Abstract
BackgroundComprehensive primary care practices, through preconception, preventive, curative, and rehabilitative care, have been a global priority in the promotion of health. However, the scope of primary care services has still been in decline in China. Studies on the factors for primary care service scope have centred on human resources and infrastructure; the role of direct government subsidies (DGS) on services scope of primary care facilities were left unanswered. This study aimed to explore the association between the DGS and services scope of primary care facilities in China.MethodsA multi-stage, clustered cross-sectional survey using self-administrated questionnaire was conducted among primary care facilities of 36 districts/counties in China. A total of 770 primary care facilities were surveyed with 757 (98.3%) valid respondents. Of the 757 primary care facilities, 469 (62.0%) provided us detailed information of financial revenue and DGS from 2009 to 2016. Therefore, 469 primary care facilities from 31 counties/districts were included in this study. Sasabuchi-Lind-Mehlum tests and multivariate regression models were used to examine the inverted U-shaped relationship between the DGS and service scope.ResultsOf 469 PCFs, 332 (70.8%) were township health centres. Proportion of annul DGS to FR arose from 26.5% in 2009 to 50.5% in 2016. At the low proportion of DGS to financial revenue, an increase in DGS was associated with an increased service scope of primary care facilities, whereas the proportion of DGS to financial revenue over 42.5% might cause narrowed service scope (P = 0.023, 95% CI 11.59–51.74%); for the basic medical care dimension, the cut point is 42.6%. However, association between DGS and service scope of public health by primary care facilities is statistically insignificant.ConclusionWhile the DGS successfully achieved equalization of basic preventive and public health services, the disproportionate proportion of DGS to financial revenue is associated with narrowed service scope, which might cause underutilization of primary care and distorted incentive structure of primary care. Future improvements of DGS should focus on the incentive of broader basic medical services provision, such as clarifying service scope of primary care facilities and strategic procurement with a performance-based subsidies system to determine resource allocation.
Highlights
Comprehensive primary care practices, through preconception, preventive, curative, and rehabilitative care, have been a global priority in the promotion of health
To fill the evidence gap, we aimed to investigate the association between the proportion of direct government subsidies (DGS) to financial revenue (FR) and the service scope of the Primary care facilities (PCF), facilitating early detection of the narrowed scope of primary care services and informing the capacity-building policies for PCFs at the risk of poor performance
A total of 362 (77.2%) PCFs were enrolled into integrated delivery systems in 2017
Summary
Comprehensive primary care practices, through preconception, preventive, curative, and rehabilitative care, have been a global priority in the promotion of health. Studies on the factors for primary care service scope have centred on human resources and infrastructure; the role of direct government subsidies (DGS) on services scope of primary care facilities were left unanswered. This study aimed to explore the association between the DGS and services scope of primary care facilities in China. A comprehensive scope of care has been proven to be associated with reductions in medical expenditures (− 1.7%), hospitalizations (− 2.4%), and emergency department (ED) visits (− 2.5%) between the population in the highest and lowest quartiles of comprehensiveness of care [5]. With the substantial amount of government subsidies in infrastructure construction, workforce training and salaries since the Healthcare Reform in 2009, the government had gradually started to cover preventive and public health services, infrastructure and a large proportion of salaries. Healthcare services outside of traditional face-to-face office visits were gradually paid or reimbursed, such as long-term care and chronic care management [7, 8]
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