Does health reform achieve the goal of strengthening primary healthcare in China?

Background: Re-constructing the primary healthcare system is the focus of the new round of Chinese health reform. Nevertheless, there have been few studies focusing on whether the role of primary healthcare in the health system is strengthened in China. Methods: The data of this study came from the China Health Statistical Yearbook (2009–2018). We evaluated the development of primary healthcare based on the absolute values of health resources allocation and health service provision, and evaluated the status of primary healthcare throughout the health system based on the composition ratios of the indicators across the health system. Results: From 2009 to 2018, the amounts of health resources allocation and health service provision of Chinese primary healthcare institutions showed a signicant upward trend (P<0.001). However, compared the indicators in 2009, excepting for the proportion of grants from the government in the whole health system has an upward trend, the proportions of other indicators had an escalating trend in 2018 by 4.04% for practicing (assistant) physicians, by 2.55% for nurses, by 4.06% for total revenues , by 5.54% for beds, by 7.37% for outpatient visits. Conclusion: The primary healthcare system has developed rapidly, but its development speed lagged behind the entire health system, resulting in the weakening of its actual functions, which is not in line with the goal of health reform. The government should improve the awareness of the importance of primary healthcare at all levels of local governments and ensure adequate nancial input.


Introduction
Primary healthcare is the key for achieving the goal of "health for all". (1) Chinese government had established a relatively complete primary healthcare system in the late 1950s. (2) Under the conditions of social and economic backwardness and health resource shortages at the time, this system played an important role in protecting the health of population. (3)(4)(5)(6) However, after 1978, when a market-oriented economy reform was implemented in Chinese health sector (7)(8)(9)(10) , Chinese primitive health system had undergone tremendous changes, which mainly manifested was that the government funding in the health system has been extremely reduced (5,7,11) . Subsequently, the primary healthcare system, which mainly relied on government funding to maintain normal operation, collapsed almost overnight (6,12) , and health costs increased rapidly in the next 30 years. The availability and fairness of health services became a sharply social issue in China. (13)(14)(15) In response to the above problems, the government began to launch a new round of health reform in 2009. (3,13,16) Re-constructing the primary healthcare system is the focus of this reform (16,17) , and it is also the key to realizing the reform goal. The government stated that increasing the input in primary healthcare was one of the ve top priorities of this plan. In the rst three years from 2009, the government health investment amounted to approximate CNY 1409.9 billion (equivalent of $ 206 billion), and 44% of those were allocated for primary healthcare institutions. (18) The 12th 5-Year Plan for Health, announced in 2012, recon rmed the government's commitment to the ongoing reform and set new targets for 2015, including continuous improvements in primary healthcare infrastructure and training of general practitioners (19) .
Up to now, Chinese health reform has been launched for 10 years. In the context of this still developing healthcare system, efforts are needed to assess the development of Chinese primary healthcare system. Such assessments would provide indications of the health reforms domains that are performing successfully, as well as the domains that require further attention and improvement. At present, studies mainly summarized the history and development of Chinese primary healthcare (2,3,20) , and evaluated the fairness of resource allocation and utilization of primary healthcare service. (21)(22)(23)(24)(25) However, there have been few studies focusing on whether the role of primary healthcare in the health system is strengthened in China, which is the core goal of this round of health reform. Thus, based on the Chinese health statistics data in the past 10 years, this study evaluated the development of primary healthcare system via analyzing the changing trend of health resources and health service quantities, and evaluated the role of primary healthcare in the whole health system by analyzing the proportion of health resources and health service provision in the whole health system.

Study design and data source
This study was a longitudinal observational study based on the China Health Statistics Yearbook (2009-2018), which provided information on health resources and health services of different kinds of medical institutions in China. In order to assess whether Chinese health resources were tilted toward primary healthcare institutions and whether the service quantity of primary healthcare services has been increased, we analyzed the dynamic changes in the absolute value and the constituent ratio of health resource allocation and health service provision in primary healthcare institutions from 2009 to 2018.

Indicators and de nitions
In this study, the de nition of primary healthcare institutions refers to the statistical caliber of the China Health Statistics Yearbook. In China, primary healthcare institutions include community health service centers (stations), township health centers, village clinics, outpatient departments, clinics, in rmaries and nursing stations. The main indicators of this study are health resource allocation and health service provision. Health resources include human resources, nancial resources and material resources. Human resources include the number of health workers, practicing (assistant) physicians, nurses, and pharmacists. Financial resources include total revenues, grants from the government and business incomes. Material resources include total number of equipment at or above CNY 10,000, building areas, and the total number of beds. Health service provision includes annual number of outpatient visits and inpatient care.

Statistical Analysis
In this study, analyses were performed using SAS version 9.2 (SAS Inc., Cary, NC, USA). We used the absolute value of each indicator to analyze the development of primary healthcare institutions and the linear regression analysis to test the trend of absolute values over time. We evaluated the status of primary healthcare throughout the health system based on the composition ratio of the indicators across the health system, and used the Cochran-Armitage trend test to examine the trend of composition ratio for each indicator over time. All statistical tests were two-tailed, and a P value <0.05 were considered to be statistically signi cant.

Results
Basic information on health resources allocation and health service provision of Chinese medical institutions α "%" were the value's growth rates in 2018 compared with the value in 2009; β P values were associated with linear regression analysis.
Basic information on health resources allocation and health service provision of Chinese primary healthcare institutions  health resource allocation and health service provision. The present study found that Chinese primary healthcare system has made some progress after the health reform during the past 10 years, but its development rate was slow, lagging behind the whole health system, which indicated that the role of primary healthcare has been indeed weakened in China.
With the prosperity of Chinese economy, the government funding in the health system has steadily increased, and the total health expenditure has increased from CNY 1,720.5 billion (US$ 252.0 billion) in 2009 to CNY 5,912.2 billion (US$ 835.8 billion) in 2018 (26,27) . At the same time, the government was actively building an integrated health system and encouraging social capital to establish private medical institutions. (28) In addition, with the improvement of residents' living standards, the health service system need to meet higher healthcare requirements, such as the release of health demand, high quality of health services. (29) These factors have contributed to the rapid development of the Chinese health system over the past decade.
As an important part of the health system, the primary healthcare has been paid more attention by the Chinese government in terms of funding and policies. (18,26,(30)(31)(32)(33)(34)(35) Unfortunately, the results of this study showed that the development of Chinese primary healthcare might have lagged behind the whole health system in the past decade, which had not yet reached the goal of health reform to strengthen the role of primary healthcare. The reasons for this result may be multifaceted. Firstly, in spite of the Chinese central government had formulated a series of policies and measures to promote the development of primary healthcare, the implementation of the policies were mainly done by local governments. (36) The implementation of policies was inevitably accompanied by the allocation of health resources. Due to lacking awareness of the importance of primary healthcare among local governments, they might have allocated more resources to general hospitals and specialist hospitals. Secondly, the development of primary healthcare lacked su cient nancial support in China. Although the total amounts and the proportions of the government's nancial investments to primary healthcare institutions had a signi cant increase, the government's nancial investment ratio only accounted for 32.85% of the total incomes of primary healthcare institutions. Furthermore, compared with hospitals, primary healthcare institutions had lower remuneration and limited career development prospects in China, which led to extremely low attraction for excellent health professionals (35) .For a long time, residents had no con dence in primary healthcare and blindly chose high-level hospitals. (37)(38)(39)(40)(41) In the past decade, the lag in the development of primary healthcare has further intensi ed patients to choose hospitals for medical services, resulting in reducing the business incomes of primary healthcare institutions and aggravating the shortage of health funds, then forming a vicious circle of "the development backwardness of primary healthcare-low attractiveness for patients-more backward of primary healthcare". Therefore, ensuring adequate nancial input, mobilizing the enthusiasm of local governments and improving occupational attraction should be the priorities for the Chinese government to develop primary healthcare in the next stage.
On the occasion of the 10th anniversary of Chinese health reform, there have been many studies expounding the effectiveness of health reform. Our study revealed an easily ignored problem in Chinese health reform process. Considering the importance of primary healthcare, the problem should be taken seriously. This study also had some limitations. Due to the limited data provided by the China Health Statistics Yearbook, we could only analyze the development of primary healthcare based on health resource allocation and health service provision. Other important evaluation dimensions, such as the health service quality and the development equity of primary healthcare, were not analyzed, which could limit the overall understanding of primary healthcare development in China.