores to G-CHCs in the coordination domain for those who were chronically ill, suggesting a more cohesive linkage of health care services between different levels of health system.

Previous studies conducted in the United States^37,38 have shown that government-funded and -regulated CHCs were able to deliver a higher quality of primary care when compared with hospital outpatient clinics or private doctors’ offices in terms of better service coordination, comprehensiveness, and community orientation. In a recent Canadian study³⁹ that compared several organizational models and outcomes for chronic disease management, government-funded CHCs were associated with better chronic disease care when compared with other organizational models. It is worthy to note that the key differences among these government-funded and -managed primary care facilities are that the CHCs in the United States and Canada are third-sector organizations operated under community governance,⁴⁰ whereas the G-CHCs in China are part of the government sector and managed directly by the local governmental departments.¹⁵

Under the H-CHC and P-CHC models, the role of local government in providing primary care is limited. In these models, primary care delivery is governed by hospitals and private investors, which are financially self-sufficient, for-profit organizations.⁴¹ Our results show that H-CHC respondents who were not medically insured had significantly lower overall and individual domain PCAT scores. When comparing medical insurance coverage between H-CHC survey respondents and the general population,⁴² H-CHC respondents without medical insurance coverage reported less health service utilization, suggesting H-CHC might be less utilized by vulnerable patients. In addition, the lower PCAT scores for service coordination and fewer subsequent visits by patients at hospitals might indicate a weaker linkage between H-CHC and different levels of health system.

International studies have shown inconsistency in the quality of primary care provided by the private sector.^19,43 Although China’s P-CHCs have less-rigid administrative and bureaucratic structures and may be more responsive to local needs,^44,45 the profit-driven nature and the poorer coordination of care with other health services might result in a poorer primary care experience, in particular where the care is less incentivized.⁴⁶ Our study showed that respondents gave P-CHCs lower overall PCAT scores, especially in the coordination domain. One of the explanations could be that the P-CHC model might lack incentives to refer patients to other care services provided by other health organizations that compete for patient enrolment,⁴⁴ although we cannot confirm this explanation based on our current findings. Lower PCAT scores given by P-CHC respondents with chronic diseases (in comprehensiveness domain) and by respondents with lower household incomes (in first-contact utilization and service availability domain) (figure available from authors upon request) might be due to the lack of government subsidies to provide more comprehensive services, as P-CHCs receive the least financial support from the local government.⁴⁷

Factors positively associated with better primary care experiences among all respondents also included having a chronic condition, having medical insurance covererage, and a self-reported good health status. Patient’s sociodemographic factors were not sensitive to overall PCAT scores shown in the study. A study conducted in Hong Kong¹⁹ previously reported that higher PCAT scores were found in patients with chronic conditions and those with medical insurance. The national agenda under China’s current health care reform requires local commitment from CHCs to cope with noncommunicable chronic diseases^48–50 so that chronically ill patients might receive more attention. Meanwhile, progress toward the expansion of medical insurance coverage^12,13 might enable patients to have better primary care experiences.

This large cross-sectional study has a number of limitations. First, many unmeasured confounders potentially exist between CHC ownership and management and PCAT scores, and a patient self-report survey restricted inclusion of questions relating to physician information, which was not accounted for in this study. Second, there were differences in the patients’ characteristics, although factors previously identified to be significantly associated with PCAT scores were all controlled for. Third, we have not used symptoms or disease-specific outcomes; instead, we used a validated tool measuring only the key attributes of primary care. Thus, our study is related more to the process of care.