Yuan Shasha, Wang Fang, Li Xi, Jia Meng, Tian Miaomiao
Centre for Health System and Policy, Institute of Medical Information & Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
Centre for Health System and Policy, Institute of Medical Information & Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
BMJ Open. 2019 Oct 8;9(10):e032444. doi: 10.1136/bmjopen-2019-032444.
To identify the facilitators and barriers to implement family doctor contracting services in China by using Consolidated Framework for Implementation Research (CFIR) to shed new light on establishing family doctor systems in developing countries.
A qualitative study conducted from June to August 2017 using semistructured interview guides for focus group discussions (FGDs) and individual interviews. CFIR was used to guide data coding, data analysis and reporting of findings.
19 primary health institutions in nine provinces purposively selected from the eastern, middle and western areas of China.
From the nine sampled provinces in China, 62 policy makers from health related departments at the province, city and county/district levels participated in 9 FGDs; 19 leaders of primary health institutions participated in individual interviews; and 48 family doctor team members participated in 15 FGDs.
Based on CFIR constructs, notable facilitators included national reform involving both top-down and bottom-up policy making (Intervention); support from essential public health funds, fiscal subsidies and health insurance (Outer setting); extra performance-based payments for family doctor teams based on evaluation (Inner setting); and positive engagement of health administrators (Process). Notable barriers included a lack of essential matching mechanisms at national level (Intervention); distrust in the quality of primary care, a lack of government subsidies and health insurance reimbursement and performance ceiling policy (Outer setting); the low competency of family doctors and weak influence of evaluations on performance-based salary (Inner setting); and misunderstandings about family doctor contracting services (Process).
The national design with essential features including financing, incentive mechanisms and multidepartment cooperation, was vital for implementing family doctor contracting services in China. More attention should be paid to the quality of primary care and competency of family doctors. All stakeholders must be informed, be involved and participate before and during the process.
运用实施研究综合框架（CFIR）确定在中国实施家庭医生签约服务的促进因素和障碍，为发展中国家建立家庭医生制度提供新的思路。
2017年6月至8月进行的一项定性研究，使用半结构化访谈指南进行焦点小组讨论（FGD）和个人访谈。CFIR用于指导数据编码、数据分析和研究结果报告。
从中国东部、中部和西部地区有目的地选取9个省份的19家基层医疗卫生机构。
来自中国9个抽样省份的省级、市级和县级/区级卫生相关部门的62名政策制定者参加了9次焦点小组讨论；19名基层医疗卫生机构负责人参加了个人访谈；48名家庭医生团队成员参加了15次焦点小组讨论。
基于CFIR的构建，显著的促进因素包括涉及自上而下和自下而上政策制定的国家改革（干预）；基本公共卫生资金、财政补贴和医疗保险的支持（外部环境）；基于评估的家庭医生团队额外绩效支付（内部环境）；以及卫生管理人员的积极参与（过程）。显著的障碍包括国家层面缺乏必要的匹配机制（干预）；对基层医疗质量的不信任、缺乏政府补贴和医疗保险报销以及绩效上限政策（外部环境）；家庭医生能力低下以及评估对绩效工资的影响较弱（内部环境）；以及对家庭医生签约服务的误解（过程）。
具有融资性、激励机制和多部门合作等基本特征的国家设计，对于在中国实施家庭医生签约服务至关重要。应更加关注基层医疗质量和家庭医生的能力。在整个过程之前和期间，必须让所有利益相关者了解情况、参与其中。
