China Center for Health Development Studies, Peking University, Beijing, 100191, China.
London School of Hygiene & Tropical Medicine, London, United Kingdom.
Int J Equity Health. 2017 Jul 1;16(1):106. doi: 10.1186/s12939-017-0593-z.
Gatekeeping involves a generalist doctor who controls patients' access to specialist care, and has been discussed as an important policy option to rebalance the primary care and hospital sectors in low- and middle-income countries, despite thin evidence. A gatekeeping pilot in a Chinese rural setting launched in 2013 has offered an opportunity to study the functioning of gatekeeping under such conditions.
In this qualitative study within a mixed-method evaluation of the gatekeeping pilot, we developed an innovative systems analysis method, combining the World Health Organisation categorisation of health system building blocks, the "Framework" approach of policy analysis and causal loop analysis. We conducted in-depth interviews with 20 stakeholders from 4 groups (patients, doctors, health facility managers and government administrators) in the pilot area over two years. Based on information extracted from the interviews, we drew a causal loop diagram which highlighted the feedback loops within the system that had self-reinforcing or self-balancing characteristics, and used the diagram to examine systematically the mechanisms of intended and actual functioning of gatekeeping and analyse the systems level challenges that affected the effectiveness of gatekeeping.
Had the gatekeeping pilot programme worked as intended, it would incentivize both providers and patients to increase service utilization at primary care level, as well as establish and enhance two reinforcing feedback loops to shift balance towards primary care. However, a performance-based salary policy undermined the motivation for clinical primary care. Furthermore, the primary care providers suffered from three reinforcing feedback loops (related to primary care capacity, human resource sustainability, patients' faith) that trapped primary care development in vicious cycles. At the interface between hospitals and primary care providers, there were also feedback loops exacerbating the existing hospital dominance. These feedback loops were intensified by the unintended consequences of concurrent policies (restrictions on technologies and medicines) and delayed reform in hospitals. Furthermore, the gatekeeping policy itself faced resistance to further development, due to the prevailing ineffective and ritualistic nature of gatekeeping, which formed a balancing loop.
The study shows that the intended benefits of gatekeeping were illusionary largely due to weak and worsening primary care conditions, and delay, ineffectiveness or unintended consequences of several other ongoing reforms. One particularly dangerous development of the system, which deserves urgent attention, is the harming of the professional prospects of primary care doctors. Our findings highlight the need for coordination and prioritization in designing policies related to primary care and managing changes with multiple on-going reforms. The approach used here facilitates comprehensive study of intended and actual mechanisms, and demonstrates the challenges of a complex health system intervention in a dynamic environment.
把关涉及到控制患者获得专科护理的通科医生，作为重新平衡中低收入国家基层医疗和医院部门的一项重要政策选择，已被多次讨论，尽管证据有限。2013 年在中国农村地区启动的一项把关试点为在这种情况下研究把关的运作提供了机会。
在对把关试点的混合方法评价的这项定性研究中，我们开发了一种创新的系统分析方法，结合世界卫生组织对卫生系统组成部分的分类、政策分析的“框架”方法和因果回路分析。我们在两年内对试点地区的 4 组（患者、医生、医疗机构管理人员和政府行政管理人员）的 20 名利益相关者进行了深入访谈。根据访谈中提取的信息，我们绘制了一个因果回路图，突出了系统内具有自我强化或自我平衡特征的反馈回路，并利用该图系统地检查了把关的预期和实际运作机制，并分析了影响把关效果的系统层面挑战。
如果把关试点项目按计划实施，它将激励提供者和患者增加基层医疗服务的利用，同时建立和加强两个强化反馈回路，将平衡转向基层医疗。然而，基于绩效的薪酬政策破坏了临床基层医疗的激励。此外，基层医疗提供者受到三个强化反馈回路（与基层医疗能力、人力资源可持续性、患者信任有关）的影响，使基层医疗发展陷入恶性循环。在医院和基层医疗提供者之间的界面上，也存在加剧现有医院主导地位的反馈回路。这些反馈回路因同时实施的政策（对技术和药物的限制）的意外后果和医院改革的延迟而加剧。此外，把关政策本身也因把关的现行无效和例行公事性质而面临进一步发展的阻力，形成一个平衡回路。
研究表明，把关的预期收益在很大程度上是虚幻的，主要原因是基层医疗条件薄弱且不断恶化，以及其他几项正在进行的改革延迟、无效或产生意外后果。系统中一个特别危险的发展值得紧急关注，即基层医疗医生的职业前景受到损害。我们的研究结果强调了在设计与基层医疗相关的政策和管理与多项正在进行的改革相关的变化时需要协调和优先考虑。这里使用的方法便于全面研究预期和实际的机制，并展示了在动态环境下对复杂卫生系统干预的挑战。
