Strengthening China's National Essential Public Health Services Package for hypertension and diabetes care: protocol for an interrupted time series study with mixed-methods process evaluation and health economic evaluation.

BACKGROUND: Despite major primary health care (PHC) reforms in China with the 2009 launch of the National Essential Public Health Service Package, the country experiences many challenges in improving the management of non-communicable diseases in PHC facilities. "EMERALD" is a multifaceted implementation strategy to strengthen the management of hypertension and type-2 diabetes mellitus (T2DM) in PHC facilities. The study aims to: (1) examine the effectiveness of EMERALD in improving hypertension and T2DM management; (2) evaluate the implementation of the interventions; and (3) use the study findings to model the long-term health economic impact of the interventions. METHODS: The EMERALD intervention components include: (1) empowerment for PHC providers through training and capacity building; (2) empowerment for patient communities through multi-media health education; and  (3) empowerment for local health administrators through health data monitoring and strengthening governance of local PHC programs. An interrupted time series design will be used to determine the effectiveness of the interventions based on routinely collected health data extracted from local health information systems. The primary effectiveness outcome is the guideline-recommended treatment rates for people with hypertension and T2DM. Secondary effectiveness outcomes include hypertension and T2DM diagnosis and control rates, and enrolment and adherence rates to the recommended care processes in the National Essential Public Health Service Package. A mixed-methods process evaluation will be conducted to evaluate the implementation of the interventions, including the reach of the target population, adequacy of adoption, level of implementation fidelity, and maintenance. Qualitative interviews with policy makers, health administrators, PHC providers, and patients with hypertension and/or T2DM will be conducted to further identify factors influencing the implementation. In addition, health economic modelling will be performed to explore the long-term incremental costs and benefits of the interventions. DISCUSSION: This study is expected to generate important evidence on the effectiveness, implementation, and health economic impact of complex PHC interventions to strengthen the primary care sector's contribution to addressing the growing burden of non-communicable diseases in China. TRIAL REGISTRATION: The study has been registered on Chinese Clinical Trial Registry at https://www.chictr.org.cn/ (Registration number ChiCTR2400082036, on March 19th 2024).

Using routinely collected data to determine care cascades of hypertension and type-2 diabetes management in China: a cross-sectional study.

Background: China's National Essential Public Health Service Package (NEPHSP) aims to promote health for all at the primary health care level and includes a focus on hypertension and type-2 diabetes mellitus (T2DM). However, there are limited contemporary data to quantify the care cascades of hypertension and T2DM in primary health care. Methods: This cross-sectional study involved individual level linkage of routinely collected data from the NEPHSP, health insurance claims and hospital electronic health records, from four diverse regions in China, including Xiling District (central China), Wenchuan County (western), Acheng District and Jiao District (northern). We first compared numbers of people aged ≥35 with a recorded diagnosis of hypertension and T2DM against expected numbers derived from epidemiological data. We then constructed care cascades to assess the percentages (1) enrolled in the NEPHSP, (2) adherent to the follow-up care of NEPHSP, (3) receiving medication treatment, and (4) having hypertension and/or T2DM controlled. Findings: In the four regions, the total numbers of people aged ≥35 diagnosed of hypertension and T2DM from any data source were 149,176 and 50,828, respectively. This was estimated to be 46.0% (95% confidence interval [CI]: 45.8%-46.2%) and 45.6% (95% CI: 45.3%-45.9%) of the expected totals for hypertension and T2DM, respectively. Among those diagnosed, 65.4% (95% CI: 65.1%-65.6%) with hypertension and 66.1% (95% CI: 65.7%-66.5%) with T2DM were enrolled in the NEPHSP, respectively, in which 54.8% (95% CI: 54.5%-55.2%) with hypertension and 64.7% (95% CI: 64.1%-65.2%) with T2DM were adherent to the required services. Among those enrolled, the overall treatment rates were 70.8% (95% CI: 70.6%-71.1%) for hypertension and 82.2% (95% CI: 81.8%-82.6%) for T2DM. Among those treated, a further 80.9% (95% CI: 80.6%-81.2%) with hypertension and 73.9% (95% CI: 73.3%-74.4%) with T2DM achieved control. These results varied considerably across regions, with the northern sites showing relatively higher enrolment rates while the central site had higher control rates. Interpretation: Detection and control rates for hypertension and T2DM are suboptimal in these four regions of China. Further strategies are needed to improve people's enrolment in and adherence to the NEPHSP and strengthen care delivery processes. Of note, our estimations of the diagnosis rates for each region are based on national level large epidemiological data. The interpretation of these data needs caution due to potential bias caused by regional variations. Funding: This study is funded by National Health and Medical Research Council (NHMRC) Global Alliance for Chronic Diseases funding (APP1169757), and National Natural Science Foundation of China (72074065).

Co-designing interventions to strengthen the primary health care system for the management of hypertension and type 2 diabetes in China.

Background: Policy makers and researchers are tasked with exploring ways to strengthen primary health care (PHC) to address the growing burden of non-communicable diseases (NCDs). This study aims to use a co-design approach (i.e., meaningful involvement of research end users in study planning and design) to develop PHC interventions to improve the management of hypertension and type 2 diabetes (T2DM) in four study sites in China. Methods: The study adopted a three-step co-design approach, including (1) a two-round Delphi panel with health system and NCD professionals to identify prioritised health system challenges, (2) three co-design workshops (in each study site) with local health administrators, PHC providers, and residents with hypertension and/or T2DM, respectively, to develop interventions and identify factors influencing implementation, and (3) another round of co-design workshops with local health administrators to summarise findings and reach consensus. Qualitative synthesis was conducted to analyse results from the workshops. Findings: Thirteen experts were involved in the two-round Delphi panel, which identified three prioritised health system challenges, including limited capacities of PHC providers, suboptimal service quality and evaluation mechanisms, and unreliable health information systems. The co-design workshops involved 116 local stakeholders in 16 sessions (four in each site), and developed three groups of interventions to address the challenges: (1) empowering PHC providers through on-the-job training for capacity building; (2) empowering patient communities through health education on healthy lifestyles and NCD self-management; and (3) empowering health administrators through local health data monitoring and strengthening governance for local PHC programs. Site-specific interventions were also considered to cater for different local contexts. Several recommendations were further identified for the implementation of these interventions, emphasising the importance of local customisation, community participation, and cross-sectoral collaborations. Interpretation: By engaging multiple stakeholders in priority setting and solution generation, this study summarised several key areas for change in health workforce, service delivery, and health information. Future research should examine the effectiveness and implementation of these interventions to improve NCD management in PHC in China. Funding: This study is funded by National Health and Medical Research Council (NHMRC) Global Alliance for Chronic Diseases funding (APP1169757) and National Natural Science Foundation of China (72074065). Shangzhi Xiong is supported by University of New South Wales tuition fee scholarship.

Factors associated with the uptake of national essential public health service package for hypertension and type-2 diabetes management in China's primary health care system: a mixed-methods study.

Background: China launched the primary health care (PHC) system oriented National Essential Public Health Service Package (NEPHSP) in 2009, to combat health challenges including the increasing burden from hypertension and type-2 diabetes (T2DM). In this study, the PHC system was assessed to understand factors influencing the uptake of the NEPHSP for hypertension and T2DM management. Methods: A mixed-methods study was conducted in seven counties/districts from five provinces across the mainland of China. Data included a PHC facility level survey and interviews with policy makers, health administrators, PHC providers, and individuals with hypertension and/or T2DM. The facility survey used the World Health Organisation (WHO) service availability and readiness assessment questionnaire. Interviews were thematically analysed using the WHO health systems building blocks. Findings: A total of 518 facility surveys were collected with over 90% in rural settings (n = 474). Forty-eight in-depth individual interviews and 19 focus-group discussions were conducted across all sites. Triangulating the quantitative and qualitative data found that China's continuous political commitment to strengthening the PHC system led to improvements in workforce and infrastructure. Despite this, many barriers were identified, including insufficient and under-qualified PHC personnel, remaining gaps in medicines and equipment, fragmented health information systems, residents' low trust and utilization of PHC, challenges in coordinated and continuous care, and lack of cross-sectorial collaborations. Interpretation: The study findings provided recommendation for future PHC system strengthening, including improving the quality of NEPHSP delivery, facilitating resource-sharing across health facilities, establishing integrated care systems, and exploring mechanisms for better cross-sectorial engagement in health governance. Funding: The study is supported by National Health and Medical Research Council (NHMRC) Global Alliance for Chronic Disease funding (APP1169757).

Primary health care system responses to non-communicable disease prevention and control: a scoping review of national policies in Mainland China since the 2009 health reform.

This study aims to review China's national policies related to non-communicable disease (NCD) prevention and control at the primary health care (PHC) level since China's 2009 health system reform. Policy documents from official websites of China's State Council and 20 affiliated ministries were screened, where 151 out of 1,799 were included. Thematic content analysis was performed, and fourteen 'major policy initiatives' were identified, including the basic health insurance schemes and essential public health services. Several areas showed to have strong policy support, including service delivery, health financing, and leadership/governance. Compared with WHO recommendations, several gaps remain, including lack of emphasis on multi-sectoral collaboration, underuse of non-health-professionals, and lack of quality-oriented PHC services evaluations. Over the past decade, China continues to demonstrate its policy commitment to strengthen the PHC system for NCD prevention and control. We recommend future policies to facilitate multi-sectoral collaboration, enhance community engagement, and improve performance evaluation mechanisms.