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Shanghai community medical service in steady development
7/11/2003 18:16



(Shanghai Health Bureau November 3, 2003)

Guided by the Shanghai Party Committee and the Shanghai Municipal Government which have continued to adjust the layout and functions of local primary care, local community medical service has steadily improved.

1. History of the Shanghai community medical service
1.1 Framework establishment
With guidance and help from the local municipal government and the industrial medical associations after 1949 when the People's Republic of China was founded, private doctors in Shanghai established a 'united clinic' of their own accord. In the 1950s, the united clinic was formed into sub-district hospitals or village- and town-based medical institutes, according to the geographic divisions of different sub-districts, villages and towns. In order to improve the local disease prevention and health-care network and enlarge the coverage of primary care institutes, local sub-district, village and town-based primary care facilities were required to be in charge of the disease prevention and health-care work in the city. Since they were founded, therefore, the sub-district, village and town-based primary care institutes in Shanghai have been taking the responsibilities of local disease prevention and health-care with the fundamental framework of local community medical services established in the 1950s. Local primary care facilities have made tremendous efforts to create new services such as establishing family practice settings and offering a medical care visiting service.

As the Shanghai population began aging in the late 70s, in the 1980s, some sub-district hospitals began to focus on health-care work for senior citizens and to develop new medical services. The Shanghai Health Bureau chose four sub-district hospitals for experiments. The Yanzhong sub-district hospital of Jing'an District, one of the four, investigated overall health for all the local elderly, and worked out supervisory health-care measures especially for the elderly group. Their community medical care work for the senior citizens has won high praise from the World Health Organization (WHO), and the WHO Shanghai medical health-care cooperative center for the elderly was founded. Other sub-district hospitals then learned from Yanzhong to start such services.

1.2 Rapid development in 1990s
The community medical services in Shanghai have made faster development since the 1990s.
1991 to 1994: following the requirements of the Shanghai Party Committee and Shanghai Municipal Government, all the local sub-districts established 'community service centers', mainly providing health services. Offering medical services is the main prerequisite to being recognized as a civilized social community.
1994: a work conference on sub-district hospitals was held in Shanghai, requiring medical workers in sub-district hospitals to leave the hospitals, go deep into neighborhood committees and be in close contact with local households to offer close medical services to residents, and consolidate supervision and management on family practice settings and visiting services. Such services were warmly hailed by local residents.

1997: the Shanghai Municipal Government listed the community health service as one of the main tasks for the residents.
1997-1998: all the local sub-district hospitals and village or town-based medical institutes established 240 community medical service outlets
1999: Shanghai built ten standardized hospitals for the elderly
2000: all the sub-district hospitals in local downtown areas were transformed into community medical service centers, with 20 model centers founded.
2000-2001: standardized construction was completed for community medical service centers in local downtown areas.
2003: Shanghai started standardized construction to transform the village or town-based medical institutes into community medical service centers, with the work expected to be completed by 2005

2 Community medical service centers

2.1 Framework

There are 2,422 medical facilities, including 435 hospitals and 229 sub-district centers (52.6%), in the 18 districts and 1 county in Shanghai. Every sub-district has a basic medical institution (community medical service center or village & township medical health center), with 18,100 beds (22.1%)in all. Sub-district facilities target the elderly most, with 1,360 beds (23.4%) designated for the Homes for the Elderly already.
All residential block hospitals have been transformed into community medical service centers, each serving an average population of 77,000, with minor regional differences. These centers have set up 422 stations in the neighborhood committees to serve a smaller population of 10,000 on average.
Village & township health centers in the suburbs of Shanghai serve on average 43,000. These centers have set up 2,218 stations in selected residential blocks, with about one station for every 2,000 people.
Starting in 2003, Shanghai has launched a three-year project to streamline these village stations so that villagers can reach the nearest station within 15 minutes by foot.
By 2005, all village & township health centers will have the same functions as the community medical service centers.
Existing standards require that every center will have a spacious hall for outpatient services with touch interfaces for inquiries and electronic screens for direction. Also, they should be equipped with lanes with handrails, aisles with gentle slopes for the disabled, and toilets with sirens. There should be rehabilitation centers, health education centers, information management centers, and outpatient centers for health care consultation. There are also regulations for the size of the wards and admitting rooms, and heating and cooling equipment.


2.2 Human Resource

There are 24,000 employees, including a medical staff of 19,000, at the community medical service centers and village & township health centers. Among the 8,819 doctors, 57.6% have a background of junior college or higher education and 13.9% above senior college, 80.0% are resident physicians and 33.8% are physicians-in-charge. A team of 4,896 assistant doctors are serving in local suburbs, with two in each sub-village health center.
The local government is offering basic level education and training programs to doctors and fixing job qualifications to transfer doctors with specialties into general practitioners. The move is aimed at improving medical care and disease prevention services in the basic medical centers.
Instituted by the local health authorities and kept in line with the standard by the Ministry of Health of China, the systemic program for general practitioners' training takes into account the local situation.
It has a city-wide unified goal and a semester agenda with contents to be covered in 600 school hours. It also designates training sites, organizes stable teaching staff and sets evaluation standards.
Currently more than 3,200 general practitioners have received training, received certificates, and registered with the local health bureau.


table1

Human Resources at the community medical service center and village & township health center

number %in hospital %in city

medical staff 19,154 80.4 (of all employed) 19.8
Including
doctors　　 8,819 46.0 (of medical staff)　　 27.2
nurses　　 4,819 25.2 (of medical staff)　　 13.8



table2

Educational Background & Titles of the doctors at the community medical service center and village & township health center


EB-Educational Background
EB　　 number (%) title number %
Post Graduate 14 0.2 Director/vice Director 456 5.1
Senior College 1,215 13.8 Physician-in-chief　　 2,533 28.7
Junior College 3,847 43.6 Resident Physician　　 4,065 46.1
Secondary Sch. 3,743 42.4 Assistants　　　　 1,765 20.0


3 Service & Forms

The Sub-district (Village & township health centers) is being transformed into community medical service centers, with focuses on goals and attitudes. The centers are serving the patients in groups rather than as individuals, actively rather than passively waiting. They are targeting more elderly people, children, women and the handicapped (including migrants). They are making full use of the community resources to satisfy patients' needs and help foster good health. Community medical service centers have also set up health archives for the residents, especially those above 60, who are under the administration of the territory within the sub-district. Preventive group activities targeting different ages, types and abilities, are providing the residents aid and directions in health, rehabilitation, education, family planning and sex.
Almost one-third of the cases of common, frequently caught (occuring) diseases and chronic diseases are diagnosed at these city centers.

table3

Community medical service centers and village & township health centers

Projects　　 Volume　　 %in city
Outpatient/Emergency Dept. 25.5971 million person-time 34.5
Inpatient Care　　　　　　 352,900 person-time　　　　 28.3



3.1 Main Services

* Prevention & Health Care
Community prevention service includes prevention against the acute diseases such as the acute infectious disease, tuberculosis, vermin sis, venereal disease/AIDS, and chronic diseases such as hypertension, coronary heart disease, cancer, psychopathy, diabetes, dental and eye diseases.
It also plans immunization and manages school and food hygiene,and environmental and vocational health protection.
Community health care service includes:
--publicizing information for newly weds, pregnant & laboring women, and genital hygiene,
--caring for the women, especially those with chronic female sexual diseases, for the new-born, kindergarten and pre-school children, and for the elderly whose personal records show identified health concerns.

* Treatment and Heath Care

Targets of community medical service (CMS) mainly include primary triage of diseases, diagnosis and treatment of common and frequently-occurring diseases as well as continuous treatment of diagnosed chronic diseases; improvement of the community medical system and community health based on psychological treatment and community medical care as for babies and mothers in puerperium, senile chronics and the dying.

* Health Education and Family Planning Instruction

Community health education takes full advantages of all kinds of promotional and educational vehicles to provide health consulting, promotion and education on special topics; It carries out health survey and, based on these results, applies intervention and distributes health descriptions targeted at the main dangerous elements. The CMS operates family planning clinics, availing instructions and services for contraception skills and technologies and providing random visits to those receiving contraceptive operations.

3.2 Work Performance

Typical Items　　　　　　　　　　　　　　　　　　　　　　 Yearly Workload

Family beds　　　　　　　　　　　　　　　　　　　　 15,000

Those receiving family bed service　　　　　　　　　　37,200

seniors covered by the health file　　 　　 92%

Those visiting medical service　　　　　　 　　 33,000

Those being monitored for chronic diseases 1.49 million

Those receiving community health instruction　　　　　　2.9 million

Those receiving community healing instruction　　　　　　 110,700

Those receiving community nursing service　　　　　　　　 756,700

Those receiving charity medical service　　　　　　　　　　15,900

4. CMS Management and Support

Under the leadership and deployment of the municipal government, Shanghai has established a complete CMS management system, enlisting strong support and aid from the governments of all levels and their related departments.

4.1 Management System:

Shanghai has established a CMS management system that stresses "leadership of government, responsibility of the neighborhood communities, coordination of the departments, participation of the whole society and industrial management by the medical administrative body."

With governments of all levels placing high emphasis on CMS, the municipal government set up a "Health Improvement Committee" comprising officials from the relevant departments and headed by the mayor in charge of the medical sector. District and county governments each launched leadership teams for CMS (also called primary medical leadership organization in the suburbs), to carry out and coordinate for the district or county's CMS. The neighborhood communities (or townships) set up "Health Improvement Committees" to apply the local community's medical service such as charting the community's medical planning and merging it into the community's entire development planning as well as coordinating the relevant departments to enlist their help. The CMS centers, under the leadership and support of the neighborhood committees (or township governments) and headed by the committee deans, motivated all their medical staff to eagerly provide CMS. The complete management system has effectively pushed ahead the continuous development of the city's community medical service.

4.2 Financial Support Channels

For years, except for the neighborhood hospitals' increasing input to infrastructure construction, health care and monitoring, prevention and control of the infectious chronic diseases, the lion's share of the city's CMS financing has come from the governments and the society.

From 2000-2002, all neighborhood hospitals of the downtown areas were transformed into standard CMS centers, with 20 constructed as model centers. Of the total 780 million yuan investment to the three-year program, the municipal and district governments have shouldered half.
In a bid to support the local CMS, the district governments have made an effort to ensure input into the medical sector. In 2000, the input reached 80,000 yuan per capita, while in some districts and counties, the investment far surpassed that level and reached 150,000 yuan.
With each district's finance departments arranging specific funds for the CMS, the city's district and county government investment in 1999 mounted to 5.29 million yuan, with financing from nine district medical bureaus topping 9.04 million yuan.

After applying a medical control policy that stresses macro adjusting and structural tuning, the local pricing authority has drafted specific pricing policies for the grassroots hospitals to encourage CMS development. The medical insurance system has provided a positive support to the CMS. When receiving urgent clinical service at these grassroots medical institutions, the proportion of the medical fees that should be handled by the patients is 5 percent lower than with district-level hospitals and 10 percent lower than with city-level hospitals; From May 1997, the medical fee for the family bed service with the CMS centers was covered by the city medical insurance system.

5. Existing problems and countermeasures

The problem of Shanghai's community medical service lies in three aspects:
--Lack of family physicians in community medical service;
--Community medical aid service is similar to that in traditional hospitals;
--Infancy of operational and governmental supportive system.

In order to solve these problems, the city's government seeks to explore a new type of public health care with the following steps:

5.1 Reform in service mode

The city is examining a "family physician team" service model [mode]. The community medical service center in each neighborhood will establish a family physician team, consisting of family physicians assisted by nursing and health care staff. The center will keep a record of the health condition of each community member, and give medical education and health care assistance accordingly. The principle of this model [mode] is to make disease prevention a priority of medical service, and combine prevention with treatment. The model [mode] will help identify serious patients that need to be transferred to higher levels of medical institutes, at the same time, it will give diagnosis, treatment and recovery aid for those common, frequently-occurring diseases and diagnosed chronic disease.

Community medical service centers are reforming their functions. The center is no longer an assembly of various specialized medical departments. Instead, it now becomes a team of family physicians guarding the health of all community members. Therefore, the center is turned into a channel through which the government provides medical service to community members.

Based on the reform of service model [mode], the community medical service centers should increase its service to cope with the aging population, the changing disease spectrum, and the increasing demand for chronic, non-infectious disease prevention and treatment. New service items, such as family health care, family nursing, hospice care and other needed items, will be added to the service list.


5.2 Speed the building of a family physician team

Shanghai has already established a technical post evaluation system for family physician. In order to meet the demand for family doctors in community medical service center, the city is changing specialist doctors into family doctors on trial basis. Moreover, specialized doctors from the lower levels of medical institutes are encouraged to sit for the family physician qualification test held by the Ministry of Health. By 2002, as many as 230 physicians had passed the test, and another 600 or more took part in the test in the first half of 2003. The city will offer further education and training on being a family physician for those that have passed the test, in order to improve their knowledge, skill and service standard consistently. Furthermore, the government is working on preferential policies to encourage doctors with both clinical medical experience in higher-level hospitals and family physician training to serve in community medical service centers. Through the above measures, we wish to build up a dependable and qualified medical service team.


5.3 Grant more subsidies to community medical service

In 2003, the Shanghai government worked out a plan for a public sanitation system. The plan clarified the government's responsibility of public health, and included community medical services in economic development. Therefore, the government vows to give more supports to community medical service. Each community is to have at least one medical service center. The city government will provide the center with essential operating expenses, housing, elementary facilities and will cover the expense on its equipment, maintenance and renovation. Giving policy priority to health care and prevention, the government subsidy on this section will increase every year till it reaches 200,000 yuan in 2005. It aims to keep community members healthy as long as possible, so they fall sick as little as possible, and stay well always. Hopefully, the occurrence of complications should be reduced to as little as possible, thus improving the citizen's health and living standard.