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Strengthening Community-based Health Care in Urban China

2001-02-02

[Photo: Doctor and patient at Zhongguancun health centre.]

When residents of Beijing's Zhongguancun neighbourhood wanted medical treatment they used to go to a hospital. Sometimes they waited several hours to get treated by a specialist. Now, thanks to a pilot project funded by the International Development Research Centre (IDRC) and China's Ministry of Health, they can phone their new family doctor to make an appointment, or they can drop in to the new community health centre (CHC).

Over the last two years, the Zhongguancun project has investigated a new model of primary health care delivery aimed at improving quality and access to health care, and controlling rapidly rising costs. The project also involves a second pilot CHC in Chengdu, the capital of Sichuan province.

Family physician model

Project leader Chen Bowen, Director of Child Health and Development at the Capital Institute of Pediatrics, and the doctors in the two community health centres are introducing the concept of the family physician to China. Dr Chen first had this idea in 1995, while attending McGill University in Montreal. "In Canada I learned a lot about the Canadian [health care] system," he says. "I think everyone should have their own family doctor." The model Dr Chen proposed to IDRC is loosely based on the community health centres he saw while living in Quebec.

In China, 80 % of urban dwellers seek treatment on an episodic basis at large, modern hospitals — even for minor illnesses. By contrast, facilities at the grassroots level are underused. But this is changing in Zhongguancun. After some initial reluctance, most people now prefer their new CHC, established in a wing of the Zhongguancun Hospital. "It was difficult at first," recalls Dr Chen. "Residents didn't trust the doctors. They didn't like small hospitals." Now, each doctor at the Zhongguancun CHC has 500 residents under his or her care on an ongoing basis, and the total number of patients is rising.

Choosing a doctor

At the CHC, each patient selects one of the centre's doctors and signs a one-year renewable service contract that costs 30 yuan (about CA$5.45). Each doctor's résumé and photo are on display. Onil Bhattaacharyya, a resident at the University of Montreal's Family Medicine Department, spent six months in China in late 1999, conducting a mid-term evaluation of the project. He says 90 % of the patients at the Beijing CHC have some kind of insurance that covers all or most of their costs.

The CHC doctors are former specialists who have undergone three months of training as family physicians. The focus of the CHC is on providing comprehensive care and raising the health awareness of the local populations. This is done by linking the CHC with the strong network of community groups organized throughout China by the Communist Party. For example, a monthly newsletter is sent to patients with health tips and information about free lectures on health care. In addition, family members are taught how to help care for ill relatives.

Chronic diseases

Wang Guan Bao, Director of the Zhongguancun Hospital, says they now want to focus on preventing chronic conditions like hypertension. A high blood pressure club has been launched, which holds regular classes on managing the disease. The continual doctor-patient relationships also allow the Centre to track the prevalence of chronic diseases in the area and identify lifestyles and behaviours that may influence those statistics.

Each doctor has a computer linked to an intranet with software for data compilation and analysis. By computerizing patient records and prescriptions, the project team "has generated very detailed 'prescription profiles' by doctor and by disease, which are beginning to be analysed," says Dr Bhattaacharyya. Such data will help the researchers monitor prescription patterns to avoid the over-prescription of medicines — one of the main factors driving up health care costs in China.

Convenient care

Many patients like the convenience and atmosphere of the CHC, and appreciate their ongoing relationship with a doctor. Area resident Ruan Ji Sheng says the CHC environment is like a big family. "My wife has cancer. When she's not well, our doctor comes to pay a visit," he says. "Before we would have to wait at a hospital for two hours and maybe we wouldn't get a good doctor. He would just give us some medicine and send us home." Ruan adds that their doctor always phones a couple of days after a consultation to see how things are. At the CHC, health care is convenient and available 24 hours a day, seven days a week, stresses Dr Chen.

"After 25 half-days observing — and transcribing — patient-doctor conversations in the CHC clinic, as well as in a regular outpatient patient clinic in another wing of the hospital, it was clear to me that the CHC model offers better care," notes Dr Bhattaacharyya. "Regular clinic doctors see 70 to 80 patients a day, spending from one to five minutes with each. This leaves little time for a medical history, and much less for developing any relationship with the patient. The fact that there are two doctors per office and patients lined up behind the desk does not help."

One patient at a time

"But in the CHC, each doctor has a private office and usually sees one patient at a time. They see 20 to 30 patients a day, spend 5 to 25 minutes with each patient, conduct more detailed case histories, review medications more often, and are more likely to inquire about the psychosocial aspects of illness," he adds.

The success of the Zhongguancun and Chengdu CHCs has encouraged other jurisdictions to follow suit. According to Zhu Zong Han, Director of the Beijing Municipal Health Bureau, the CHC model is now being copied around Beijing. There will eventually be about 250 of such centres in the city. The model is also being adopted city-wide in Chengdu. Dr Wang notes that 47 hospital directors and 11 provincial health directors from all over China have visited the CHC to see how it works. As a result, China's Ministry of Health wants the two pilot schemes to serve as national teaching examples.

Improved access

Although there is much to be done to reform China's health care system, the project is a step in the right direction, concludes Dr Chen. He says the computerized patient information system is a big improvement over paper-based patient files; they have shown how to successfully convert both medium and small hospitals to CHCs; and they have educated citizens about the benefits of having a family doctor. While it's too early to tell if the overall health of CHC patients is improving, at least there is now a system in place to find out — and in the meantime, patients are enjoying better access to health care.

Michael Dobie is a writer based in Beijing. (Photo: M. Dobie)

[Reference: IDRC Project Number 97022501]

If you have any comments about this article, please contact mag@idrc.ca .

For more information:

Dr Onil Bhattaacharyya, Resident, Family Medicine Department, University of Montreal, 4870 Côte-des-Neiges, Montréal, Québec, Canada H3V 1H3; Email: onilb@yahoo.com

Dr Zhu Zong Han, MD., Director, Beijing Municipal Health Bureau, No. 2 Huai Bai Shu Street, Beijing, 100053, China; Tel: (86-10) 6301-1361; Fax: (86-10) 6301-6844; Email: bhbo@public.bta.net.cn

Dr Wang Guan Bao, MD, Director, Zhongguancun Hospital; Tel: (86-10) 1350-109-6030

Links to explore ...

Sidebar: Why China's Health Care System Needs Fixing

Improving Health Care in Tanzania: The Tanzania Essential Health Interventions Program, by Mike Crawley

Reshaping Health Care in Latin America

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