Maximising the potential of the National Compulsory Service Programme in rural China: a mixed methods study

To alleviate the shortage of qualified physicians in rural areas, since 2010, the Chinese government has launched a National Compulsory Service Programme (NCSP) to enrol medical students for future work in township health centres (THCs) as general practitioners (GPs). The educational background of NCSP GPs is the best at THCs. This study aims to evaluate whether NCSP GPs have contributed to improving the quality of patient care at THCs and in what way.

This is an explanatory sequential mixed methods study.

NCSP GPs are assigned to THCs in the rural areas of central and western China, where assistant physicians are permitted to practice independently as licensed physicians. The contribution of NCSP GPs was defined as the extent to which they were perceived to improve the quality of care at THCs. Job performance was defined as the aggregated value to the organisation of discrete behaviour episodes that an individual performs.

For the quantitative component, nine provinces were selected by using a stratified random sampling method based on NCSP admission numbers. A total of 2815 THC leaders completed the survey (response rate, 32%). For the qualitative component, 33 NCSP GPs were recruited for semi-structured interviews through purposive and snowball sampling method.

The contribution of NCSP GPs to improvements in the quality of care at THCs was assessed as a key outcome measure.

68% of THC leaders reported that NCSP GPs contributed considerably to improving the quality of care. The contribution of NCSP GPs was significantly and positively associated with the performance of NCSP GPs themselves (β=0.789, 95% CI 0.724 ~ 0.854) and THC remoteness (β=0.144, 95% CI 0.067 ~ 0.222), but negatively associated with the percentage of licensed physicians at the THC (β=-0.340, 95% CI -0.483 ~ -0.197) and with the turnover of NCSP GPs (β=-0.119, 95% CI -0.221 ~ -0.016). The percentage of licensed physicians has a mediating role between THC remoteness and the contribution of NCSP GPs. Interviews revealed that NCSP GPs contributed to the THC as individual clinicians, and a majority also contributed by influencing others or participating in THC management, such as by improving diagnosis and treatment performance of others, standardising patient care, teaching and training and implementing safety processes.

NCSP GPs have a positive impact on the quality of care at THCs. In addition to working as individual competent physicians, they can contribute to the THCs in many ways. Adjustments in NCSP curriculum design, more supportive measures and better allocation processes are recommended to maximise this programme's potential.