Policy practice People-centred integrated care in urban China Xin Wang,Xizhuo Sun,5 Stephen Birch,Fangfang Gong,Pim Valentijn,Lijin Chen,a Yong Zhang,? Yixiang Huang&Hongwei Yange Abstract In most countries,the demand for integrated care for people with chronic diseases is increasing as the population ages.This demand requires a fundamental shift of health-care systems towards more integrated service delivery models.To achieve this shift in China, the World Health Organization,the World Bank and the Chinese government proposed a tiered health-care delivery system in accordance with a people-centred integrated care model.The approach was pioneered in Luohu district of Shenzhen city from 2015 to 2017 as a template for practice.In September 2017,China's health ministry introduced this approach to people-centred integrated care to the entire country.We describe the features of the Luohu model in relation to the core action areas and implementation strategies proposed and we summarize data from an evaluation of the first two years of the programme.We discuss the challenges faced during implementation and the lessons learnt from it for other health-care systems.We consider how to improve collaboration between institutions,how to change the population's behaviour about using community health services as the first point of contact and how to manage resources effectively to avoid budget deficits.Finally,we outline next steps of the Luohu model and its potential application to strengthen health care in other urban health-care systems Abstracts in,Francais,PyccKn and Espanol at the end of each article. The World Health Organization (WHO)describes Introduction people-centred integrated care as health services that are On 1 September 2017,China's health ministry introduced a managed and delivered so that patients receive a continuum new approach to people-centred integrated care to the entire of preventive and curative services according to their needs over time that is coordinated across different levels of the country.'Called the Luohu model,the approach was pioneered in Luohu district of Shenzhen city.This development was a health-care system.Over the last decade,integrated response to the problems faced by the existing health-care care has been suggested as one strategy for promoting system in addressing the increased demands of delivering coordinated health-care delivery,improving quality of integrated care.Health-care systems worldwide are facing care and reducing costs.2 In 2016,the report Deepening similar problems emerging from epidemiological transition health reform in China was published jointly by the WHO, and population ageing.Many people-centred integrated the World Bank and the Chinese government.S The report care programmes have been initiated,implemented and evalu- proposed strengthening health care in China through a ated in high-income countries.While experience from other tiered health-care delivery system in accordance with a countries provides a useful basis for planning,the ability to people-centred integrated care model. The introduction of the Luohu model set an example for achieve people-centred integrated care can be highly context- specific and there is a lack of knowledge about how to stimu- urban areas in China to build people-centred integrated care late integrated care in low-and middle-income countries.0 delivery systems.This represented a big step in pursuing higher The current system of health-care delivery in China is quality health care,better outcomes and more affordable costs fragmented,hospital-centred and treatment-dominated,with for the population in China.In this paper,we describe the little effective collaboration among institutions in different features of the Luohu model,discuss lessons learnt from its tiers of the system.312 In 2016,there were an estimated 231 implementation and outline next steps for the Luohu model million people aged 60 years or older in China,16.7%of the and its application in other Chinese urban health-care systems. population of 1383 billion,and more than 100 million among We also provide suggestions on adapting the Luohu model in them had at least one chronic noncommunicable disease. other low-and middle-income countries. Predictions suggested that without health-care reform,China's health-care costs in United States dollars(US$)would increase The Luohu model from 5.6%of gross domestic product in 2015(USS 592 billion of US$10571 billion)to 9.1%in 2035(US$2713 billion of Background USS 29810 billion).'5 System reform was therefore viewed as The Luohu model was a response to the needs of patients and necessary to avoid the risk of becoming a high-cost,low-value their families in Luohu district(Health and Family Planning health-care system. Commission of Shenzhen city,unpublished data,2015).With School of Public Health,SUN Yat-sen University,No.74,Zhongshan 2nd Road,Yuexiu District,Guangzhou 510080,China Shenzhen Luohu Hospital Group,Shenzhen,China. Centre for the Business and Economics of Health,University of Queensland,Brisbane,Australia. dDepartment of Health Services Research,Care and Public Health Research Institute(CAPHRI),Faculty of Health,Medicine and Life Sciences,Maastricht University, Maastricht,Netherlands. China National Health Development Research Centre,Beijing,China Correspondence to Yixiang Huang (email:huangyx@mail sysu.edu.cn). (Submitted:22 April 2018-Revised version received:7 September 2018-Accepted:7 September 2018-Published online:1 October 2018) Bull World Health Organ 2018:96:843-852 doi:http://dx.doi.org/10.2471/BLT.18.214908 843Bull World Health Organ 2018;96:843–852 | doi: http://dx.doi.org/10.2471/BLT.18.214908 Policy & practice 843 Introduction On 1 September 2017, China’s health ministry introduced a new approach to people-centred integrated care to the entire country.1 Called the Luohu model, the approach was pioneered in Luohu district of Shenzhen city. This development was a response to the problems faced by the existing health-care system in addressing the increased demands of delivering integrated care.2,3 Health-care systems worldwide are facing similar problems emerging from epidemiological transition and population ageing.4–6 Many people-centred integrated care programmes have been initiated, implemented and evalu￾ated in high-income countries. While experience from other countries provides a useful basis for planning,7,8 the ability to achieve people-centred integrated care can be highly context￾specific8,9 and there is a lack of knowledge about how to stimu￾late integrated care in low- and middle-income countries.10 The current system of health-care delivery in China is fragmented, hospital-centred and treatment-dominated, with little effective collaboration among institutions in different tiers of the system.3,11,12 In 2016, there were an estimated 231 million people aged 60 years or older in China, 16.7% of the population of 1 383 billion, and more than 100 million among them had at least one chronic noncommunicable disease.13,14 Predictions suggested that without health-care reform, China’s health-care costs in United States dollars (US$) would increase from 5.6% of gross domestic product in 2015 (US$ 592 billion of US$ 10 571 billion) to 9.1% in 2035 (US$ 2713 billion of US$ 29 810 billion).15 System reform was therefore viewed as necessary to avoid the risk of becoming a high-cost, low-value health-care system. The World Health Organization (WHO) describes people-centred integrated care as health services that are managed and delivered so that patients receive a continuum of preventive and curative services according to their needs over time that is coordinated across different levels of the health-care system.16–19 Over the last decade, integrated care has been suggested as one strategy for promoting coordinated health-care delivery, improving quality of care and reducing costs.20,21 In 2016, the report Deepening health reform in China was published jointly by the WHO, the World Bank and the Chinese government.15 The report proposed strengthening health care in China through a tiered health-care delivery system in accordance with a people-centred integrated care model. The introduction of the Luohu model set an example for urban areas in China to build people-centred integrated care delivery systems. This represented a big step in pursuing higher quality health care, better outcomes and more affordable costs for the population in China. In this paper, we describe the features of the Luohu model, discuss lessons learnt from its implementation and outline next steps for the Luohu model and its application in other Chinese urban health-care systems. We also provide suggestions on adapting the Luohu model in other low- and middle-income countries. The Luohu model Background The Luohu model was a response to the needs of patients and their families in Luohu district (Health and Family Planning Commission of Shenzhen city, unpublished data, 2015). With Abstract In most countries, the demand for integrated care for people with chronic diseases is increasing as the population ages. This demand requires a fundamental shift of health-care systems towards more integrated service delivery models. To achieve this shift in China, the World Health Organization, the World Bank and the Chinese government proposed a tiered health-care delivery system in accordance with a people-centred integrated care model. The approach was pioneered in Luohu district of Shenzhen city from 2015 to 2017 as a template for practice. In September 2017, China’s health ministry introduced this approach to people-centred integrated care to the entire country. We describe the features of the Luohu model in relation to the core action areas and implementation strategies proposed and we summarize data from an evaluation of the first two years of the programme. We discuss the challenges faced during implementation and the lessons learnt from it for other health-care systems. We consider how to improve collaboration between institutions, how to change the population’s behaviour about using community health services as the first point of contact and how to manage resources effectively to avoid budget deficits. Finally, we outline next steps of the Luohu model and its potential application to strengthen health care in other urban health-care systems. a School of Public Health, SUN Yat-sen University, No. 74, Zhongshan 2nd Road, Yuexiu District, Guangzhou 510080, China. b Shenzhen Luohu Hospital Group, Shenzhen, China. c Centre for the Business and Economics of Health, University of Queensland, Brisbane, Australia. d Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands. e China National Health Development Research Centre, Beijing, China. Correspondence to Yixiang Huang (email: huangyx@mail.sysu.edu.cn). (Submitted: 22 April 2018 – Revised version received: 7 September 2018 – Accepted: 7 September 2018 – Published online: 1 October 2018 ) People-centred integrated care in urban China Xin Wang,a Xizhuo Sun,b Stephen Birch,c Fangfang Gong,b Pim Valentijn,d Lijin Chen,a Yong Zhang,a Yixiang Huanga & Hongwei Yange Policy & practice