{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,15]],"date-time":"2026-10-15T20:32:07Z","timestamp":1792096327070,"version":"4.4.0"},"reference-count":99,"publisher":"BMJ","issue":"1","license":[{"start":{"date-parts":[[2025,3,20]],"date-time":"2025-03-20T00:00:00Z","timestamp":1742428800000},"content-version":"unspecified","delay-in-days":78,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["bmjph"],"accepted":{"date-parts":[[2025,2,24]]},"published-print":{"date-parts":[[2025,1]]},"abstract":"<jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>Comprehensive health reforms aimed at strengthening primary healthcare (PHC) are infrequently adopted and often poorly evaluated in low-income and middle-income countries. China launched a system-wide PHC reform with a staggered roll-out between 2014 and 2018 with multiple components: (1) gatekeeping via tiered reimbursement, (2) a family physician scheme and (3) a two-way referral system between PHC facilities and hospitals. This study examines the reform impacts on health service utilisation, out-of-pocket expenditures, health outcomes and health inequalities.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>The staggered roll-out of the reforms in 125 cities across China was identified using web-scraping. Using longitudinal data (2011\u20132018) from the China Health and Retirement Longitudinal Study (a cohort aged \u226545), this study adopted a difference-in-differences method to assess the reform\u2019s impacts on: (1) visits to PHC facilities, (2) hospitalisation, (3) out-of-pocket expenditures (OOPEs) and (4) self-reported health. Subgroup analyses were conducted by rural\/urban populations and wealth quartiles.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>The reform had small and short-lived impacts\u2014a 7.8% increase in the probability of visiting PHC facilities (95%\u2009CI 0.3 to 15.2), a 10.2% increase in reporting good health (95%\u2009CI 0.6 to 19.8) and an 873.9 Chinese Yuan (US$129.1) increase in average annual OOPEs (95%\u2009CI 57.9 to 1689.9) in the first year of reform implementation. There was no impact on hospitalisation. Increases in PHC utilisation were only found in rural and lower-income populations.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>China\u2019s PHC reforms had some modest, temporary impacts on increasing primary care utilisation and self-reported health. However, further interventions are needed to transition away from the hospital-centric health system and to increase financial protection and health equity in China.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1136\/bmjph-2024-001595","type":"journal-article","created":{"date-parts":[[2025,3,24]],"date-time":"2025-03-24T01:58:19Z","timestamp":1742781499000},"page":"e001595","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":4,"title":["Impact of China\u2019s primary healthcare reforms on utilisation, payments and self-reported health: a quasi-experimental analysis of a middle-aged and older cohort 2011\u20132018"],"prefix":"10.1136","volume":"3","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0883-5021","authenticated-orcid":false,"given":"Chang","family":"Cai","sequence":"first","affiliation":[{"name":"Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, Imperial College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher","family":"Millett","sequence":"additional","affiliation":[{"name":"Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, Imperial College London, London, UK"},{"name":"Public Health Research Centre and Comprehensive Health Research Centre, NOVA National School of Public Health, NOVA University Lisbon, Lisbon, Portugal"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shangzhi","family":"Xiong","sequence":"additional","affiliation":[{"name":"The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maoyi","family":"Tian","sequence":"additional","affiliation":[{"name":"The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia"},{"name":"School of Public Health, Harbin Medical University, Harbin, Heilongjiang, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jin","family":"Xu","sequence":"additional","affiliation":[{"name":"China Center for Health Development Studies, Peking University, Beijing, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas","family":"Hone","sequence":"additional","affiliation":[{"name":"Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, Imperial College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2025,3,23]]},"reference":[{"key":"2025083110244914000_3.1.e001595.1","unstructured":"World Health Organization . 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