Table 3 Summary of the barriers and facilitators of diabetes management at PHC level

Capacity (PHC service providers)

Barrier 1: Education gap

Education level is low in general. In urban areas, less than half of the PHC providers hold a college degree: 25.7% in clinics, 50.0% in centers. In rural areas, the figures are only 2.3% and 13.9%, respectively.

At rural clinics, most village doctors only attended technical school. Retaining doctors with higher education levels or experience working at hospitals in rural clinics posed a significant challenge due to low income, heavy workload, and unclear career development.

Barrier 2: Licensure gap

More than 90% doctors in urban PHC facilities were licensed, whereas fewer doctors were licensed in rural areas (47.9% in clinics and 75.2% in centers).

Despite the legal prohibition on unlicensed practice, this study has observed the presence of village doctors practicing without a license.

Barrier 3: Ageing of doctors in rural clinics

The mean age of village doctors, at 47 years, was notably higher compared to the mean age of 37 years observed among other PHC facilities.

About 19.1% village doctors were older than 60 years vs. 2.6% doctors in other PHC facilities.

The village doctors we interviewed had an average age of 43 years. It was challenging to recruit young and capable doctors in remote areas.

Barrier 4: Overburdened

Not including other public health services, around 400 patients with hypertension or diabetes need to be managed using one FTE by medical staff. This is a tremendous workload for NCD managers considering at least 4 BP/BG measurements and face-to-face consultations should be provided for each of the patients.

In rural and urban clinics, except for clinical services, more than 14 public health services should be provided by PHC providers. In rural area, half of their time has to be devoted to NCD management.

Barrier 5: Clinical inertia

Doctors were reluctant to intensify treatment to the elderly patients who were not at evidence-based goals for care. They were worried about the negative feedback from patients, and they were not confident about their capacity.

Facilitator 1: Workshops on NCD prevention and control

Almost all PHC facilities (95%) reported that they received training workshops about NCD prevention and control which facilitated the implementation of NBPHSP.

NCD prevention and control trainings were provided by local health department, CDC, hospitals, center level PHC facilities and other institutes.

Facilitator 2: On-site technical guidance and visits by hospital chief experts

Most the clinic level PHC facilities (94%) reported that they have received on-site technical guidance provided by the center level facilities, while 77.0% urban centers and 94.3% rural centers reported that they have offered such guidance to clinic level facilities.

The proportions of PHC facilities that received hospital expert visits were 58.8%, 61.5%, 92.3%, and 73.1% for urban clinics, rural clinics, urban centers, and rural centers respectively.

Hospital medical experts from specific fields visit PHC facilities to offer consultation services, guidance, and support.

Capacity (PHC service recipients)

Barrier 1: Low education level and ageing population

More than half of the interviewed patients with T2DM were over 50 years old and all of their education levels were high school or below.

Barrier 2: Insufficient health literacy and misinformation

Patients’ knowledge of diabetes management was often lacking, incorrect, or easily misled by misinformation.

Misleading TV advertisements and quack doctors promoting the less effective and expensive treatment regimes.

Facilitator 1: Health education activities organized by PHC facilities

The availability of audiovisual equipment for health education purposes is as follows: 91.2% in urban clinics, 64.4% in rural clinics, 84.6% in urban centers, and 100% in rural centers.

95% clinics have organized health education lectures on NCD prevention and control. 98% clinics have distributed promotional materials.

The health education activities included (1) banner (2) free medical consultation (3) lecture (4) pamphlets (5) broadcasting. However, most patients demonstrated passive engagement in these activities, and there was a lack of incentives and evaluation for these activities.

Opportunity (PHC service providers)

Facilitator 1: High availability of essential medical equipment across all levels of PHC facilities and access to advanced medical equipment at center level PHC facilities

99% PHC facilities were equipped with blood pressure measuring devices and glucometers; 89% owned an electrocardiograph and 76% owned audiovisual equipment for health education purposes.

98% health centers were equipped with ultrasound machines, 97% had a biochemical analyzer, and 80% had an X-ray machine (54% in rural areas and 87% in urban areas).

There were clear policy guidelines in place to regulate the establishment of PHC facility infrastructure, taking into account the size of the population it served.

Facilitator 2: Access to essential medicine

Affordable drugs are available in PHC level based on the National List of Essential Medicines and the Provincial List of Essential Medicines.

Facilitator 3: Health information systems

The majority of patients’ information was digitally archived and regularly updated.

All PHC facilities had access to computers and internet. The health information system was established to streamline the management and follow-up of NCD patients. However, the PHC system was segregated from the hospital system which caused repetitive data entry work and discontinuity in care.

Opportunity (PHC service recipients)

Barrier 1: Lack of self-monitoring

It was estimated that 80% of hypertensive patients in urban area owned blood pressure measuring devices at home, whereas only 20% rural patients owned such equipment. 50% urban patients owned glucometers at home, and only 10% rural patients had glucometers.

Some patients owned glucometers or blood pressure measuring devices at home, but few monitored and tracked health themselves regularly. Some only used the measuring devices when they felt unwell.

Facilitator 1: The NBPHSP and health insurance

On average, each urban clinic followed up 461.5 hypertensive patients and 171 diabetic patients. Each rural clinic followed up 178 hypertensive patients and 50 diabetic patients. The NBPHSP required village doctors to conduct at least 4 BP/BG measurements and face-to-face consultations to them per year.

The NBPHSP provided of a standardized set of health services such as establishing health records, diabetes and hypertension screening, follow-up, and health check.

All interviewed participants were covered by health insurance and experienced reimbursement.

Facilitator 2: Support from family members and mHealth technology

Family members expressed their willingness to take care of the patients, but their knowledge on diabetes management was inadequate.

Several family members mentioned their previous experience with mobile health management applications.

Motivation (PHC service providers)

Barrier 1: Pay gap

A significant proportion of village doctors (61.9%) received a salary below 1500 CNY, whereas the majority of PHC providers in other facilities were paid between 1500 and 3000 CNY (78.2% in urban clinics, 83.3% in urban centers, and 76.2% in urban clinics).

Village doctors complained about the low income and inadequate social benefits.

PHC providers were compensated based on the quantity of public health work they done, such as the number of hypertensive patients they followed up, rather than the quality of the services they delivered.

Barrier 2: Heavy workload and unclear career development path

In regard to NCD management and control, PHC providers were tasked with establishing health records for patients, conducting at least four follow-ups per year, and participating in intensive trainings. Given the size of the patient population and the limited number of PHC staff, these responsibilities place a substantial burden on PHC doctors.

NCD prevention and control represents only a fraction of the 14 tasks mandated by the NBPHSP. There were limited opportunities for promotion, specialization, or career advancement within the rural healthcare system.

Facilitator 1: Recognition in society and job fulfillment

Job satisfaction among village doctors is positively influenced by factors such as recognition of social status and maintaining good relationships with patients.

Motivation (PHC service recipients)

Barrier 1: Lack of motivation

A limited proportion of patients were reported to actively seek health services from PHC facilities (41% hypertensive patients in urban clinics, 65% hypertensive patients in rural clinics, 49% diabetic patients in urban clinic and 65% diabatic patients in rural clinics)

Patients didn’t acknowledge the seriousness of diabetes complications and they were not motivated to monitor themselves or follow the doctors’ prescription unless they felt the physical discomfort. Doctors had to urge and push patients to participate in community health education events.

Barrier 2: Patient inertia

A few patients did not believe that their treatment had to be intensified or continued unless they noticed physical symptoms.