Riding the Tailwinds of China's Intensified Tiered Diagnosis Policies: Unlocking Opportunities in Primary Healthcare Services

At the end of 2015, the National Health and Family Planning Commission (NHFPC) issued a series of policy documents to guide the direction of grassroots healthcare reform. On December 1, the NHFPC and the State Administration of Traditional Chinese Medicine jointly formulated a plan to guide pilot provinces for comprehensive medical system reform and nationally linked pilot cities for public hospital reform in carrying out pilot programs for tiered diagnosis and treatment of chronic diseases such as hypertension and diabetes.

On November 25, the National Health and Family Planning Commission and the State Administration of Traditional Chinese Medicine jointly issued the “Guiding Opinions on Further Standardizing Community Health Service Management and Improving Service Quality,” which emphasizes strengthening the development of general practice and traditional Chinese medicine (TCM) departments, and fully leveraging TCM resources to capitalize on its advantages and role in basic medical care, public health services, and chronic disease rehabilitation.

It is evident that the national healthcare reform strategy aims to implement tiered diagnosis and treatment by clearly defining the functional roles of primary healthcare institutions and secondary-and-above hospitals, initially focusing on chronic diseases such as hypertension and diabetes. So, what is the current status of primary healthcare institutions in China? What policies have been introduced sequentially, and what highlights deserve attention? This article provides a comprehensive overview addressing these questions.

China’s healthcare institutions are categorized into three types: hospitals, primary healthcare institutions, and specialized public health institutions. According to statistical data from the National Health and Family Planning Commission, by the end of May 2015, the total number of healthcare institutions nationwide reached 987,000, including 26,000 hospitals, 922,000 primary healthcare institutions, 35,000 specialized public health institutions, and 3,000 other institutions. Among primary healthcare institutions, there were 34,000 community health service centers (stations), 37,000 township health centers, 646,000 village clinics, and 192,000 outpatient clinics (infirmary). In addition, compared with the end of May 2014, the number of healthcare institutions nationwide increased by 6,804, including an increase of 1,433 hospitals, 2,112 primary healthcare institutions, and 3,140 specialized public health institutions.



The National Health and Family Planning Commission also reported that from January to May 2015, the total number of outpatient visits at medical and health institutions nationwide reached 3.11 billion, a year-on-year increase of 3.0%. Among these, hospitals accounted for 1.22 billion visits, up 5.4% year on year; primary medical and health institutions accounted for 1.80 billion visits, up 1.6% year on year; and other institutions accounted for 1.01 billion visits. Within primary medical and health institutions: community health service centers (stations) recorded 270 million visits, up 4.7% year on year; township health centers recorded 410 million visits, up 0.5% year on year; and village clinics recorded 840 million visits.



Therefore, the data above reveals that although primary healthcare institutions account for 93.4% of all medical and health institutions in China, they handle only 57.9% of the total patient visits nationwide. This significant disparity indicates substantial untapped service potential and considerable room for growth in primary care. Meanwhile, compared with the same period last year, although the increase in the number of hospitals (1,433) was lower than that of primary healthcare institutions (2,112), hospital patient visits grew by 5.4% year-on-year, significantly outpacing the growth rate of primary healthcare institutions. This indirectly suggests that hospitals remain the primary point of contact for patients and possess stronger patient attraction capabilities than primary care facilities. Consequently, deepening healthcare reform should continue to be vigorously promoted to address the imbalanced phenomenon of patient overcrowding in hospitals.



Amid this trend, the government has visibly accelerated the pace of healthcare reform. In September, the General Office of the State Council issued the Guiding Opinions on Promoting the Construction of a Tiered Diagnosis and Treatment System, deploying measures to expedite its establishment. Relevant officials from the National Health and Family Planning Commission also stated that the tiered diagnosis and treatment system would be gradually improved within two years, with a comprehensive model featuring initial consultations at primary care institutions, two-way referrals, triage based on urgency and chronicity, and coordinated care across different levels fully established by 2020.

The Guiding Opinions propose that the focus of the tiered diagnosis and treatment system is to “strengthen primary care,” improve the construction of the national community health service system, enhance service functions, promote equalization of basic public health services, and improve residents’ health levels. With the acceleration of urbanization and population aging, the National Health and Family Planning Commission has called for further standardization of the management of community health service institutions, improvement of service quality, meeting the public’s demand for health services, and enhancing the patient experience. To this end, it has specially studied and formulated the Guiding Opinions on Further Standardizing Community Health Service Management and Improving Service Quality, which were officially issued on November 17.

In fact, just one day earlier, the National Health and Family Planning Commission and the State Administration of Traditional Chinese Medicine had jointly issued the “Notice on Launching the Community Health Service Improvement Project,” explicitly announcing the decision to initiate the project starting in 2015. The accompanying “Implementation Plan for the Community Health Service Improvement Project” was distributed, requiring health and family planning commissions, administrations of traditional Chinese medicine, and the Health Bureau of the Xinjiang Production and Construction Corps across all provinces, autonomous regions, and municipalities directly under the Central Government to earnestly implement its provisions. The primary entities responsible for executing this notice are community health service stations, with specific content focusing on enhancing service capacity, improving service quality, strengthening management capabilities, and upgrading support conditions.

Subsequently, the “Guiding Opinions on Further Standardizing the Management of Community Health Services and Improving Service Quality,” issued on the 17th, also put forward a total of 17 basic requirements, which are summarized into the following aspects:

First, build a robust primary healthcare service network—

1. Regarding government-run healthcare, regional factors should be comprehensively considered to gradually improve the community health service network in accordance with planning: encourage community health institutions to jointly establish facilities with elderly care institutions within the region; appropriately increase the number of community health service institutions in areas with dense migrant populations; and adapt to local conditions by establishing, upgrading, developing, or discontinuing community health service institutions as appropriate.

2. Encourage private investment in healthcare. Localities should actively create favorable conditions to encourage social forces to establish primary healthcare institutions, and actively explore providing subsidies for basic medical and health services delivered by such institutions through government procurement of services.

Second, enhance the service capacity of primary healthcare institutions—

First, service capacity can be enhanced through the use of automated equipment to improve the patient experience. This includes encouraging the use of facilities such as self-service registration, electronic queue management, self-service printing of laboratory results, and self-health testing. We should promote the use of a unified medical card for residents and make full and effective use of electronic health records. At the provincial (autonomous region, municipality) level, we should coordinate the development of information management systems for community health service institutions, further integrating various related business systems—including maternal and child health care, family planning, immunization, infectious disease reporting, and severe mental disorder management—to avoid duplicate data entry.

Secondly, prioritize strengthening the development of general practice and traditional Chinese medicine (TCM) departments to enhance diagnostic and treatment capabilities for common, frequently occurring, and chronic diseases. Based on community needs, specialized departments such as rehabilitation, chronic disease management, stomatology, obstetrics and gynecology (maternal health care), pediatrics (child health care), and psychiatry/psychology may be developed. Community health service institutions should designate their inpatient beds primarily for nursing and rehabilitation purposes, vigorously promote community nursing, and encourage the provision of home-based nursing services. Therefore, regional coordinated planning should be implemented to determine the scale of inpatient beds in community health service institutions, rationally allocate the number of beds per facility, and improve bed utilization efficiency.

Meanwhile, vigorously develop traditional Chinese medicine (TCM) services by fully leveraging TCM resources and harnessing its advantages and roles in basic medical care, public health services, and chronic disease rehabilitation. Strengthen publicity and training on the rational use of proprietary Chinese medicines, and promote appropriate TCM techniques such as acupuncture, tuina (therapeutic massage), cupping, and herbal fumigation. Fully utilize TCM’s “preventive treatment of disease” services to provide TCM health consultations for community residents.

Again, enhance the supply capacity for specialized services.

Provide convenient services. Community health service institutions with the necessary conditions should appropriately extend consultation hours, remain open on weekends and public holidays, and implement staggered-hour services to meet the healthcare needs of the working population;

Strengthen Community Health Services for the Floating Population. Localities shall include migrant workers and their accompanying family members within the service scope of community health service institutions, thereby facilitating access to medical and healthcare services for the floating population in nearby areas. Expand the functions of community health services. Based on the basic medical and healthcare needs of the community population, continuously improve the content of community health services, diversify service delivery models, and broaden the range of service offerings.

Simultaneously implement community public health services. Make full use of information such as resident health records, health statistics, and specialized surveys to conduct regular community health diagnoses, identify the basic health issues of residents within the jurisdiction, and formulate population health intervention plans.

Third, ensuring the supply of talent for primary healthcare institutions—

First, standardize the practice registration of general practitioners. It is stipulated that all regions shall complete the registration changes for existing eligible personnel by the end of June 2016.

Secondly, strengthen the development of the community health workforce. Rationally configure the staffing structure of community health service institutions, and prioritize building a workforce centered on general practitioners and community nurses. With a focus on enhancing practical skills, strengthen in-service training and continuing medical education for community health personnel; community health technical staff shall accumulate no less than three months of technical training every five years.

Fourth, using primary healthcare institutions as a bridge to connect hospitals with community residents—

First, establish contracted physician teams composed of physicians from secondary-level or higher hospitals and medical personnel from primary healthcare institutions. Promote the signing of service agreements between these contracted physician teams and residents or families to establish a contractual service relationship. During the initial phase of contracted services, priority should be given to populations that frequently utilize community health services, such as the elderly, patients with chronic diseases and severe mental disorders, pregnant and postpartum women, children, and individuals with disabilities, with gradual expansion to the general population. By 2020, efforts should be made to ensure that every family has access to a qualified contracted physician and that every resident maintains an electronic health record.

Secondly, strengthen vertical integration and collaboration between public hospitals and community health institutions. Encourage physicians from public hospitals to practice at multiple sites in community health service institutions, enhancing community healthcare capacity through outpatient consultations, teaching mentorship, ward rounds, and other methods. Focusing on diseases such as hypertension, diabetes, and tuberculosis, establish communication platforms between general practitioners and specialists in public hospitals to improve division of labor and coordination, facilitate vertical linkage, and explore systems for initial diagnosis at the community level and two-way referrals. Gradually establish a follow-up service system for patients discharged from public hospitals to provide continuous care for those referred down to community settings. Advance the development of telemedicine systems by offering remote services such as teleconsultations, medical imaging interpretation, and electrocardiogram (ECG) diagnosis. Fully leverage resources from public hospitals and other entities to develop centralized testing services, promote mutual recognition of examination and test results, and reduce redundant medical visits.

Furthermore, two recently introduced policy changes related to the “Guiding Opinions on Further Standardizing the Management of Community Health Services and Improving Service Quality” are worth reading.

First, on November 15, the Ministry of Human Resources and Social Security and the National Health and Family Planning Commission proposed further reforms to improve the professional title evaluation system for grassroots health professionals. The core elements include strengthening the evaluation framework: implementing a unified national examination for intermediate and junior professional titles in the health sector, while allowing various regions to establish separate review panels within their senior professional title evaluation committees for senior health professional titles.

Optimization of Evaluation Criteria: Foreign language test scores are not required for primary-level health professional title applications. There are no mandatory requirements for papers or scientific research; these may serve as reference criteria in the evaluation process. Primary-level health professionals must complete the specified number of continuing education credits before applying for senior professional titles.

Refine Evaluation Criteria. In accordance with the functional positioning of healthcare institutions and the requirements for tiered diagnosis and treatment, the assessment of health professionals in county-level healthcare institutions should focus on their performance in the diagnosis and treatment of common and frequently occurring diseases, nursing, rehabilitation, imaging, and laboratory services; emergency rescue of critically ill patients and management of complex cases; training and guidance of personnel in lower-level healthcare institutions; fulfillment of corresponding public health service functions; and emergency medical rescue during sudden public health incidents.

The Guiding Opinions issued by the Ministry of Human Resources and Social Security aim to substantially strengthen the workforce of grassroots health professionals, enhance their service capabilities, encourage them to serve at the grassroots level, and provide talent support for strengthening primary care, ensuring basic services, establishing mechanisms, and implementing a tiered diagnosis and treatment system.

Second, on November 17, the General Office of the National Health and Family Planning Commission and the General Office of the State Administration of Traditional Chinese Medicine concurrently issued the Notice on Conducting Pilot Programs for Tiered Diagnosis and Treatment of Hypertension and Diabetes.

The Notice proposes that the key tasks for the tiered diagnosis and treatment of hypertension and diabetes include establishing health records for patients with these conditions, clarifying the functional roles of medical institutions at different levels, and implementing a team-based contract service model.

(I)Service Process of Primary Healthcare Institutions:



(2)Service Processes in Hospitals at Level II and Above:



In fact, prior to the release of the “Guiding Opinions on Advancing the Construction of a Tiered Diagnosis and Treatment System,” namely this MarchJune 6On [date], the General Office of the State Council issued the Outline of the National Medical and Health Service System Plan (2015—2020Notice on [Year]).

The Outline points out that China’s current healthcare services face prominent issues, including insufficient total health resources, low quality, unreasonable structure and layout, fragmentation of the service system, and irrational expansion of the scale of some public hospitals. It also analyzes the goal of deepening medical reform, which is to ensure universal access to basic medical and health services. Challenges to medical reform include intensified shortages of medical resources driven by an increasing floating population and rising urbanization, as well as the contradiction between accelerating population aging and inadequate rehabilitative and elderly care services. In the face of these contradictions and practical challenges, the rapid development of new technologies—including cloud computing, the Internet of Things (IoT), mobile internet, and big data—has created conditions for optimizing healthcare business processes and improving service efficiency, inevitably driving a profound transformation in healthcare service and management models.

The Outline defines the functional positioning of primary healthcare institutions as follows: Their main responsibilities are to provide basic public health services, including prevention, healthcare, health education, and family planning; diagnosis and treatment services for common and frequently occurring diseases; and rehabilitation and nursing services for certain conditions. They are also responsible for referring patients with common and frequently occurring diseases that exceed their service capacity, as well as critically ill and complex cases, to hospitals. Primary healthcare institutions mainly include township health centers, community health service centers (and stations), village clinics, medical rooms, outpatient departments (and clinics), and military primary healthcare institutions.

According to the Outline, the indicators for the allocation of national medical and health service resources in 2020 are as follows:



In addition to the National Health and Family Planning Commission’s intensive rollout of a series of policies in November 2015 aimed at improving services at primary healthcare institutions, relevant healthcare reform policies were already being frequently issued in 2006, with reforms in primary healthcare services serving as a key focus at that time. Coupled with the gradual improvement of the tiered diagnosis and treatment system by 2017 and the goal of fully establishing this model by 2020, it is evident that the pace of China’s deepening healthcare reforms generally follows five- and ten-year cycles, aligning with the country’s long-term five-year plans for economic and social development. The following is a timeline of policy implementation for health services at primary healthcare institutions: