Primary care institutions revisited: no epidemic peak in Spring Festival, how to strengthen the role of graded care

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In the Spring Festival of the Year of the Rabbit, village doctor Cao Pingan had a few days of leisure as in previous years, because according to custom, local villagers rarely choose to see a doctor during the Spring Festival, and more importantly, the previous speculation and worry that the Spring Festival will usher in a peak of epidemic outbreak in rural areas did not appear.

This is Dawang Town, Yangxin County, Hubei Province, which, like many rural areas, has just experienced the panic following the adjustment of the new crown epidemic prevention and control policy, and now, people’s lives are gradually returning to normal.

Similar to Cao Pingan and Dawang town scenery of many.

During this special Spring Festival, the First Financial Reporter visited medical workers at all levels, including villages and towns, to understand the current situation of primary care and the deeper problems that exist in the medical system. The medical system and social structure are constantly being updated, the promotion of urbanization, the implementation of the new rural cooperative medical system, and the forward shift of public health tasks …… many factors have made many changes in the work and life of village doctors, and above them, from township health centers to district and county hospitals, medical associations and medical communities have been established one after another, and the new large triple A The hospital district has opened up to the remote suburbs, and deeper reforms are changing the ecology of primary care.

According to the information provided by the interviewers and the villages they visited, the most recent epidemic in the countryside peaked in mid-December last year and fell back in the following ten days or so, and few patients came to the door after the Spring Festival holidays. When interviewing village doctors, the sound of traffic and firecrackers on the street was faintly audible. Occasionally, conversations were interrupted by visitors who came to the hospital with gifts or food to show their appreciation and follow-up. A number of township health center directors also told reporters that the health center ran smoothly during the Spring Festival, with no increase in febrile patients, and that the doctors on duty could cope.

On January 30, at a press conference on the State Council’s joint prevention and control mechanism, Mi Feng, spokesman for the National Health Commission and deputy director of the propaganda department, said that rural areas are still the top priority for the prevention and control of the current epidemic.

Village doctor

Zhang Xinjun, a village doctor in Xiaoleishan village, Chengui town, Hubei province, got about 13,000 yuan in public health subsidies last year, and some more will be issued perhaps after the year. “But overall not as much as in 2021, the year the state subsidies were issued 30,000 yuan.” According to him, the amount of the subsidy is linked to the population, and the subsidy became less because it was previously calculated on the basis of a household population of 4,200, which was later changed to a permanent population of 2,600. “The population allocated to me is decreasing, and some of them are allocated to community health service centers.”

Zhang Xinjun has been a village doctor for 27 years, and has been rooted longer than his other two colleagues, and the surrounding villagers are more willing to choose to see a doctor with him. This kind of stable patients relying on the accumulation of time or the level of medical skills, locally known as “country foot”, that is, relying on the resources accumulated by walking in the countryside. The more country feet there are, the more famous the doctor is and the higher the income is likely to be.

Chengui town is a wealthy town in Erdong, which is always among the top 1,000 towns in China. Zhang Xinjun’s annual income before the epidemic can be up to 100,000 yuan up and down, higher than the local average, and among the local group of village doctors. But many rural doctors in their 30s and 40s are trying to find ways to get a license to practice medicine and then go to the town health center for a job. “I took the exam last year, too, and missed it by 23 points.” He is old, the exam is not his strong point, this year he is ready to fight again. The reason why he wants to “test out” is because he saw the dilemma of this job in his long-term grassroots practice – the rural population is in exodus, fewer and fewer people are coming to see the doctor, and the income level is declining year by year.

In fact, the income from going to work in the town health center is about 70,000 to 80,000 yuan a year, which is not higher than Zhang Xinjun. But Zhang Xinjun feels that the town doctor’s income is stable, and the pension is higher. Village doctors can take 6,000 yuan a year after retirement pension, while town doctors can take four or five thousand dollars a month after retirement, a pension of 50,000 to 60,000 yuan. Out of pessimism about the future of the industry, Zhang Xinjun did not let his son become a village doctor, and he chose to go to a private hospital in Wuhan.

The dozens of interviewees interviewed by First Financial constitute the main portrait of contemporary village doctors: middle-aged and elderly men, graduates of health schools, practicing medicine for more than 20 years, consulting in health rooms with a dozen or so infusion seats or in their own homes, radiating hundreds to thousands of villagers around, and undertaking more than ten public health services together with village and town health offices, with few young people taking over. During the visit, the reporter also met young, short time in practice, and even female village doctors, but the vast majority said they did not plan to village doctors as a long-term career.

Chen Guizhen Ruiyun Chinese Medicine Hall chairman Zhang Cong previously served as an attending physician in a public hospital, two years ago returned to take over the family’s Chinese medicine industry. His great-grandfather Zhang Ruiyun was a barefoot doctor who became a well-known veteran herbalist and founded this famous Chinese medicine hall in the area. He told China Business News that “the probability of becoming a famous doctor of the generation by being a village doctor is much smaller in this era.” But he noted that master TCM practitioners have been doing well in recent years, and some TCM practitioners with specialist expertise can take on apprentices to teach and gain national recognition. “The master must have a license to practice medicine and reach a certain level before accepting apprentices. After leaving the division to take the unified examination, after passing can practice medicine at the local level.”

The reporter visited and found that the reason why older village doctors like Zhang Xinjun still want to “test out”, young village doctors do not want to take root for a long time, because they also have their own practical difficulties, especially in the case of limited resources and levels, their ability to take risks is also much lower than that of the higher hospitals.

Zhang Xinjun said that last year a patient was not cured here in him, transferred to the town health center also did not cure, and finally cured in a higher hospital, the patient claimed 5,000 yuan from him. “Two years ago the town also appeared in the village doctor after the injection of the patient died in the case, and finally lost all their money to pay people. The emergence of these disputes is not necessarily a village doctor diagnosis problems, and now many doctors are increasingly afraid to see patients.” And in the use of drugs, many village doctors reflect that the procurement platform base drug species are too few to meet the needs of villagers to see the doctor.

Health center

The town health center is like a walled city, outside Zhang Xinjun wants to go in, inside Liu Hongxia wants to come out.

Liu Hongxia worked in a remote township health center in Shanxi, after the liberalization and did not have to deal with the embarrassing experience of a large number of fever cases at home. “Three or five patients come to see the doctor every day, and more patients come to get medicine for common diseases.” As a clinical medicine student in directed training, she was assigned to this health center with a dozen people on staff after 3 years of training, and immediately experienced 3 years of epidemics. She soon found that not many people chose to visit them in this township with a resident population of over 3,000, and her work centered around public health work such as nucleic acid testing, vaccination, and science education. This is a far cry from her original intention of joining clinical medicine.

A number of township health directors told reporters that the health center ran smoothly during the Spring Festival, with no increase in febrile patients, and that the doctors on duty could cope.

In the positioning of the three-tier health network, community health service centers (stations), township health centers and village health offices are responsible for providing basic medical services for residents in their areas, as well as undertaking basic public health services. The secondary and tertiary general hospitals mainly provide outpatient and inpatient medical services.

According to the process of graded treatment, patients will complete their first consultation with them, they judge whether to send them to higher level hospitals for treatment according to their conditions, and they also need to follow up with patients after treatment is completed. But in reality, Liu Hongxia said, “there is no such process.

“First, we have a lot of mountain roads here, it is not convenient to come to the health center; second, there are almost no serious emergencies, come to the headache and brain fever, there are problems directly to the county. People also know that the health center (medical) conditions are limited, basically will not consider coming here; third, many elderly people here are not willing to do routine medical examinations, and do not want to take medication when they have high blood pressure. So if there is no epidemic, in fact, this job is very leisurely.” Liu Hongxia introduced.

Limited conditions, specifically in: auxiliary examination equipment only an X-ray machine, only clinical doctors sometimes go to do a do, “and often can not come out of the film”; commonly used drugs procurement cycle as fast as a month, as long as six months, so spend more than an hour to come here patients may not be able to buy the drugs needed.

The reporter obtained a regional “health centers, community health service centers to implement the basic drug system performance evaluation score sheet” shows that the evaluation of primary medical institutions, “the proportion of essential drugs equipped and used”, the heaviest score, 20 points. The institutions are required to consult the relevant data of the provincial centralized drug procurement platform, the proportion of the total amount and variety of essential drugs should reach 75% and 80% respectively of the total amount of drug procurement for the year, and 2 points will be deducted for each 1% lower proportion that does not meet the standard. The second in line is the prescription review, accounting for 15 points.

And Liu Hongxia different, a large number of districts, township health center workload is very heavy, in addition to the basic medical treatment, but also need to do a lot of popular science promotion, health file establishment and regular medical checkups, and generally operating pressure.

A health center director in Hunan bluntly told reporters, “Human energy is limited, I have to do more than 60 science lectures a year, (the last two or three years also) to go to the isolation hotel stationed, the spirit of the document from above is too much, the grassroots implementation of various policies difficult to focus.”

He said, “It is not uncommon for the primary health care system to run in debt, many local health centers can’t even pay their salaries, and some local finances fail to achieve full or differential funding. Everyone has taken on heavy public health tasks in the past few years, and when the leaders can’t make more benefits for them, the work is done very passively.” He also said that his health center is a self-supporting unit, although it is non-profit nature, but the usual health insurance port access, secondary hospital system access, medical waste sorting labels, etc. are expenses, in addition to financial underwriting the source of income is relatively limited.

According to the division of the three types of government institutions, public welfare class I, public welfare class II and public welfare class III correspond to the full financial allocation, differential funding and self-supporting units, respectively. The specific division of community health service centers and town hospitals also differs according to the effectiveness or the actual situation of each region, such as the implementation of the “public welfare category one guarantee, public welfare category two management (incentive)” in some regions.

According to a research report by the China Health Development Research Center of Peking University in November last year, in a city in Shandong Province, for example, the primary health service institutions are in a loss-making state as a whole, and institutions with strong medical business and public health services at a low to medium level have achieved a balanced income and expenditure and a slight balance, but institutions covering a large population and more basic public health services still have higher expenses than income.

In terms of physician promotion, differences in staffing sometimes hinder the upward flow of township physicians. A grassroots health director reflected that doctors who are self-supporting in the health center, want to go to a fully or differentially funded secondary hospital or health department, there is a lack of equivalence in the establishment.

Liu Hongxia’s town health center, there are not many young people. Many of them are health school graduates, think that this job less things close to home. And like Liu Hongxia such as undergraduate directed medical students, after completing the contracted work years want to escape, even at the expense of breaking the contract to escape the unit is not a few. They are either enrolled in graduate school or working hard to work in hospitals above the county level.

And a grassroots doctor told the First Financial Reporter that the promotion of township health center staff requires some luck, such as waiting for the expansion of higher-level hospitals and the introduction of talent, “If township doctors actively take the examination and get the qualification of associate high or attending or above, it is easier to enter higher-level hospitals. In the medical association system doctors flow up and down more smoothly, there are also township health dean because of the ability to be mentioned in higher hospitals”.

Medical consortium

At the peak of the epidemic, primary care resources were once strained, and many doctors were not familiar with the methods of judging minor and serious illnesses and using medical drugs. To some extent, this was also related to the fact that they had long been restricted in their treatment work.

From the point of view of medical reform, the majority of consultations for the general public should be done at county hospitals and below, which are more financially underwritten and have a higher reimbursement rate than large hospitals, thus alleviating the problem of medical cramming in large hospitals. However, from the actual case, on the one hand, with the development of transportation as people’s income level increases and health awareness grows, primary care in some townships has been marginalized. On the other hand, the current medical system for primary care doctors to make strict restrictions on the use of medical drugs, which put an end to the occurrence of indiscriminate prescription of drugs, astronomical medical events, standardize the construction of primary care, but in practice also more or less tied the hands of primary care doctors: in order to avoid medical disputes, primary care doctors sometimes directly recommended to transfer to higher hospitals; patients to prescribe drugs are sometimes told that the stock is insufficient. Over time, some patients lose trust in village medicine and even district hospitals, and the effect of graded treatment is naturally not achieved.

“Many people have a misconception that doctors are all-powerful.” Since 2020, Hao Nan has been doing civil New Crown out-of-hospital aid work for three years, and he initiated the NCP (New Crown) Life Support Network, which has become an important civil triage force. Hao Nan worked as a dentist at Peking University, and after three years of out-of-hospital aid work, he knows how difficult it is to learn the treatment guidelines, “You ask a surgeon to do the dispensing of fluids and to adjust the ventilator, and it is actually as far apart as a mountain.”

Cao Pingan told reporters that he has followed the Beijing Good Medical Practice Village Medical Support Center in recent years to learn appropriate techniques for Chinese medicine, twice with the class, dozens of large class training, respectively, in Hebei, Henan, Beijing, Sichuan, Yunnan and other places to learn, and as assistant teachers to train rural doctors in remote areas.

The profit and loss level of primary care institutions is influenced by at least two variables – medical operational capacity and the volume of basic public health services. So can improved medical practice capacity attract more patients to primary care and break the logjam of primary care?

The medical association and medical community models have been actively explored by local governments in recent years. In other words, through the integration of regional medical resources, led by high-level hospitals, through the sinking of experts to grassroots hospitals, resource sharing, etc. to establish the mechanism of primary care, two-way referral, acute and slow treatment, up and down linkage. 2019 adopted the Basic Medical Health and Health Promotion Law, Article 30 provides that local people’s governments above the county level, according to the medical and health needs of the administrative region, integrate the regional government-run medical and health resources, and establish medical consortia and other collaborative and linked medical service cooperation mechanisms according to local conditions.

In some areas, grassroots medical personnel said that the sinking of experts has established a stronger specialist level for them, and the mutual recognition of medical records and green channels for referrals are also smoother; while some doctors said that medical consortia are good things, but they take a long time to establish and have little impact on them as far as they are concerned.

“Every hospital and even every department has a book, and their own hospitals are too busy to help themselves, so how can they selflessly divide their resources to help the grassroots hospitals?” A chief physician at a tertiary hospital in a city in Hubei told reporters that their hospital and a local maternal and child hospital are medical consortium units, but no links have been established in terms of administration, finance or even referrals. “Women’s and children’s units enjoy state financial subsidies, and in terms of interest, they (women’s and children’s hospitals) have no subjective initiative to join forces with us.”

Dr. Wu of a district health service center in the city told reporters about the other side of the construction of the local medical association. in 2017, the health service center and the above-mentioned tertiary hospital had reached an agreement in which tertiary hospital personnel were parachuted in to manage the health service center and provided annual financial support of 200,000 yuan, with experts sinking every Monday, Wednesday and Friday. However, two or three years later, the terms of the agreement were not implemented, the parachuted leaders returned to their original units, and everything was left unresolved. During this period, the local medical association leaders fell due to corruption, the matter of medical association in the grassroots hospital is no one mentioned again.

“Medical association is a good thing, in order to the senior resources down, but now many local hospital leaders do not know how to engage in, into our general hospital here to control the source of disease in the village health room below, the interests of other tertiary hospitals are compromised. The lower hospitals get their fees by referral and don’t bother to see patients.” A grassroots doctor who is a CPPCC member somewhere in central China told reporters that at CPPCC meetings, there is no shortage of delegates who bluntly suggest to the local secretary that the local general hospital be abolished.

Hospital interests, personnel relations, establishment differences, local finances …… a series of key words make the construction of medical association stagnate in some places. However, there are some places that have outstanding results in the reform of graded treatment, such as Sanming, Fujian.

“Graded diagnosis and treatment has been well resolved in our Sanming, with the proportion of hospitalization volume reaching more than 68% at the county level and the proportion of grassroots treatment reaching 58% last year, which is still a beautiful figure.” A relevant person in charge of Sanming told Firstrade that Sanming’s medical reform is not quite the same as other places, as the local general hospital was formed in 2017 to form a medical community with shared responsibility and shared benefits with a high degree of unity of county and village, human and financial resources. “We are not integrating for the sake of integration, but for the needs of the health care reform. The county hospital will not go and grab food from the township health center, it’s all one account and one heart.”