Primary Health Care and Medical Impoverishment in Rural China


Poverty alleviation is a major development goal worldwide and has been identified as a national priority in China. While much of the Chinese health care reform effort has targeted health-related poverty due to hospitalization, less attention has been paid to reducing health-related poverty through strengthening primary health care. To address this gap, the Bill and Melinda Gates Foundation (BMGF) is funding a multi-year project in collaboration with the National Health Commission in China that aims to prevent medical impoverishment by strengthening the local primary health care system.


The primary objectives of the Harvard China Health Partnership in this project are to evaluate different interventions on strengthening primary health care in China and their impacts on health-related poverty and catastrophic health expenditure and to use the findings to inform policy formulation.

Research Activities

The project conducts evaluations on:

  • Interventions on improving chronic disease management at primary health care in rural areas of three provinces—Shanxi, Hubei, and Henan—supported by BMGF.
  • The role and effects of primary health care in three selected integrated delivery systems (医联体) in China.
  • The relationship between primary health care strength and avoidable hospitalizations.

Research Articles

  1. LIU Haoran, CHEN Siyuan, ZHANG Lanyue, FU Hongqiao, and JIAN Weiyan. 2023. “Expanding outpatient benefits package can reduce diabetes-related avoidable hospitalizations.Frontiers in Public Health 11. DOI: 10.3389/fpubh.2023.964789

Summary: China has the largest number of diabetic patients in the world. In 2021, diabetes-related health costs in China were as high as $165.3 billion. This study evaluates the policy effect of replacing hospitalization service with outpatient service and reducing diabetes-related avoidable hospitalizations by improving outpatient benefits package.  A difference-in-difference model was used to analyze the effect of improving outpatient benefits package level of diabetes from 1800 yuan (about $252.82) to 2400 yuan (about $337.09) per capita per year. The avoidable hospitalization rate of diabetes mellitus decreased by 0.21 percentage points, the average total cost of hospitalization increased by 7.89%, and the average length of stay per hospitalization increased by 5.63%. Improving the outpatient benefits package of diabetes can play a role in replacing hospitalization service with outpatient service, reducing diabetes-related avoidable hospitalizations, and reducing the disease burden and financial burden.

  1. CHEN Siyuan, ZHOU Wuping, and JIAN Weiyan. 2021. “Avoidable Hospitalization for Diabetes and Hypertension in Rural Residents in Central China” (我国中部农村居民糖尿病和高血压可避免住院现状研究). Chinese Health Quality Management. 28(5):95-97. DOI: 10.13912/j.cnki.chqm.2021.28.5.26.

Summary: Objective. To analyze the current situation of avoidable hospitalization for diabetes and hypertension in rural residents in central China to provide policy suggestions. Methods. The quantitative data from a field survey conducted by the China-Gates Foundation Rural Basic Health Care Project in rural areas of central China was used to select a random sample of hospitalized cases in 2017 and/or 2018 in five counties. Data were analyzed using STATA/MP 14.0 software. Results. A total of 28 392 hospitalizations were included, of which 863 cases of diabetes and 1 003 cases of hypertension could have been avoided. From 2017 to 2018, total hospitalization costs, average cost per hospitalization, average out-of-pocket cost per hospitalization, and average out-of-pocket cost per hospitalization for diabetes and hypertension showed an increasing trend. The length of avoidable hospitalization and length of stay per hospitalization were decreased for diabetes and hypertension. Conclusion. The avoidable hospitalization was common for diabetes and hypertension which increased the economic burden of patients. It was suggested to improve the primary health care service system, strengthen the health education and management of chronic diseases, and increase the reimbursement rate of community-level outpatient clinics.

2. HU Haiyan, JIAN Weiyan, FU Hongqiao, ZHANG Hao, PAN Jay, and YIP Winnie. 2021. “Health service underutilization and its associated factors for chronic diseases patients in poverty-stricken areas in China: a multilevel analysis.” BMC Health Services. doi: 10.1186/s12913-021-06725-5.

Summary: This study aims to describe health services underutilization for people diagnosed with chronic diseases in impoverished regions and to identify its associated factors, which is expected to have practical implications for the implementations of interventions tailored to the specific needs of disadvantaged residents in rural China to achieve effective utilization of health services in a timely manner. Our results suggest that the implementation of a series of comprehensive strategies should be addressed throughout the policy-making process to improve the provision of regular source of care as a significant determinant for reducing health services underutilization, thus ultimately achieving equal utilization of health services in impoverished regions, especially among chronic disease patients.

3. Zhao, X., Zhang, Y., Yang, Y. & Pan, J. “Diabetes-related avoidable hospitalisations and its relationship with primary healthcare resourcing in China: A cross-sectional study from Sichuan Province.” Health & Social Care in the Community 00, 1–14 (2021). DOI:

Abstract: The reduction of diabetes-related avoidable hospitalisations (AHs) can be achieved via the provision of timely and effective primary healthcare (PHC), which has made diabetes AHs rate a widely adopted indicator for evaluating the performances of PHC systems. This study reported the AHs rate of diabetes and further explored its relationship with PHC resourcing in China. Hospital discharge data of the fourth quarters of 2016 and 2017 in Sichuan Province, China were used. The number of PHC doctors per 10,000 population and the proportion of PHC doctors on all doctors were used as indicators reflective of PHC resourcing. Linear regression models were used to explore the associations between PHC resourcing and AHs of diabetes. Age-standardised rates of diabetes-related AHs in Sichuan province, China were found to be 248.102 and 272.368 per 100,000 population in 2016 and 2017, respectively. A 10% increase in the number of PHC doctors per 10,000 population was associated with a reduction of 2.574 per 100,000 population in the age-standardised AHs rate of diabetes. In addition, 10% increase in the proportion of PHC doctors on all doctors was associated with a reduction of 10.839 diabetes-related AHs per 100,000 population. Based on subgroup analysis, PHC resourcing demonstrated to have a stronger impact on AHs of diabetes with long-term complications than on that of uncontrolled diabetes. Our findings reported that the diabetes AHs rates in Sichuan Province were prevalently high. We also found that increased PHC resourcing was associated with decreased diabetes-related AHs rates.

Partners and Funding

This work involves faculty from the Harvard T.H. Chan School of Public Health, Department of Global Health and Population, as well as researchers from Sichuan University and Peking University. The work is funded from a grant from the Bill and Melinda Gates Foundation.