The health system and health impacts of primary healthcare reform in China: A systematic review

Abstract Background China has undergone a comprehensive primary healthcare(PHC) reform since 2009 aiming to deliver accessible, higher-quality, and equitable healthcare. However, there is limited understanding of the effectiveness of this reform. This systematic review synthesizes evidence on health system and health impacts of this reform. Methods We searched 13 international databases and three Chinese databases for quantitative studies assessing the impacts of this reform published between January 2009 and March 2020. We searched for studies in English or Mandarin. Eligible study designs were RCTs, quasi-experimental studies and controlled before-after studies. We included studies that: assessed PHC policies since 2009; had geographical, temporal or population comparators; and assessed any outcome measures of health expenditures, health service utilisation, quality of care or health outcomes. Study quality was assessed using ROBINS-I, and results synthesized narratively. PROSPERO: CRD42021239991. Results Of 35,480 titles, 37 studies were included (27 in English and ten in Mandarin). Eight were considered at low risk of bias. The 37 studies covered all major PHC policies since 2009, but mostly focused on the essential medicine (N = 15) and financing (N = 10). The quantity and quality of studies on service delivery policies(e.g., family physician and essential health services), were low(N = 3,with moderate or serious risk of bias). 17 studies found that the PHC reforms promoted primary care utilisation. Its impacts on quality and health improvement appear limited to people with chronic diseases(N = 11). Evidence on primary care costs and OOPs were not clear. Some evidence showed that the reforms were pro-equity with benefits accrued in disadvantaged regions and groups. Conclusions Comprehensive PHC reforms can deliver some benefits related to utilisation and health for high-risk and vulnerable populations. Policymakers should continue to prioritize PHC to achieve Universal Health Coverage. Key messages • The finding suggests that large-scale and comprehensive primary healthcare reforms can deliver benefits related to utilisation and health for high-risk and vulnerable populations. • Future research should include more robust study designs and seek to better understand the impact of major PHC reforms on quality of care, health outcomes and equity.

Public health and social measures (PHSM) are preventative measures taken by individuals, communities and government institutions at national and local levels to prevent and reduce transmission of an infectious disease -in this instance SARS-CoV-2.The decision to introduce, adapt or lift PHSM should be based primarily on a situational assessment of the intensity of transmission of SARS-CoV-2 and the capacity of the health system to respond to subsequent increases in hospital admissions, but must also consider the effects these measures may have on the general welfare of society and individuals.The WHO Regional Office for Europe developed an online public health and social measures (PHSM) calibration tool to assist Member States in decision-making relating to PHSM implementation during the COVID-19 pandemic.The tool, designed to be used primarily by policy-makers in national and local government authorities, provides guidance based on a situational-level assessment framework that is determined by the level of community transmission and the overall capacity of health systems and public health services within a country or region to respond.By using a combination of countryreported and user-input data, the tool automatically generates Background: Due to SARS-CoV-2 rapid mutations, the ending of the pandemic is still proceeding at a slow pace and there is the need to strengthen and invest in health systems that avoid hospital overload and its consequences on patients' health.Most symptomatic infections have mild to moderate respiratory symptoms and patients are managed in the context of primary care.In Italy, literature on COVID-19 outpatients management by general practitioners (GPs) is scarce.This study explores the effect of GP active care and monitoring on COVID-19-related hospitalization in patients in the province of Modena (Italy) and investigates the possible determinants of GP's management.Methods: This is a retrospective cohort study of SARS-CoV-2 infected adult outpatients managed by their GPs from March 2020 to April 2021 in the province of Modena (Italy).Data on GPs' characteristics, management strategies (visits and remote monitoring), patients' socio-demographic characteristics, and hospitalization were extracted from the GP's electronic medical records and were analyzed using descriptive statistics and multiple logistic regression.

Results:
46 GPs agreed to participate, and 5340 patients were included in the analyses.3014 (56%) patients received active daily remote monitoring and 840 (16%) were visited at home.Remote monitoring and home visits were both associated with a reduction of the probability of hospitalization rate of approximately 50% (respectively OR:0.52, 95%CI:0.33,0.80 and OR:0.50, 95%CI;0.33,0.78).Preliminary analysis of determinants showed that GPs' patient load, setting, age, and sex were significantly associated with management strategies.

Conclusions:
Active monitoring performed by GPs was effective in reducing the probability of hospitalization.Primary and hospital care integration can be effective for COVID-19 management.Studies on GPs' characteristics and patient load and their effect on their ability to care for patients are needed.

Background:
China has undergone a comprehensive primary healthcare(PHC) reform since 2009 aiming to deliver accessible, higher-quality, and equitable healthcare.However, there is limited understanding of the effectiveness of this reform.This systematic review synthesizes evidence on health system and health impacts of this reform.

Methods:
We searched 13 international databases and three Chinese databases for quantitative studies assessing the impacts of this reform published between January 2009 and March 2020.We searched for studies in English or Mandarin.Eligible study designs were RCTs, quasi-experimental studies and controlled before-after studies.We included studies that: assessed PHC policies since 2009; had geographical, temporal or population comparators; and assessed any outcome measures of health expenditures, health service utilisation, quality of care or health outcomes.Study quality was assessed using ROBINS-I, and results synthesized narratively.PROSPERO: CRD42021239991.

Results:
Of 35,480 titles, 37 studies were included (27 in English and ten in Mandarin).Eight were considered at low risk of bias.The 37 studies covered all major PHC policies since 2009, but mostly focused on the essential medicine (N = 15) and financing (N = 10).The quantity and quality of studies on service delivery policies(e.g., family physician and essential health services), were low(N = 3,with moderate or serious risk of bias).17 studies found that the PHC reforms promoted primary care utilisation.Its impacts on quality and health improvement appear limited to people with chronic diseases(N = 11).Evidence on primary care costs and OOPs were not clear.Some evidence showed that the reforms were pro-equity with benefits accrued in disadvantaged regions and groups.

Conclusions:
Comprehensive PHC reforms can deliver some benefits related to utilisation and health for high-risk and vulnerable populations.Policymakers should continue to prioritize PHC to achieve Universal Health Coverage.