Abstract
BackgroundChina has made remarkable progress in scaling up essential services during the last six decades, making health care increasingly available in rural areas. This was partly achieved through the building of a three-tier health system in the 1950s, established as a linked network with health service facilities at county, township and village level, to extend services to the whole population.MethodsWe developed a Theory of Change to chart the policy context, contents and mechanisms that may have facilitated the establishment of the three-tier health service delivery system in rural China. We systematically synthesized the best available evidence on how China achieved universal access to essential services in resource-scarce rural settings, with a particular emphasis on the experiences learned before the 1980s, when the country suffered a particularly acute lack of resources.ResultsThe search identified only three peered-reviewed articles that fit our criteria for scientific rigor. We therefore drew extensively on government policy documents, and triangulated them with other publications and key informant interviews. We found that China’s three-tier health service delivery system was established in response to acute health challenges, including high fertility and mortality rates. Health system resources were extremely low in view of the needs and insufficient to extend access to even basic care. With strong political commitment to rural health and a “health-for-all” policy vision underlying implementation, a three-tier health service delivery model connecting villages, townships and counties was quickly established. We identified several factors that contributed to the success of the three-tier system in China: a realistic health human resource development strategy, use of mass campaigns as a vehicle to increase demand, an innovative financing mechanisms, public-private partnership models in the early stages of scale up, and an integrated approach to service delivery. An implementation process involving gradual adaptation and incorporation of the lessons learnt was also essential.ConclusionsChina’s 60 year experience in establishing a de-professionalized, community-based, health service delivery model that is economically feasible, institutionally and culturally appropriate mechanism can be useful to other low- and middle-income countries (LMICs) seeking to extend essential services. Lessons can be drawn from both reform content and from its implementation pathway, identifying the political, institutional and contextual factors shaping the three-tier delivery model over time.
Highlights
China has made remarkable progress in scaling up essential services during the last six decades, making health care increasingly available in rural areas
We aim to answer the following questions: (i) how did China establish the three-tier service delivery system? (ii) what were the characteristics of the system and what kind of health services were offered to the rural population? (iii) what factors made the three-tier system successful, and (iv) what were the implications of the structural changes of the China’s rural health service delivery system within the rapidly evolving economic, social and political context, for the availability, efficiency, quality and equity of essential care?
Results are presented following the four components of the theory of change (ToC) framework: how political and socio-economic processes facilitated or obstructed the establishment of particular types of policies, the main policies and their operationalisation to a set of concrete policies, how these policies were implemented in practice and what factors made them work as intended and shaped the establishment of the three-tier health service delivery system in rural China as a key vehicle for extending access to primary health care (PHC)
Summary
China has made remarkable progress in scaling up essential services during the last six decades, making health care increasingly available in rural areas This was partly achieved through the building of a three-tier health system in the 1950s, established as a linked network with health service facilities at county, township and village level, to extend services to the whole population. Since the establishment of the People’s Republic of China in 1949, the country has experienced major socioeconomic changes; the population has more than doubled and the country has progressed from low to uppermiddle-income status, according to the World Bank classification [1] This has been accompanied by dramatic increases in the number of health facilities and human resources, and improvements in the accessibility to medicines and medical supplies. The Chinese experience of implementing these principles has inspired a range of initiatives towards developing comprehensive and inclusive primary care, and many local adaptations in low- and middle-income countries (LMICs) [7,8,9,10]
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
