Art.3,page 2 of 10 Wang et al:The Luohu Model economy,and the government dramatically reduced hospi- tricts in Shenzhen,with an area of 78.36 km2 and a popu- tal funding.Responding to these reductions,hospitals tried lation of 1.4 million.Per capital Gross Domestic Product to earn revenues by providing more profitable health care (GDP)in Luohu was $25,200 in 2016 [23].It also has the primarily diagnosis and treatment rather than prevention largest proportion of the elderly residents in Shenzhen. and rehabilitation.The traditional three-tier healthcare sys It is estimated that the number of elderly individuals and tem collapsed,and primary health care stations no longer patients with chronic conditions exceeds over 451,000. served as gatekeepers 13.Since new health reforms were The government of Luohu has the tradition of reform,not introduced in 2009,China's government has been encour- only in economy but also in health. aging health care provision in primary health stations by Luohu District has five district-level hospitals and 83 financial subsidies and a program entitled Equalization of community health stations.While most cities with two- Basic Public Health Services [14.However,measures to level primary health care institutions [24].Luohu has improve collaboration among institutions and reduce frag- only one-level community health stations.Furthermore, mentation of services have been insufficient. all 83 community health stations are affiliated with one Over the last decade,integrated care has been sug- of the five hospitals.For example,the community health gested as one strategy for promoting coordinated health management center in the Luohu General Hospital is care delivery,improving the quality of care and reduc- in charge of 18 community health stations,managing ing costs [15-17].In 2016,the report "Deepening health human resources,finance,assets and service delivery in reform in China"[18].published by the World Health each station.Also located in Luohu is a city-level gen- Organization(WHO),World Bank(WB),and the Chinese eral hospital with 2,000 beds,under the charge of the Government,proposed strengthening healthcare in China Shenzhen city government.The numbers of beds and through a tiered health care delivery system in accord- physicians in the city hospital exceed those in the five ance with a People-Centered Integrated Care model.In independent district hospitals.The expansion of the April 2017,the General Office of the State Council issued a city hospital has been associated with the weakening of Guideline for constructing Medical Consortia [19].In the the ability of district hospitals and community health guideline,four types of medical consortia were suggested: stations to provide care as patients are free to seek ser hospital groups in urban areas,medical associations in vices at the city hospital directly.Therefore,"line up for rural areas,cross-regional specialist alliances and tele- 3 hours,treatment for 3 minutes"became a problem collaboration networks in remote areas.Medical consortia in Luohu,especially for the elderly and patients with thus became a main means for achieving People-Centered chronic diseases.The Luohu health reform system aims Integrated Care.On Sept 1st 2017,China's National Health to achieve "less illness,fewer hospital admissions,lower and Family Planning Commission introduced the Luohu financial burdens,and better services"25 by develop- model,an approach to healthcare integration pioneered ment of a community-based and prevention-oriented in Luohu District,to the entire country and encouraged integrated care system. all cities to learn from it [20].Subsequently,more than 1,500 policy makers from health and other social sectors Process of the Luohu reform in 321 cities received on-site training in the Luohu model. Figure 1 shows the timeline of the Luohu reform.In The aims of this study are to introduce the Luohu model, February 2015,the district government began with the to evaluate its effects and to explore lessons learned.With concept "Shifting focus from treatment to health".After enhancement of the Belt and Road health collaboration 10 rounds of expert consultations,the Luohu hospital [21,22],health reforms in urban China may have a con- group was established in Aug 2015.It consists of five siderable impact on other countries'health systems,espe- district hospitals,23 community health stations,and an cially low-and-middle-income countries facing the same institute of precision medicine,along with six resource challenges.Moreover,features of healthcare integration sharing centers and six administrative centers(Figure 2). in China,which may differ from those in European coun After being established,the hospital group adopted a tries,may provide references for other countries. series of reforms.In Dec 2015,a Quality Management Center took action to improve the quality of care in all Development of the Luohu Model institutions,especially in community health stations.In Background of Shenzhen City and the Luohu District May 2016,a new health insurance policy,"Global budget, China's Reform and Opening in 1980s began in Shenzhen balance retained",was introduced which funded hospitals City,which,in 2016,ranked first in economic competitive- via global budgets and allowed institutions to retain any ness among cities nationwide.Luohu is one of the ten dis- funds not spent during the financial year.At the same Figure 1:Timeline of the Luohu reformArt. 3, page 2 of 10 Wang et al: The Luohu Model economy, and the government dramatically reduced hospi￾tal funding. Responding to these reductions, hospitals tried to earn revenues by providing more profitable health care, primarily diagnosis and treatment rather than prevention and rehabilitation. The traditional three-tier healthcare sys￾tem collapsed, and primary health care stations no longer served as gatekeepers [13]. Since new health reforms were introduced in 2009, China’s government has been encour￾aging health care provision in primary health stations by financial subsidies and a program entitled Equalization of Basic Public Health Services [14]. However, measures to improve collaboration among institutions and reduce frag￾mentation of services have been insufficient. Over the last decade, integrated care has been sug￾gested as one strategy for promoting coordinated health care delivery, improving the quality of care and reduc￾ing costs [15–17]. In 2016, the report “Deepening health reform in China” [18], published by the World Health Organization (WHO), World Bank (WB), and the Chinese Government, proposed strengthening healthcare in China through a tiered health care delivery system in accord￾ance with a People-Centered Integrated Care model. In April 2017, the General Office of the State Council issued a Guideline for constructing Medical Consortia [19]. In the guideline, four types of medical consortia were suggested: hospital groups in urban areas, medical associations in rural areas, cross-regional specialist alliances and tele￾collaboration networks in remote areas. Medical consortia thus became a main means for achieving People-Centered Integrated Care. On Sept 1st 2017, China’s National Health and Family Planning Commission introduced the Luohu model, an approach to healthcare integration pioneered in Luohu District, to the entire country and encouraged all cities to learn from it [20]. Subsequently, more than 1,500 policy makers from health and other social sectors in 321 cities received on-site training in the Luohu model. The aims of this study are to introduce the Luohu model, to evaluate its effects and to explore lessons learned. With enhancement of the Belt and Road health collaboration [21, 22], health reforms in urban China may have a con￾siderable impact on other countries’ health systems, espe￾cially low- and-middle-income countries facing the same challenges. Moreover, features of healthcare integration in China, which may differ from those in European coun￾tries, may provide references for other countries. Development of the Luohu Model Background of Shenzhen City and the Luohu District China’s Reform and Opening in 1980s began in Shenzhen City, which, in 2016, ranked first in economic competitive￾ness among cities nationwide. Luohu is one of the ten dis￾tricts in Shenzhen, with an area of 78.36 km2 and a popu￾lation of 1.4 million. Per capital Gross Domestic Product (GDP) in Luohu was $25,200 in 2016 [23]. It also has the largest proportion of the elderly residents in Shenzhen. It is estimated that the number of elderly individuals and patients with chronic conditions exceeds over 451,000. The government of Luohu has the tradition of reform, not only in economy but also in health. Luohu District has five district-level hospitals and 83 community health stations. While most cities with two￾level primary health care institutions [24], Luohu has only one-level community health stations. Furthermore, all 83 community health stations are affiliated with one of the five hospitals. For example, the community health management center in the Luohu General Hospital is in charge of 18 community health stations, managing human resources, finance, assets and service delivery in each station. Also located in Luohu is a city-level gen￾eral hospital with 2,000 beds, under the charge of the Shenzhen city government. The numbers of beds and physicians in the city hospital exceed those in the five independent district hospitals. The expansion of the city hospital has been associated with the weakening of the ability of district hospitals and community health stations to provide care as patients are free to seek ser￾vices at the city hospital directly. Therefore, “line up for 3 hours, treatment for 3 minutes” became a problem in Luohu, especially for the elderly and patients with chronic diseases. The Luohu health reform system aims to achieve “less illness, fewer hospital admissions, lower financial burdens, and better services” [25] by develop￾ment of a community-based and prevention-oriented integrated care system. Process of the Luohu reform Figure 1 shows the timeline of the Luohu reform. In February 2015, the district government began with the concept “Shifting focus from treatment to health”. After 10 rounds of expert consultations, the Luohu hospital group was established in Aug 2015. It consists of five district hospitals, 23 community health stations, and an institute of precision medicine, along with six resource sharing centers and six administrative centers (Figure 2). After being established, the hospital group adopted a series of reforms. In Dec 2015, a Quality Management Center took action to improve the quality of care in all institutions, especially in community health stations. In May 2016, a new health insurance policy, “Global budget, balance retained”, was introduced which funded hospitals via global budgets and allowed institutions to retain any funds not spent during the financial year. At the same Figure 1: Timeline of the Luohu reform