Experts call for improved grassroots facilities

Following the outbreak of severe acute respiratory syndrome in 2003, China increased investment in the national public health system.

The resulting improvements included construction of a first-class Center for Disease Control and Prevention, and the establishment of a national network to report infectious diseases and public health emergencies.

This year's novel coronavirus outbreak was the first time an infectious disease－such as H1N1 flu, aka swine flu, or Middle East respiratory syndrome－had caused a major epidemic in China since 2003.

With the COVID-19 epidemic increasingly being brought under control, the nation, especially experts and officials, is reflecting on deficiencies in the health system, including emergency responses to outbreaks of infectious disease.

The COVID-19 epidemic is a major public health emergency. The virus has spread faster and wider than any other since the founding of the People's Republic of China in 1949, and has proven to be the most difficult to contain.

By Saturday night, there had been more than 83,000 confirmed COVID-19 cases on the Chinese mainland, resulting in more than 4,600 deaths, according to the National Health Commission.

The commission's figures show that there are currently 129 patients being treated for COVID-19 on the mainland.

Meanwhile, nearly 80,000 patients had beaten the illness and had been discharged from hospitals, it said.

In the past month, the number of new cases reported daily had mostly remained in single digits－a sharp contrast to the thousands that were reported every day at the height of the outbreak in February－until a rise was reported in Beijing toward the end of last week.

Intensification

In the Government Work Report, delivered to the National People's Congress, the top legislative body, on May 22, Premier Li Keqiang called for greater intensity in the construction of the public health system this year.

Li stressed reform of the disease prevention and control system, and improvements to the mechanism for reporting and issuing early warnings about infectious diseases.

Information about epidemics will continue to be released in a timely, open and transparent manner, he said.

During this year's two sessions－the annual meetings of the NPC and the Chinese People's Political Consultative Conference－national legislators and political advisers proposed ways of improving the health system to eliminate loopholes and prevent epidemics.

Dong Xiaoping, director of global public health at the Chinese Center for Disease Control and Prevention, said reforming the CDCs, a core part of the health system, and improving talent selection are necessary to improve the system.

"In the reforms, the CDCs should be given certain administrative powers," said Dong, a member of the National Committee of the CPPCC, the top advisory body.

Under the law on the prevention of infectious and contagious diseases, CDCs across China may only collect and analyze information related to outbreaks and then report to health authorities.

CDCs across China are managed by local authorities. However, those at higher levels, such as the national CDC, lack the authority to direct local CDCs, which results in poor coordination, Dong said.

Higher-level CDCs should be given certain administrative roles during national medical crises, so they can mobilize control and prevention resources in urgent cases, he added.

Information sharing

In addition to reforming the CDCs, connectivity between CDCs and hospitals, and CDCs and related government departments, must be improved to provide efficient information sharing, he said.

"In the case of epidemics, the CDCs are the scouts and they must be better linked with hospitals in terms of both information and personnel, so they have adequate information to fight epidemics," he added.

Meanwhile, government departments such as the customs and the aviation authority, which hold information on travelers' movements, can provide CDCs with valuable information in the event of a major outbreak of disease.

At present, it is difficult for CDCs to obtain such information from those authorities, Dong said.

Following the coronavirus outbreak, many health experts called for improved efforts to strengthen CDCs nationwide, including raising their status and improving talent building, so they can play a better role in epidemic control.

He Lin, a deputy to the NPC, said more attention urgently needs to be paid to talent building, so public health bodies are capable of assuming such duties.

"Talent in CDCs has been draining since 2010, mainly due to low wages, and some CDC workers would rather work as testers at hospitals," said He, deputy director of the Health Education Department at the Guizhou Provincial Center for Disease Control and Prevention in Guiyang, Guizhou province.

"I suggest improving CDC workers' salaries and putting them under government management, similar to government employees, to improve their career prospects and team stability."

Dong said CDCs face a dilemma: the better their work, the better it is for disease control and prevention, but that poses a risk that they will become less visible to the public.

"It is important to prioritize disease prevention over treatment at all times, rather than just during outbreaks," he said.

"The mission for CDC workers is to ensure that epidemics don't occur－but to do this they have to make consistent efforts every day."

Huang Gairong is a member of the National Committee of the CPPCC and also director of the Department of Geriatric Medicine at Henan Provincial People's Hospital in Zhengzhou, Henan province.

He said the outbreak has exposed failings in the basic health system.

The problems include a lack of disease prevention and control capacity in many grassroots institutions, such as community health centers, he said.

Following the SARS outbreak, government investment in basic public health rose markedly for several years, but it has been falling since 2010, he added.

Investment

"Many problems at county-level public health institutions have been revealed by the epidemic, including outdated equipment and poor capacity for virus testing and monitoring," Huang said.

"I suggest that financial investment should be increased to ensure the health system at the grassroots is well-equipped."

Wu Hao, another member of the CPPCC National Committee and director of the Fangzhuang Community Health Center in Beijing, said the lower capabilities of local community health centers in Wuhan, Hubei, to provide services meant many patients preferred to visit large hospitals for diagnosis and treatment.

Local patients crowded into a few big hospitals during the initial stages of the coronavirus outbreak in Central China's largest city.

That resulted in some cross-infection and contributed to the city quickly becoming overwhelmed by large numbers of patients in late January and early February, even though Wuhan has many big hospitals, including several leading facilities.

"Rather than continuing to build massive glittering hospitals in big cities, we must empower smaller medical facilities in communities and rural areas so they become scouts for disease outbreaks," Wu said.

"More integration is needed between these medical institutions and local disease control and prevention centers, so they work better together for epidemic control during major health emergencies."

Meanwhile, smaller medical facilities, such as community health centers, should adopt the latest information technology－such as big data－to aid epidemic prevention and control, including the quick and effective tracing of close contacts of patients with infectious diseases, he said.

China has promoted reform of the healthcare system in recent years－including narrowing the gap between grassroots medical facilities and better-equipped larger hospitals.

However, significant progress has not yet been achieved, and consistent efforts are needed, Wu said.

Tiered system

"A tiered healthcare system should be set up to give basic providers, such as community health centers, a more important role in disease prevention, control and treatment," he said.

A crucial step in the process is to improve the career prospects of general practitioners at grassroots medical facilities to attract sufficient qualified talent, who will serve as an effective guard for public health, he added.

Huang, from Henan Provincial People's Hospital, said a national-level government department should be established to deal exclusively with basic health services nationwide and prevent the marginalization of the basic health program within the overall healthcare system.

The department should be empowered to supervise the basic health system nationwide, including local CDCs and health centers, he said.

That would allow the CDCs and health centers to tackle duties such as disease control and prevention, management of chronic diseases, routine monitoring of food safety and environmental health, and also work with hospitals for epidemic control during outbreaks of major infectious diseases, he added.

National political advisers have also called for improvements to the emergency response system for major crises, including the establishment of a number of national centers for emergency medicine and reserves.

Zhu Tongyu, a member of the CPPCC National Committee and director of the Shanghai Public Health Center, urged the construction of about 10 emergency medical centers in cities with populations of more than 10 million.

Each center could serve as a major hospital, with between 1,000 and 2,000 beds, but could quickly be transformed into a designated treatment center with 5,000 beds for major health emergencies, he said.

"Such hospitals could accommodate large numbers of patients quickly in the event of a major outbreak, so other hospitals would have time to increase the number of beds, thus reducing fatalities to the minimum," Zhu said.

Such centers should be well-equipped and have strong capabilities to treat patients and conduct scientific research, including supporting the development of vaccines and drugs, he said.

During the initial period of the COVID-19 epidemic in Wuhan, the city's hospitals were overwhelmed by the rapidly rising number of patients and a severe shortage of beds.

Many patients were obliged to self-isolate at home, posing a risk to themselves and others.

In response, authorities built a number of temporary hospitals, including transforming major sports stadiums and exhibition halls into makeshift facilities that could receive all patients who needed treatment.

Better preparation

Zhu said that while these measures played an important role in epidemic control, it is essential to provide purpose-built emergency medical centers to allow better preparation.

That's because China still faces severe challenges from major outbreaks of both well-known diseases, such as tuberculosis, hepatitis B and HIV/AIDS, and new illnesses.

Li Yanping, a deputy to the NPC and vice-president of the Chongqing Traditional Chinese Medicine Hospital, said TCM played an important role in treating COVID-19 patients, which means more importance should be given to TCM in future prevention and control strategies.

For example, regular fever clinics and wards equipped with proper emergency rescue equipment could be established at all county-level TCM hospitals, so they could be transformed into facilities to receive patients with infectious diseases.

Meanwhile, authorities should provide more support for research into the role of TCM in fighting infectious diseases, she said.