Effectiveness of specialist involvement in case discussion conferences with primary healthcare providers on the management of type 2 diabetes patients: a study protocol for a cluster randomized controlled trial.

BACKGROUND: In supporting primary healthcare in delivering high-quality care for individuals with type 2 diabetes mellitus (T2DM), previous research emphasized strategies to facilitate communication and collaboration between primary healthcare providers and hospitals. This study aims to evaluate the effectiveness of case discussion conferences between specialists from hospitals and primary healthcare providers in China on the optimization of diabetes management and the improvement of patient health outcomes. METHODS: This study will be a parallel cluster randomized controlled trial in which primary healthcare institutions in Shouguang city and Shangsi County will be randomly allocated to the intervention and control groups. The intervention will involve regular case discussion conferences where attendants will meet to discuss complex cases with patients diagnosed with type 2 diabetes mellitus, exchange experiences, and seek and provide expert advice. Family doctor teams from primary healthcare institutions and specialists from secondary or tertiary hospitals will engage in these conferences. Data will be collected at baseline and at the 6- and 12-month follow-ups. The primary clinical outcome measures will focus on the changes in the HbA1c and FBG levels of patients under management. The secondary outcomes will include other physiological indicators, such as blood pressure, BMI, and cholesterol. The evaluation will extend to changes in the capabilities and behaviors of primary healthcare providers. Furthermore, the feasibility and adherence of this intervention will be thoroughly assessed. DISCUSSION: This study is designed to generate robust evidence on the effectiveness of case discussion conferences, an interprofessional collaboration strategy, in enhancing diabetes care delivery in primary healthcare, with the ultimate goal of improving patient health outcomes. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2300078829. Registered on December 19, 2023. https://www.chictr.org.cn/showproj.html?proj=210293.

Preferences and Willingness to Pay for Herpes Zoster Vaccination Among Chinese Adults: Discrete Choice Experiment.

BACKGROUND: The incidence of herpes zoster (HZ) is rapidly increasing, causing both clinical and economic burdens in China. Very little is known about Chinese residents' HZ vaccine preferences and willingness to pay (WTP) for each vaccination attribute. OBJECTIVE: This study aims to elicit the preferences of Chinese urban adults (aged 25 years or older) regarding HZ vaccination programs and to calculate WTP for each vaccination attribute. METHODS: In this study, we interviewed 2864 residents in 9 cities in China. A discrete choice experiment was conducted to investigate the residents' preferences for HZ vaccination and to predict the uptake rate for different vaccine scenarios. A mixed logit model was used to estimate the preferences and WTP for each attribute. Seven attributes with different levels were included in the experiment, and we divided the coefficients of other attributes by the coefficient of price to measure WTP. RESULTS: Vaccine effectiveness, protection duration, risk of side effects, place of origin, and cost were proven to influence Chinese adults' preferences for HZ vaccination. The effectiveness of the HZ vaccine was the attribute that had the most predominant impact on residents' preferences, followed by protection duration. The residents were willing to pay CN ¥974 (US $145) to increase the vaccine effectiveness from 45% to 90%, and they would barely pay to exchange the vaccination schedule from 2 doses to 1 dose. It is suggested that the expected uptake could be promoted the most (by 20.84%) with an increase in the protection rate from 45% to 90%. CONCLUSIONS: Chinese urban adults made trade-offs between vaccine effectiveness, protection duration, place of origin, side effects, and cost of HZ vaccination. Vaccine effectiveness was the most important characteristic. The residents have the highest WTP (CN ¥974; US $145) for enhancing the effectiveness of vaccines. To maximize HZ vaccine uptake, health authorities should promote vaccine effectiveness.

Trends in resource allocation for primary health care in rural China: Concentration curve and decomposition analysis.

Since 2009, China has made large investments in strengthening the primary healthcare system. This study aimed to examine the trends in the number and distribution of health resources in rural China following the health system reform and to decompose the sources of inequalities. Data were collected from standardized reports compiled by each county in rural China and compiled by the National Health Commission and Bureau of Statistics. From the findings of this empirical study, resource allocation per capita for primary health care (PHC) improved gradually from 2008 to 2014. The distribution of beds across counties (ranked by level of economic development) was relatively equitable. However, the concentration curve analysis indicated that the distribution of primary care professionals remained skewed in favour of wealthier and more urbanised counties. Economic status was proved to be a major contributor to the inequality of health human resource. China's primary care reforms resulted in simultaneously improved supply of PHC resources as well as pro-rich inequality in distribution of the workforce. To advance equality in health resource allocation, greater attention should be paid to the substantial inequality of economic status within counties.

Primary care providers' preferences for pay-for-performance programs: a discrete choice experiment study in Shandong China.

BACKGROUND: Pay-for-performance (P4P) schemes are commonly used to incentivize primary healthcare (PHC) providers to improve the quality of care they deliver. However, the effectiveness of P4P schemes can vary depending on their design. In this study, we aimed to investigate the preferences of PHC providers for participating in P4P programs in a city in Shandong province, China. METHOD: We conducted a discrete choice experiment (DCE) with 882 PHC providers, using six attributes: type of incentive, whom to incentivize, frequency of incentive, size of incentive, the domain of performance measurement, and release of performance results. Mixed logit models and latent class models were used for the statistical analyses. RESULTS: Our results showed that PHC providers had a strong negative preference for fines compared to bonuses (- 1.91; 95%CI - 2.13 to - 1.69) and for annual incentive payments compared to monthly (- 1.37; 95%CI - 1.59 to - 1.14). Providers also showed negative preferences for incentive size of 60% of monthly income, group incentives, and non-release of performance results. On the other hand, an incentive size of 20% of monthly income and including quality of care in performance measures were preferred. We identified four distinct classes of providers with different preferences for P4P schemes. Class 2 and Class 3 valued most of the attributes differently, while Class 1 and Class 4 had a relatively small influence from most attributes. CONCLUSION: P4P schemes that offer bonuses rather than fines, monthly rather than annual payments, incentive size of 20% of monthly income, paid to individuals, including quality of care in performance measures, and release of performance results are likely to be more effective in improving PHC performance. Our findings also highlight the importance of considering preference heterogeneity when designing P4P schemes.

Willingness to vaccinate against herpes zoster in Chinese urban population: a mixed-methods study.

OBJECTIVE: Although the herpes zoster vaccine has been available in mainland China since June 2020, residents' knowledge of herpes zoster and the herpes zoster vaccine is poor, and vaccination rates are low, especially among the elderly, who are at high risk for herpes zoster. This study assessed willingness to be vaccinated against herpes zoster and factors associated with vaccination among urban residents in China. METHODS: A mixed-methods study was conducted in community health centres from August 2022 to September 2022. We used convenience sampling to select 2864 residents from 9 Chinese cities for the quantitative study and 67 adults for the qualitative study. A structured questionnaire was used for the quantitative study, and data were collected through face-to-face interviews. Multinomial logistic regression was used to analyse factors associated with willingness to vaccinate. Qualitative data were analysed using thematic analysis of barriers to herpes zoster vaccination. RESULTS: A total of 2864 eligible respondents were included in the study. Of these, 42.67% intended to receive the herpes zoster vaccine, 21.44% refused and 35.89% were hesitant. The results of the quantitative and qualitative analyses showed that the factors associated with respondents' willingness to be vaccinated against herpes zoster included: personal characteristics such as gender, age and income; knowledge and attitudes about herpes zoster and the vaccine; vaccine characteristics such as efficacy, safety and price; and other factors such as pain tolerance and accessibility to vaccination. CONCLUSION: The low willingness to vaccinate, especially among the elderly, is mainly related to their poor knowledge and negative attitude towards the infection and vaccination. Therefore, health education about herpes zoster, immunisation promotion, and improvement of accessibility and affordability would be valuable in China.

Study on the determinants of health professionals' performance on diabetes management care in China.

BACKGROUND: As the direct providers of diabetes management care in primary health care facilities (PHFs) in China, health professionals' performance on management care of diabetes determines the quality of services and patients' outcomes. This study aims to analyze the key determinants of health professionals' performance on diabetes management care in PHFs in China. METHODS: We conducted a cross-sectional study in 72 PHFs in 6 cities that piloted the contracted family doctor service (CFDS). Self-developed questionnaire was used to measure three kinds of factors (capacity, motivation and opportunity) potentially influencing the performance of health professionals. The performance of diabetes management care in the study was measured as whether health professionals delivered 7 service items required by the National Basic Public Health Service Guideline with a total of 7 points and was divided into three grades of good, medium and bad. The questionnaire is self-administered by all the health professionals involved in the study with the number of 434. The Chi-square tests were used to compare differences of performance on diabetes management care among health professionals with different characteristics. The ordinal logistic regression was used to analyze the determinants on the performance of diabetes management care. RESULTS: Health professionals who got higher score on diabetes knowledge test had odds of better performance on diabetes management care (OR = 1.529, P < 0.001). health professionals with higher degree of self-reported satisfaction on training (OR = 1.224, P < 0.05) and perception of decreasing workload (OR = 3.336, P < 0.01) had odds of better performance on diabetes management care. While health professionals with negative feeling on information system support had odds of worse performance on diabetes management care (OR = 0.664, P < 0.01). CONCLUSIONS: Attention should be paid to the training of health professionals' knowledge on diabetes management capacity. Furthermore, measures to improve training for health professionals could satisfying their needs for self-growth and improve the motivation of health professionals. The information system supporting management care should be improved continuously to improve the health professionals' working opportunities and decrease the workload.

Continuity of health care: measurement and application in two rural counties of Guangxi Province, China.

BACKGROUND: Continuity of care (COC) is highly regarded in health promotion and health system strengthening. However, there is a lack of multidimensional quantitative assessment of continuity, making it challenging to evaluate and compare. Our objective was to create a novel measurement for COC and apply it in two rural counties in China to assess its validity and feasibility in evaluating health system reform. METHOD: This study conducted a scoping literature review on COC, examining existing frameworks and indicators. Following an online expert poll, a composite indicator was developed using the analytical hierarchy process (AHP). The measurement tool was then applied to assess the current state of COC in two rural counties in China. In addition to descriptive analysis, demographic and economic characteristics were analyzed for their association with COC scores using t-tests and multiple linear regression models. RESULTS: The final COC measurement encompasses three dimensions, six sub-dimensions, and ten individual indicators, which integrated and improved the current frameworks and indicators. Relational continuity, informational continuity, and management continuity were identified as the primary dimensions of COC measurement. The COC score is 0.49 in County A and 0.41 in County B, with information continuity being the highest-scoring dimension. Notably, the disparity in continuity scores is most pronounced among individuals with varying attitudes towards health, demonstrating a positive correlation. CONCLUSION: The construction of the composite indicator in this study offers a scientific and effective metric for comprehensively measuring continuity of care. The empirical data analysis conducted in Western China serves as an illustrative application of the indicator, demonstrating its efficiency. The results obtained from this analysis provide a solid foundation and valuable reference for strengthening the health system.

Correlation between input on public health services and work motivation among primary health workers in China.

BACKGROUND: The integration of public health services into primary health care has been advocated and practiced worldwide for better management of preventable diseases. Health policy makers in China have started the reforms to better integrate public health services and clinical services, but public health services in China still remained neglected in primary health system. This study aimed to explore the input of Chinese primary health workers on delivering public health services and its association with their intrinsic working motivation in China. METHODS: Data were collected from a cross-sectional survey conducted in 2019. Participants in this survey included 803 primary health workers in 75 primary health institutions in China. Questions about the input on clinical and public health services delivery and intrinsic working motivation were asked. A multiple linear regression model was adopted to investigate the correlation between intrinsic working motivation and the time input on public health service. The robustness of this model was checked with a generalized linear model. RESULTS: Intrinsic motivation was found to have negative association with health workers' input on public health (ß: -1.01, p < 0.05), with the robustness checked with a generalized linear model. The significance of this association differed in the group of urban community health centers and rural township health center. Other factors that had significant relationship with the input on public health services include the being nurses instead of doctors (p < 0.01), being a member of family doctor team (p < 0.01), recognition on relative importance of clinical services (p < 0.01), and perception on better exterior support (p < 0.01). CONCLUSION: With higher intrinsic working motivation, primary health workers tended to spend less time on public health services. It reflected that doctors and nurses in primary healthcare institutions still perceived clinical treatment services as their main work responsibility and source of career recognition. Organizational level supports and system level policies should guide the primary health workers to increase their awareness on the importance of public health services and to cultivate their internal interests on public health services, in order to ensure sustainable input and performance improvement on public health services in primary health system in China.

The Association Between Financial Incentives and Job Performance Among Primary Care Providers in Six Provinces of China.

Objective: This study aims to explore the association between financial incentives and job performance of primary care providers (PCPs) from a nationally representative survey in China. Methods: This is a cross-sectional study conducted in six provinces of China in 2019. A sample of 1388 PCPs participated in the survey was selected using a stratified cluster sampling method. A self-administered questionnaire composed of socio-demographic, work-related characteristics, financial incentives received by PCPs and their job performance was used. The association between financial incentives and job performance are analyzed using logistic regression model. The significance level for statistics is set at P < 0.05. Results: The PCPs with higher real income level have lower contextual performance (OR = 0.67, p < 0.01) and learning performance (OR = 0.63, p < 0.01) than those with lower real income level. The PCPs with the expectation of income rising above 50% have lower contextual performance (OR = 0.66, p < 0.05) than those with the expectation of income rising above 20%. The PCPs with preference for monetary income have lower task performance (OR = 0.62, p < 0.01), contextual performance (OR = 0.55, p < 0.01) and learning performance (OR = 0.57, p < 0.01) than those without lower preference for monetary income. The percent of performance-based income has no significant effect on all the three dimensions of job performance. Conclusion: Financial incentive was regarded as the most important motivating factor of PCPs in China, but existing financial incentives received by PCPs could not improve their job performance. The findings can be attributed to the unsatisfying total income level, "intrinsic motivation crowding out" effect, and the poorly designed performance-based salary system for PCPs. Policy attention is called for to continuing efforts and system reform to increase the total income level for PCPs in China, and improve the performance-based salary system to better motivate PCPs and improve their job performance.

A guideline for economic evaluations of vaccines and immunization programs in China.

This study aimed to develop a consensus framework for economic evaluations of vaccines as a national guideline in China. Some unique and important aspects were particularly emphasized. Nineteen Chinese experts in the field of health economics and immunization decision-making were nominated to select and discuss relevant aspects of vaccine economic evaluations in China. A workshop attended by external experts was held to summarize unique and important aspects and formulate consensus recommendations. There were ten unique and/or important aspects identified for economic evaluations of vaccines in China, including study perspectives, comparator strategies, analysis types, model choices, costing approaches, utility measures, discounting, uncertainty, equity, and evaluation purposes. Background information and expert recommendations were provided for each aspect. Economic evaluations of vaccines should play an important role in China's immunization policy-making. This guideline can help improve the quality of economic evaluations as a good practice consensus.

Incentives Promoting Contracted Family Doctor Service Policy to Improve Continuity and Coordination in Diabetes Patient Management Care in China.

Background: As the first step toward building a gatekeeping system in China, the governments have introduced a contracted family doctor service (CFDS) policy in primary healthcare (PHC) facilities. This study was to examine the association between apply of incentive to improve the implementation of CFDS and the performance on diabetes management care. Methods: We conducted a cross-sectional study in 72 PHC facilities in 6 cities that piloted the CFDS. Multivariate regression models were applied, based on a sample of 827 PHC providers and 420 diabetic patients. Results: PHC providers who reported the performance being linked with increased income were 168.1 and 78.0% more likely to have good continuity and coordination of diabetes patient management care, respectively. Additional one-point percentage of PHC providers whose performance on CFDS was assessed was associated with 7.192 times higher probability of patients with control of blood glucose. Discussion: Inclusion of incentives rewarding better performance on CFDS were associated with better delivery process and outcome performance on diabetes management care. Conclusion: Design and implementation of the incentive should be accompanied with the policy of CFDS, in order to increase the proportion of performance-related income of PHC providers, thereby improving the quality of diabetes management care.

Work Motivation of Primary Health Workers in China: The Translation of a Measurement Scale and Its Correlation with Turnover Intention.

Background: High turnover intention, as a manifestation of low work motivation, is a crucial barrier to strengthening primary health systems worldwide, including in China. Targeting those being less motivated will be a realistic choice to retain primary health workers. This study translate, adapt, and validate the Work Motivation Scale for Health Workers (WMSHW) scale to directly measure and rate health workers' motivation composition based on Self-Determination Theory, and assessed how health workers with different levels of motivation being associated with the turnover intention. Methods: The process of translation and cross-cultural adaptation followed the recommendations of international guidelines. Participants include 1341 health workers within 75 primary health institutions from 6 provinces in China. The reliability and validity of the scale was analyzed. Cluster analysis in a person-centered approach and logistic regression analysis was used to understand how different combinations of motivations related to intention to leave. Results: Confirmatory factor analysis indicated that the modified five-factor model had a better fit than the other models in accordance with the original English version. The factor loads were high and ranged from 0.70 to 0.9. Cronbach's alpha coefficients for five dimensions of the Chinese WMSHW ranged from 0.81 to 0.94, indicating the scale's high internal consistency. Four distinct clusters of work motivation were found in this study, representing low motivated, highly controlled, highly autonomous and highly motivated primary health workers. Compared with low motivation group, both controlled and autonomous motivation groups were more likely to have lower turnover intention. The negative relationship between motivation and intention to leave became stronger with the level of motivation increasing: highly controlled cluster (OR: 0.47; 95% CI: 0.35-0.63), highly autonomous (OR: 0.27; 95% CI: 0.18-0.41) and highly motivated (OR: 0.20; 95% CI: 0.15-0.27). Conclusion: The Chinese version of WMSHW showed satisfactory reliability and validity and can be used as an instrument for measuring and rating the work motivation of Chinese health workers. The primary health workers were grouped into four motivation levels based on this scale. Both controlled and autonomous motivation could work in reduce the turnover intention, and the influence of autonomous motivation on retaining was stronger.

An extension of the RIGHT statement for introductions and interpretations of clinical practice guidelines: RIGHT for INT.

OBJECTIVE: The purpose of the extension of the RIGHT Statement for INTroductions and INTerpretations of Clinical Practice Guidelines (RIGHT for INT) is to promote the development of comprehensive and clear articles that introduce and interpret clinical practice guidelines. METHODS: The RIGHT for INT checklist was developed following methods recommended by the EQUATOR Network. The development process included three stages. In the first stage, a multidisciplinary team of experts was recruited by email and WeChat and further divided into three groups (a steering group, a consensus group, and a secretariat group); in the second stage, the initial items were collected by literature review and brainstorming; and in the third stage, the final items were formed through a Delphi survey and expert consultation. RESULTS: A total of 40 initial items were collected through literature review and brainstorming. A final checklist of 27 items was formed after the Delphi survey and expert consultation. The RIGHT for INT checklist contains items on the following 10 topics: title, abstract, background of guideline interpretation, background of guideline development, guideline development methodology, recommendations, strengths, and limitations, implications for local guidelines and clinical research, dissemination and implementation, and reporting quality. CONCLUSION: The RIGHT for INT checklist provides guidance for guideline interpreters on how to introduce and interpret clinical practice guidelines in a scientific and comprehensive manner.

Willingness to accept COVID-19 vaccine among the elderly and the chronic disease population in China.

A cross-sectional field survey was conducted from November 2020 to January 2021 among 7259 participants to investigate the public perception, willingness, and information sources for COVID-19 vaccination, with the focus on the elderly and non-communicable chronic disease (NCD) population. Multiple logistic regressions were performed to identify associated factors of the vaccination willingness. The willingness rate of the elderly to accept the future COVID-19 vaccine (79.08%) was lower than that of the adults aged 18-59 (84.75%). The multiple analysis didn't identify significant relationship between NCD status and the vaccination intention. The main reasons for vaccine hesitancy by the public were: concern for vaccine safety, low infection risk, waiting and seeing others getting vaccinated, concern of vaccine effectiveness and price. Their relative importance differed between adults aged 18-59 and the elderly, and between adults aged 18-59 with or without NCD. Perception for vaccination importance, vaccine confidence, and trust in health workers were significant predictors of the vaccination intention in both age groups. The elderly who perceived high infection risk or had trust in governments were more likely to accept the vaccine. Compared with the adults aged 18-59, the elderly used fewer sources for COVID-19 vaccination information and more trusted in traditional media and family, relatives, and friends for getting vaccination recommendations. To promote vaccine uptake, the vaccination campaigns require comprehensive interventions to improve vaccination attitude, vaccine accessibility and affordability, and tailor strategies to address specific concerns among different population groups and conducted via their trusted sources, especially for the elderly.

Satisfaction of Township Hospitals Health Workers on How They Are Paid in China.

BACKGROUND: Township Hospitals (THs) are crucial providers in China's primary health delivery system. Low job satisfaction of THs health workers has been one of biggest challenges to strengthening the health system in China. Even huge amounts of studies confirmed low remuneration level as a key demotivating factor though few studies have explored the feelings of health workers on how they were paid. OBJECTIVE: To analyze how the key design of Performance-based Salary System (PBS) influences the satisfaction of health workers on the payment system in China's THs. METHOD: A cross-sectional study was conducted in 47 THs in Shandong China, and a total of 1136 participants were recruited. Expectancy theory was applied to design the measurements on designs of PBS. The associations between PBS design and satisfaction of health workers were analyzed by logistic regression. RESULTS: Three key components of PBS design were all related to the satisfaction of health workers. Those health workers who were aware of assessment methods were more likely to be satisfied with how they were paid (OR = 2.44, p < 0.001) compared with those being not aware of the methods. The knowledge on personal performance was also associated with being satisfied (OR = 3.34, p < 0.001). The percentage of floating income in total income was negatively associated with the satisfaction, and one percentage point increase in floating income proportion could result in the possibility of being satisfied decreasing by 2.82% (95%CI -4.9 to -0.7, p = 0.01). Subgroup analysis found that only in those with lower value on monetary income, the negative influence of more floating income was significant. CONCLUSIONS: When policymakers or managers apply performance-related payment to incentivize certain work behavior, they should pay attention to the design details, including keeping transparency in the performance assessment criteria, clear performance feedback, and setting the proportion of the performance-related part based on the preference of health workers in certain cultural settings.

Prevalence and factors associated with hepatitis B virus infection among household members: a cross-sectional study in Beijing.

HBV prevention and control presents a global public health priority because of the tremendous economic and healthcare burdens involved. This study was designed to investigate the status of HBV epidemics among household members, and to analyze the risk factors of HBV infection in couples and their offspring. A total of 1,035 couples and 541 offspring were included. We sourced the data from a population-based serological survey conducted by the Beijing Center for Disease Prevention and Control in 2014. Chi-square test and multiple logistic were used to assess differences in the prevalence of categorical variables, and identify risk factors for HBV infection and exposure in couples and offspring after controlling for confounding factors. In couples, the prevalence of chronic HBV infection was 4.3% and the prevalence of exposure 32.7%. The prevalence of chronic HBV infection in offspring was 0.9%, and the prevalence of exposure 8.7%. Sharing syringes with others and living with a spouse who was infected or exposed to HBV were associated with a significantly higher risk for transmission of HBV for couples. In offspring, maternal HBV infection was a significant risk factor for HBV exposure. This study provides evidence that having household members infected or exposed to HBV increases the risk of HBV transmission, and in order to achieve better control of HBV infection effective strategies must be established to prevent intra-familial transmission.

Payment methods for healthcare providers working in outpatient healthcare settings.

BACKGROUND: Changes to the method of payment for healthcare providers, including pay-for-performance schemes, are increasingly being used by governments, health insurers, and employers to help align financial incentives with health system goals. In this review we focused on changes to the method and level of payment for all types of healthcare providers in outpatient healthcare settings. Outpatient healthcare settings, broadly defined as 'out of hospital' care including primary care, are important for health systems in reducing the use of more expensive hospital services. OBJECTIVES: To assess the impact of different payment methods for healthcare providers working in outpatient healthcare settings on the quantity and quality of health service provision, patient outcomes, healthcare provider outcomes, cost of service provision, and adverse effects. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase (searched 5 March 2019), and several other databases. In addition, we searched clinical trials platforms, grey literature, screened reference lists of included studies, did a cited reference search for included studies, and contacted study authors to identify additional studies. We screened records from an updated search in August 2020, with any potentially relevant studies categorised as awaiting classification. SELECTION CRITERIA: Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies that compared different payment methods for healthcare providers working in outpatient care settings. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We conducted a structured synthesis. We first categorised the payment methods comparisons and outcomes, and then described the effects of different types of payment methods on different outcome categories. Where feasible, we used meta-analysis to synthesise the effects of payment interventions under the same category. Where it was not possible to perform meta-analysis, we have reported means/medians and full ranges of the available point estimates. We have reported the risk ratio (RR) for dichotomous outcomes and the relative difference (as per cent change or mean difference (MD)) for continuous outcomes. MAIN RESULTS: We included 27 studies in the review: 12 randomised trials, 13 controlled before-and-after studies, one interrupted time series, and one repeated measure study. Most healthcare providers were primary care physicians. Most of the payment methods were implemented by health insurance schemes in high-income countries, with only one study from a low- or middle-income country. The included studies were categorised into four groups based on comparisons of different payment methods. (1) Pay for performance (P4P) plus existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings P4P incentives probably improve child immunisation status (RR 1.27, 95% confidence interval (CI) 1.19 to 1.36; 3760 patients; moderate-certainty evidence) and may slightly increase the number of patients who are asked more detailed questions on their disease by their pharmacist (MD 1.24, 95% CI 0.93 to 1.54; 454 patients; low-certainty evidence). P4P may slightly improve primary care physicians' prescribing of guideline-recommended antihypertensive medicines compared with an existing payment method (RR 1.07, 95% CI 1.02 to 1.12; 362 patients; low-certainty evidence). We are uncertain about the effects of extra P4P incentives on mean blood pressure reduction for patients and costs for providing services compared with an existing payment method (very low-certainty evidence). Outcomes related to workload or other health professional outcomes were not reported in the included studies. One randomised trial found that compared to the control group, the performance of incentivised professionals was not sustained after the P4P intervention had ended. (2) Fee for service (FFS) compared with existing payment methods for healthcare providers working in outpatient healthcare settings We are uncertain about the effect of FFS on the quantity of health services delivered (outpatient visits and hospitalisations), patient health outcomes, and total drugs cost compared to an existing payment method due to very low-certainty evidence. The quality of service provision and health professional outcomes were not reported in the included studies. One randomised trial reported that physicians paid via FFS may see more well patients than salaried physicians (low-certainty evidence), possibly implying that more unnecessary services were delivered through FFS. (3) FFS mixed with existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings FFS mixed payment method may increase the quantity of health services provided compared with an existing payment method (RR 1.37, 95% CI 1.07 to 1.76; low-certainty evidence). We are uncertain about the effect of FFS mixed payment on quality of services provided, patient health outcomes, and health professional outcomes compared with an existing payment method due to very low-certainty evidence. Cost outcomes and adverse effects were not reported in the included studies. (4) Enhanced FFS compared with FFS for healthcare providers working in outpatient healthcare settings Enhanced FFS (higher FFS payment) probably increases child immunisation rates (RR 1.25, 95% CI 1.06 to 1.48; moderate-certainty evidence). We are uncertain whether higher FFS payment results in more primary care visits and about the effect of enhanced FFS on the net expenditure per year on covered children with regular FFS (very low-certainty evidence). Quality of service provision, patient outcomes, health professional outcomes, and adverse effects were not reported in the included studies. AUTHORS' CONCLUSIONS: For healthcare providers working in outpatient healthcare settings, P4P or an increase in FFS payment level probably increases the quantity of health service provision (moderate-certainty evidence), and P4P may slightly improve the quality of service provision for targeted conditions (low-certainty evidence). The effects of changes in payment methods on health outcomes is uncertain due to very low-certainty evidence. Information to explore the influence of specific payment method design features, such as the size of incentives and type of performance measures, was insufficient. Furthermore, due to limited and very low-certainty evidence, it is uncertain if changing payment models without including additional funding for professionals would have similar effects. There is a need for further well-conducted research on payment methods for healthcare providers working in outpatient healthcare settings in low- and middle-income countries; more studies comparing the impacts of different designs of the same payment method; and studies that consider the unintended consequences of payment interventions.

Training primary healthcare workers in China's township hospitals: a mixed methods study.

BACKGROUND: Primary health care (PHC) was a keystone toward achieving universal health coverage and Sustainable Development Goals (SDGs). China has made efforts to strengthen its PHC institutions. As part of such efforts, regular in-service training is crucial for primary healthcare workers (PHWs) to strengthen their knowledge and keep their skills up to date. OBJECTIVE: To investigate if and how the existing training arrangements influenced the competence and job satisfaction of PHWs in township hospitals (THs). METHODS: A mixed method approach was employed. We analyzed the associations between in-service training and competence, as well as between in-service training and job satisfaction of PHWs using logistic regression. Interviews were recorded, transcribed, and analyzed using NVivo12 to better understand the trainings and the impacts on PHWs. RESULTS: The study found that training was associated with competence for all the types of PHWs except nurses. The odds of higher competence for physicians who received long-term training were 3.60 (p < 0.01) and that of those who received both types of training was 2.40 (p < 0.01). PHWs who received short-term training had odds of higher competence significantly (OR = 1.710, p < 0.05). PHWs who received training were more satisfied than their untrained colleagues in general (OR = 1.638, p < 0.01). Specifically, physicians who received short-term training (OR = 1.916, p < 0.01) and who received both types of training (OR = 1.941, p < 0.05) had greater odds of general job satisfaction. The odds ratios (ORs) of general job satisfaction for nurses who received short-term training was 2.697 (p < 0.01), but this association was not significant for public health workers. The interview data supported these results, and revealed how training influenced competence and satisfaction. CONCLUSIONS: Considering existing evidence that competence and satisfaction serve as two major determinants of health workers' performance, to further improve PHWs' performance, it is necessary to provide sufficient training opportunities and improve the quality of training.

How Can One Strengthen a Tiered Healthcare System through Health System Reform? Lessons Learnt from Beijing, China.

How one can reshape the current healthcare sector into a tiered healthcare system with clarified division of functions between primary care facilities and hospitals, and improve the utilization of primary care, is a worldwide problem, especially for the low and middle-income countries (LMICs). This paper aimed to evaluate the impact of the Beijing Reform on healthcare-seeking behavior and tried to explain the mechanism of the change of patient flow. In this before and after study, we evaluated the changes of outpatient visits and inpatient visits among different levels of health facilities. Using the monitored and statistical data of 373 healthcare institutions 1-year before and 1-year after the Beijing Reform, interrupted time series analysis was applied to evaluate the impact of the reform on healthcare-seeking behavior. Semi-structured interviews were used to further explore the mechanisms of the changes. One year after the reform, the flow of outpatients changed from tertiary hospitals to community health centers with an 11.90% decrease of outpatients in tertiary hospitals compared to a 15.01% increase in primary healthcare facilities. The number of ambulatory care visits in primary healthcare (PHC) showed a significant upward trend (P < 0.10), and the reform had a significant impact on the average number of ambulatory care visits per institution in Beijing's tertiary hospitals (p < 0.10). We concluded that the Beijing Reform has attracted a substantial number of ambulatory care visits from hospitals to primary healthcare facilities in the short-term. Comprehensive reform policies were necessary to align incentives among relative stakeholders, which was a critical lesson for other provinces in China and other LMICs.

Health system reforms in China a half century apart: Continuity but adaptation.

Well-functioning governance arrangements are an essential, but often overlooked or poorly understood contributor to high quality health systems. Yet governance systems are embedded in institutional structures and shaped by cultural norms that can be difficult to change. We look at a country that has implemented two major health system reforms separated by half a century during which it has undergone remarkable political, economic, and social change. These are the Chinese Patriotic Health Campaign (PHC), beginning in the 1950s, and the New Cooperative Medical Scheme (NCMS), in the 2000s. We use these as case studies to explore how governance arrangements supported the design and implementation of policies implemented on a large scale in these quite different contexts. Drawing on review of archival documents, published literature, and semi-structured interviews with key policy makers, we conclude that few aspects of governance underwent fundamental changes. In both periods, the policy design stage included encouragement of sub-national tiers of government to pilot policy options, accumulate evidence, and disseminate it to others facing similar challenges, all facilitated by clear lines of accountability and a willingness by those at the top of the hierarchy to learn lessons from lower levels. At the implementation stage, rapid scaling up benefitted from leadership by national institutions that could enact regulations and set policy goals and targets for lower tiers of government, evaluating the performance of local government officers in terms of their ability to implement policy, while encouraging local government to pilot innovative measures. These findings highlight the importance of a detailed understanding of governance and how it is shaped by context, demonstrating continuity over long periods even at times of major social, political, and economic change. This understanding can inform future policy development in China and measures to strengthen governance aspects of reforms elsewhere.