Deepening Health Reform In China

[Pages:202]Deepening Health Reform In China

Building High-Quality And Value-Based Service Delivery

Policy Summary

China Joint Study Partnership World Bank Group, World Health Organization, Ministry of Finance, National Health and Family Planning Commission, Ministry of Human Resources and Social Security

2016

Contents

Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv Abbreviations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxvii

Background: Impressive Gains in Health Outcomes,

but Substantial Challenges Ahead

1

Aging, chronic disease, and risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Quality of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Inefficient service delivery: hospital-centrism, fragmentation and Distorted incentives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Risk of low value care: Diminishing gains in health with escalating Health spending . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Spending projections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Part I Service Delivery Levers

17

Shaping tiered health care delivery system in accordance

with People-Centered Integrated Care Model (Lever 1)

19

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Challenges. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

DEEPENING HEALTH REFORM IN CHINA

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DEEPENING HEALTH REFORM IN CHINA

Core action areas and corresponding implementation strategies for developing and implementing PCIC-based service delivery model: lessons from international and national experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Improving Quality of Care in Support of People-Centered

Integrated Care (Lever 2)

35

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Challenges to Improving Quality of Care in China. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Recommendations for Improving the Quality of Care . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Engaging Citizens in Support of the People-Centered

Integrated Care Model (Lever 3)

49

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Challenges to engaging citizens. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Recommendations: Strengthening Citizen Engagement . . . . . . . . . . . . . . . . . . . . . . . . . 51

Reforming Public Hospitals and Improving their Performance

(Lever 4)

65

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Challenges and lessons in Public Hospital Governance and Management in China. . . . 66

Recommendations for moving forward with public hospital reform: Lessons from Chinese and international experience. . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Part II Institutional and Financial

Environment Levers

77

Realigning Incentives in Purchasing and Provider

Payment (Lever 5)

79

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Key Challenges in Purchasing Health Services and Paying Providers. . . . . . . . . . . . . . . 80

Recommendations for Realigning Incentives in the Health System in China . . . . . . . . . 82

Strengthening Health Workforce for People-Centered

Integrated Care (Lever 6)

89

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Key Challenges in the Human Resource Management in China. . . . . . . . . . . . . . . . . . . 90

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Recommendations for Moving Forward with Human Resources Reform: Lessons from Chinese and International Experience. . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

Strengthening Private Sector Engagement in Production and

Delivery of Health Services (Lever 7)

97

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Key Challenges. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

Recommendations for Strengthening Private Sector Engagement in Production and Delivery of Health Services: Lessons from Chinese and International Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

Modernizing Health Service Planning to Guide Investment

(Lever 8)

107

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

Key Capital Investment Challenges in the Health Sector in China. . . . . . . . . . . . . . . . . . . . 108

Recommendations for Moving Forward with Service Planning Reform: Lessons from Chinese and International Experience. . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

Part III Moving Forward with Implementation

117

Strengthening Implementation of Service Delivery Reform

119

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Implementation Challenges. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 An Actionable Implementation Framework. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Moving Forward: Spreading Effective and Sustainable Implementation at the Local Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Toward a sequential reform implementation plan for reaching full scale in China . . . . . . 132

Annexes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Annex 1 Levers and Recommended Core Actions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Annex 2 Government Policies In Support of the Eight Levers. . . . . . . . . . . . . . . . . . . . . 138 Annex 3 New Policy Guidelines on Tiered Service Delivery (Guo Ban Fa [2015] NO.70) and Recommended Core Actions. . . . . . . . . . . . . 142 Annex 4 Nomenclature and Summaries of 22 PCIC Performance Improvement Initiatives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Annex 5 Impact Frequency of Studies on PCIC Initiatives (no. of studies). . . . . . . . . . . . 147

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

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Boxes

I.1

What is Value in Health Care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxviii

I.2Suggestions of the CPC Central Committee on the 13th Five-year Plan for

National Economic and Social Development on the promotion of a

"Healthy China" (pp. 42?43, English translation) . . . . . . . . . . . . . . . . . . . . . . . xxix

I.3 Report Structure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxi

I.4

Nomenclature, Name and Location for Commissioned Case Studies. . . . . . . . . xxxiv

2.1Defining People-Centered Integrated Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

2.1Impacts of PCIC-like models. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

2.1The Potential Benefits of People-Centered Integrated Care. . . . . . . . . . . . . . . . . . . 22

3.1What is Quality? Why Quality is important? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

3.2Existing evidence of over-utilization of drugs and health interventions. . . . . . . . . .39

3.3Core action areas and implementation strategies to improve healthcare quality. . . 40

4.1Why is citizen engagement important? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

4.2Citizen Engagement to improve health care: core action areas and

corresponding implementation strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

4.3Health Education in the UK: Skilled For Health. . . . . . . . . . . . . . . . . . . . . . . . . . . 54

4.4Social marketing in China: Prevention and control of Hepatitis B . . . . . . . . . . . . . 55

4.5The Million Hearts Campaign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

4.6Encouraging self-management of health: Examples from the UK and India. . . . . . 59

4.7Improving patient involvement at the Beth Israel Deaconess Medical Center

in the US . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

4.8Decision Aid for Stable Coronary Heart Disease by the Informed

Medical Decisions Foundation

4.9Health Coaching to Coordinate Care in Singapore. . . . . . . . . . . . . . . . . . . . . . . . . 61

4.10Examples of using nudging and regulation to change target behaviors. . . . . . . . . . 64

5.1Management Practice Domains. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

6.1Examples of provider payment reforms in China . . . . . . . . . . . . . . . . . . . . . . . . . . 85

9.1Distinguishing Features of an Effective Service Planning Approach. . . . . . . . . . . 108

9.2Horizon's Three Step Model. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

9.3Physical Redesign of Northern Ireland's Health System Model. . . . . . . . . . . . . . . 115

10.1Government Administrative Reforms and International Experience. . . . . . . . . . . 127

Figures

ES.1 8-in-1 Interlinked Reform Levers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviii ES.2 Reform Implementation Roadmap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii 1.1Share of the Elderly in China will Rapidly Catch up with the OECD. . . . . . . . . . . . 2 1.2Prominence of NCDs in the Burden of Disease and Causes of Mortality. . . . . . . . . 3 1.3Management of Hypertension and Diabetes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.4Smoking and Alcohol Consumption in China Compared to Other Nations. . . . . . . 5 1.5Hospital beds in China compared to OECD, 2000?2013. . . . . . . . . . . . . . . . . . . . . 7 1.6Rapid Growth in the Number of Hospitals and Shift toward Higher

Level Facilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1.7 Rising Health Care Cost in China. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.8 Health Care Expenditure Growth Rate in China . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1.9 Composition of Health Spending in China, 1997?2013 . . . . . . . . . . . . . . . . . . . . . 14 1.10 Trend in Life Expectancy Compared to Total Spending on Health, 1995?2015. . . 14 1.11 Diverse Paths to Better Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2.1Illness Burden Scorecard to risk stratify patients. . . . . . . . . . . . . . . . . . . . . . . . . . . 26

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2.2Responsibilities of PACT team members. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 2.3PACE Continual Feedback Loop. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 5.1Scores by Management Practice, China 2015 (n=110 hospitals) . . . . . . . . . . . . . . . 69 6.1Composition of Total Health Expenditure in China, by facility

or provider (percent) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 7.1Health Workers Compensation across levels of Care and Providers, China 2013. . 91 8.1Growth in Hospitals by Ownership. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 8.2Growth in PHC Facilities by Ownership (2005 to 2012) . . . . . . . . . . . . . . . . . . . . 98 8.3Growth of Hospital Admissions by Ownership, 2005?2012 (in 10,000) . . . . . . . . 98 8.4Growth of Outpatients Visits by Ownership, 2005?2012 (in 10,000) . . . . . . . . . . 99 10.1Proposed Oversight, Coordination and Management for Service

delivery Reform Implementation and Scale-Up. . . . . . . . . . . . . . . . . . . . . . . . . . . 124 10.2The Transformation Learning Collaborative (TLC) model in three different

arrangements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

Tables

1.1Hypertension diagnosis, treatment and control (age 35?84): international comparison . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

2.1Core actions areas and implementation strategies to achieve PCIC. . . . . . . . . . . . . 24 5.1Hospital Governance Models in Selected Countries. . . . . . . . . . . . . . . . . . . . . . . . 73 8.1Percent of Health Workers in Private Facilities by Type. . . . . . . . . . . . . . . . . . . . . 102 10.1Examples of Policy Implementation Monitoring Guidelines for China's

Value-Driven Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 10.2Examples of monitoring indicators by reform goal. . . . . . . . . . . . . . . . . . . . . . . . 131 10.3Scoring System for Transformation Learning Collaboratives . . . . . . . . . . . . . . . . 132 10.4TLC Provincial Roll Out by Phase, Time Interval and Jurisdiction. . . . . . . . . . . . 133

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