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Challenges for Primary Health Care Services

China, a large and rapidly developing middle-income country with a hospital-based service delivery system for its aging population, makes a suitable case study of efforts to promote PHC management. Over the past several decades, PHC use in China has significantly decreased relative to hospital-based care. This trend is a natural consequence of the country’s unprecedented increases in living standards and improvements in financial risk protection, which increase patients’ demand for quality care and spur self-referral to providers with higher-perceived quality like hospital outpatient departments.

The performance differences between PHC and hospital-based care are especially stark in China’s rural areas, where management of chronic diseases relies heavily on grassroots physicians, who have limited medical education and training. That is why Eggleston and her colleagues set out to provide new empirical evidence about the effectiveness of a program that promotes PHC management of hypertension and diabetes for rural Chinese. Part of the National Basic Public Health Service Program for rural Chinese, it financially rewards PHC grassroots physicians for managing residents with chronic diseases.

Collaborative Research in the Era of Great Power Competition

Eggleston’s co-authors include her colleagues at the Zhejiang Provincial Center for Disease Control and Prevention (Zhejiang CDC). Their study is the culmination of Eggleston’s multiyear collaborative research project with the Zhejiang CDC team, "Addressing Health Disparities in China," which looks to Tongxiang county in Zhejiang as a case study of China's responses to healthcare inequalities and population aging challenges in rural and urban areas. The project also involved two Stanford doctoral students who worked with Eggleston.

“This kind of collaboration, where we utilize the data that's available to answer an important question while respecting the privacy of the individuals and hopefully delivering benefits to them through more effective or affordable programs in the future perhaps is a promising model for researchers here and elsewhere to undertake,” she notes.

Disentangling the Effect of Primary Health Care Management

To study the program’s effectiveness, the researchers assembled a unique dataset linking individual-level administrative and health information between 2011 and 2015 for rural Chinese diagnosed with hypertension or diabetes in Tongxiang, a mostly rural county of Zhejiang province in southeast China. Collected by the Tongxiang CDC and Zhejiang CDC, the compiled database links basic demographic information, health insurance claims, PHC service logs, and health check-up records — four sets of data that are rarely linked and analyzed in combination in China healthcare research.

Targeting the program’s effects on healthcare utilization, spending, and health outcomes, Eggleston and her colleagues compare residents in neighboring villages that straddle township boundaries. These residents are similar in their individual and environmental characteristics that shape health care use but are subject to different PHC management practices. This “border sampling” allows the researchers to disentangle the effects of PHC management from other underlying spatial differences that impact health care utilization. For each township, the researchers use a management intensity index that reflects the cumulative efforts of PHC physicians to screen their communities and keep patients within the PHC management programs for controlling hypertension and diabetes. Each township’s experience with PHC management over the 5-year study period is thus a case study for rural China.

Net Value in Chronic Disease Management

The results are encouraging for China's investment in primary care management of chronic diseases. Eggleston and her colleagues find that patients residing in a village within a township with more intensive PHC management had a relative increase in PHC visits, fewer specialist visits, fewer hospital admissions, and lower spending compared to neighbors with less intensive management. They also tend to have better medication adherence and better health outcomes as measured by blood pressure control.

The results suggest that PHC chronic disease management in rural China improves net value in multiple ways — increasing PHC utilization, reducing avoidable hospitalizations, decreasing medical spending, and improving intermediate- and long-run health outcomes — all while leveraging existing resources rather than restricting care.

The findings also help inform investments in primary health care in LMICs. They highlight the latent potential of frontline healthcare workers in such settings to be more productive and show that financially rewarding these grassroots workers for managing residents with chronic diseases helps improve health outcomes. Moreover, they offer empirical evidence that supports the effectiveness of chronic disease management programs as part of broader regional initiatives to address population health.

This summer, China conducted a series of tests with nuclear-capable hypersonic weapons systems that have clearly gotten the attention of officials across the U.S. government. The tests included a hypersonic glide vehicle — a delivery mechanism that can maneuver through the Earth’s atmosphere towards its target — and also incorporated a fractional orbital bombardment system. Because a fractional orbital bombardment system can deliver its payload by entering into lower orbit and then “dropping” it on the target, it could reach the U.S. homeland via the South Pole, bypassing U.S. early warning systems and missile defenses, which are primarily geared towards the interception of ballistic missiles from the north.

Read the rest at War on the Rocks

“I’m a believer in the virtues of public service and what it means to our country,” Burns told the audience.

He recognized that this moment in American policy at home and around the world is one of transition and uncertainty and that the current climate of distrust between the American public and government has had a tremendous impact on domestic politics. Abroad, the rise of China cuts across all sectors of U.S. geopolitics, while even larger, non-state challenges such as climate change, global health insecurity, and the rapid advancement of technology pose even greater existential challenges.

Still, Burns has faith in the unique relationship that the United States has to its public service institutions.

“It’s my obligation as a leader, and your opportunity [as potential future public servants] to demonstrate that we can produce institutions in this country that are professional, apolitical, and devoted to the national interest and doing things in accordance with American values,” he emphasized.

In his jurisdiction over the C.I.A, Burns has already set benchmarks to ensure the agency remains competitive and serves its purpose of providing policymakers with high-quality, timely intelligence which supports their decision-making process. He is committed to streamlining the hiring process at the C.I.A. and making it more attractive to top talent, as well as diversifying the workforce and drawing on expertise from across all types of professional backgrounds and abilities. “We’re not going to be an effective intelligence organization if everyone at the C.I.A. looks like me,” he quipped.

Keeping the bigger picture in mind, Director Burns reiterated one of the underlying principles that has guided his approach to public service. “Both [diplomacy and intelligence] require a sense of humility. There are perspectives in the world that are not identical to ours. You don’t have to accept or indulge those perspectives, but understanding them is the starting point of effective intelligence work and effective diplomacy.”