Table 4 Causes, effects and links related to gatekeeping

1. Governance

Gatekeeping created extra procedure, particularly as others are not doing this. Gatekeeping affected people with political influence mainly use tertiary hospitals.

Resentment of patients. Influential people in particular put pressure on the local government which reduced the political will of strict gatekeeping, this put a pressure on the management agency in implementing gatekeeping.

D06, D08, M01, A02

gatekeeping (+) → resistance (-) → gatekeeping

B1

Insurance management agency needs to respond to the demand of patients.

Difficulty in extending gatekeeping policy with the weak primary care service capacity.

A02, A03

hospital visits (+) → hospital bargaining power (-) → gatekeeping

R3

Insurance management agency integrated within health bureaucracy needs to respond to the demand of health facilities as a system.

Pressure to strengthen primary care facilities through gatekeeping (reducing the attractiveness of hospital care).

A02

gatekeeping (-) → hospital care attractiveness (-) → PC visits

R1’, R1a

Monitoring and evaluation focusing on public health services and NCD management

Shift of care from ambulatory curative care to public health services and NCDs.

D05, D02, M01

performance evaluation focusing on public health services (-) → PC curative service quality

R1’, R1a

2. Health financing

Revenue surplus or deficit from fundholding.

The intended effect is that surplus or deficit is used to stimulate performance improvement of primary care.

A02, A03

gatekeeping (+) → performance bonus (+) → PC curative service quality; PC visit(+) → PC revenue (+) → performance bonus

R1’, R1a

Gatekeeping makes hospital care less attractive by lowered reimbursement rate.

The intended effect is that patients are incentivized to use primary care with more visits.

A03, A02

gatekeeping (-) → hospital care attractiveness (-) → PC visits

R1’, R1a

Increased service use of primary care facilities.

The intended effects are reduced hospital visits and expenditures.

M03, M04

PC visits(-) → hospital visits(+) → hospital revenue

B1’

Fixed and low total amount of salary.

Relatively low work morale.

D03, M05, M02

PC salary policy (-) → performance bonus (+) → PC curative service quality

R1’, R1a

As primary care staff members consider that total salary should be equally distributed, actual amount variations of performance-based bonus is small.

Performance-based bonus is generally unable to incentivize curative care performance (the intended but not achieved goal).

M01, M02, M03, M04, M05, A02

performance bonus (+) → PC curative service quality

R1’

PC staff incentive related policies provides little control knob of internal management.

Relying on personal relationship for management

M01, M02

PC salary policy (-)→

performance bonus (+)→

PC curative service quality

R1’, R1a

High-powered incentive in hospitals.

Relatively high work morale in hospitals contributed hospital care attractiveness, to the large patient volume, and to large revenue.

M05

hospital incentive (+) → hospital performance (+) → hospital revenue

R2

Hospitals maintained high revenue.

Relatively higher salary for hospital doctors, with higher stress related to work.

M05

hospital revenue (+) → hospital salary (+) → hospital job attractiveness

R1’, R1a

Hospitals accounting for the lion share of expenditures and patients.

Prioritizing hospital-related policies.

M01, A02

hospital visits (+) → hospital bargaining power

R3

3. Service delivery

Poor curative service performance in primary care facilities.

Low patient trust of primary care facilities and hence higher attractiveness of hospital care.

M02

PC curative service quality (-) → hospital care attractiveness

R1’, R1a

Relatively low trust of primary care doctors by patients, contributes to higher attractiveness of hospital care.

Lower primary care visits, and unsophisticated cases (patients coming to buy drugs).

P01, D03, D05, M02

hospital care attractiveness(-) → PC visits

R1’, R1a

Small volume and unsophisticated cases of patients in curative care.

Declined clinical capacity.

M05, M02

PC visits (+) → clinical experiences (+) → PC capacity

R1a, R1’

Complicated procedures

Patient resentment against gatekeeping. Even doctors resent the policy (as they had little interest)

P01, P06, D02, D06, D04

gatekeeping (+) → inconvenience (-) → gatekeeping

B1

Integrative care arrangements are underdeveloped (Patients referred had no advantage in accessing specialist care in hospitals. Hospitals did not know doctors and their capability at primary care level).

Ineffective referral policies, which contributed to patient’s resentment to gatekeeping policies.

D02, D05, D06, D07, M01, M05, A02

lack of integrated care arrangement (+) → inconvenience (-) → gatekeeping

B1

Tension between doctors and patients

Patient get referrals if they insist, so the policy becomes an inconvenience in many cases.

D04, D06, D07, D08

doctor-patient tension (+) → inconvenience

B1

Elimination of hospitalisation and surgery at primary care level.

Surgeons’ skills are wasted. Professional development was hindered.

M01, M03, M04

restriction of PC function (-) → PC visits (+) → clinical experiences

R1a

Relatively low trust of primary care doctors by hospital doctors.

Low hospital-to-primary-care referral rates, and primary care doctors are unable to function as a coordinator of care.

D07, M05, D08

hospital doctors lack confidence in PC capacity (-) → hospital-to-PC referrals

B1’

Small volume of patients at primary care.

Primary care doctors converted to public health services staff, making the job unappealing to medical graduates.

M03, M04, D04

PC visits (-) → PC doctors pivoting to public health services (-) → PC job attractiveness

R1b

Weak primary care capacity.

Hospitals flooded with patients.

M05

PC capacity (+) → PC curative service quality (-) → hospital care attractiveness

R1a

Increasing workload and performance pressure from public health services, and small work low from curative care.

Primary care doctors required to pivot to public health services.

D02, D03, D06, M03, M04

performance evaluation focusing on public health services (+) → PC doctors pivoting to public health services

R1b

Doctors significantly abandoning their previous curative functions.

Patients perceived a decline of doctors’ capacity

P03

PC doctors pivoting to public health services(+) → low patient perception of PC doctor capacity

R2

4. Health workforce

Poor quality of primary care doctors.

Low trust in the technical competence of primary care doctors by both patients and doctors.

D02, D04, D08, M05

PC HR quality (+) → PC capacity

R1a, R1b

PC doctors training improves PC HR quality.

Good doctors leave after training due to lack of willingness to stay.

M02, M05

PC staff training (+) → PC HR quality (+) → PC brain drain

B2, R1b

Poor career prospects for primary care doctors.

Difficulty in recruiting and retain good quality doctors

D08, M02, M03, M04, M05, A02

PC job attractiveness (+) → PC recruitment (+) → PC HR quality; PC job attractiveness (-) → PC brain drain (-) → PC HR quality;

R1b, B2

Expansion of hospitals service capacity.

Recruitment of doctors trained for primary care level.

D04, A03

hospital capacity expansion (+) → hospital job attractiveness (+) → hospital recruitment (+) → hospital capacity advantage;

hospital job attractiveness (-) → PC job attractiveness (+) → PC brain drain (+) → hospital recruitment;

hospital expansion (+) → hospital job attractiveness (-) → PC job attractiveness (+) → PC recruitment

R1b, R2

Performance-based salary policy under which managers were not able to stimulate the entrepreneurship of staff.

Primary care doctors had low working morale, and tended to send patients away to hospitals.

M02

PC salary policy (+) → performance bonus (+) → PC curative service quality

R1a

Low work morale of primary care doctors perceived by hospital specialists.

Low trust in the technical competence of primary care doctors by doctors.

M05

hospital doctors lack confidence in PC capacity (-) → hospital-to-PC referral

B1’

Low work morale of primary care doctors.

Primary care facilities recruiting people with low professional aspiration.

M05

PC salary policy* (-) → PC job attractiveness

R1b

5. Medical technologies

Hospitals technical advantage (poor technical capacity in primary care facilities).

Unappealing primary care capacity, and therefore hospital attractiveness

P01, D02, D03, D04, M01

hospital capacity advantage(+) → hospital care attractiveness

R2

Physician patient tension.

Hospital technology use a necessity, therefore primary care doctors would tend to reject/refer such patients and hospital care became more attractive.

D08

doctor-patient tension* (+) → reliance on technology (+) → hospital care attractiveness

R1a, R1’

Hospital doctors prescribe medicines not available at primary care (“advanced medicines”).

Patients can only get the medicines prescribed from hospitals.

Primary care facilities the main facilities to adopt restrictive medicines policy.

P02, P03, P04, D01, D02, D03, D04, D07, M01, M02, M03, M04

restrictive pharmaceutical policies (-) → PC capacity

R1a

Essential medicine policies reduced access to “advanced medicines”

Patients cannot get from primary care facilities the medicines prescribed by hospital doctors.

M01, M04

balance of equipment (+) → PC capacity; restrictive pharmaceutical policies (-) → PC capacity

R1a

6. Information

With limited information sharing, hospital doctors don’t know primary care doctors’ capability and have little trust.

Reluctance to refer discharged patients to primary care facilities.

D04, D05, D08, A02

hospital doctors lack confidence in PC capacity (-) → hospital-to-PC referrals

B1’