Capacity evaluation for general practitioners in Pudong new area of Shanghai: an empirical study
Li et al. International Journal for Equity in Health
Capacity evaluation for general practitioners in Pudong new area of Shanghai: an empirical study
Ming Li 0 2
Zhiqun Shu 0
Xuan Huang 0 2
Zhaohui Du 1
Jun Wu 2
Qingshi Xia 1
Kun Liu 0
Jiquan Lou 0
Limei Jing 0
0 Shanghai Pudong Institute for Health Development , Shanghai , China
1 Medical Institutions Administration Center of Pudong New Area , Shanghai , China
2 Pudong New Area Commission of Health and Family Planning , Shanghai , China
Background: Building highly qualified General Practitioners (GPs) is key to the development of primary health care. It's therefore urgent to ensure the GPs' quality service under the background of the new round of health care system reforms in China. A new model of GP qualification examination was originally implemented in Pudong New Area of Shanghai, China, which aimed to empirically evaluate the GPs' capability in terms of clinical performance and social recognition. In the current study, an analysis was made of the first two years (2014-2015) of such theoretical and practical examinations on the GPs there with a view to getting a deep insight into the GP community so as to identify the barriers to such a form of GP qualification examination. Methods: The agency survey method was applied to the two-year database of the GP examinees, the formative research conducted to explore the key elements for developing the examination model. The data analysis was performed with SPSS for Windows (Version 19.0) to describe the GPs' overall characteristics, and to make comparisons between different groups. Results: In 2015, the total number of GPs was 1264 in the area, in different districts of which, statistically significant differences were found in sex, age, professional title and employment span (P < 0.05). Such results were found to be similar to those in 2014. The examinees' theoretical scores were statistically different (F = 7.76; P < 0.05), showing a sloping trend from the urban district to the suburban, to the rural and then to the farther rural, as indicated by LSD-t test (P < 0.05). From the theoretical examinations the scores were higher on the western medicine than on the traditional Chinese medicine (F = 22.11; P < 0.05). Conclusions: As suggested by the current study on the GPs' qualification examination, which was pioneered in Pudong New Area of Shanghai, the construction of GP community was far from sufficient. It was a preliminary study and further studies are merited along the construction and development in terms of continuing medical education, performance appraisal and incentive mechanism.
General Practitioner; Capacity Evaluation; Formative Evaluation; Human Resource; Primary Health Care; Health Service; Empirical Study; Preliminary Study; Shanghai
In the Opinions of the Central Committee of the
Communist Party of China and the State Council on Deepening the
Health Care System Reforms in 2009 , to promote the
construction of the four health systems of the public health
service system, medical service system, medical insurance
system and drug supply system was the most important
goal issued, and the gross medical institutions as the base
of the Chinese health service system has been playing an
important role in public health. Admittedly, the
construction of the primary health care is based on the development
of the community health service (CHS) in rural China. At
the CHS centers (CHSCs) the general practitioners (GPs)
provide the local residents with basic health care. The
issued guidelines on establishing the communities of GPs
have advocated their importance in the national health
strategy . Dr. Michael Dixon, National Health Service
Alliance chair, once said, “Numerous researches (e.g., from
Barbara Starfield and WHO) have shown that a health
service predicated on primary care delivers better mortality
statistics, improved health, and is more cost effective” .
Thus, to build highly qualified GPs is critically
important to the development of primary health care, and to
promote the construction of GPs is to strengthen the
primary healthcare system and improve the general
health of Chinese populations.
At present, China encounters such healthcare
problems as GPs’ insufficiency [4, 5], under-qualified
personnel [6–11], uneven distribution [12, 13], and
serious brain drain [14–16]. Thus the field studies and
policy strategies focusing on in GPs’ human resource
equity are of great importance to ensuring the quantity
and quality of GPs in China. In March, 2010, the National
Development and Reform Commission (NDRC), the
National Health and Family Planning Commission
(NHFPC), the State Commission Office of Public Sectors
Reform (SCOPSR), the Ministry of Education (ME), the
Ministry of Finance (MF), the Ministry of Human
Resources and Social Security (MHRSS) jointly issued the
Construction Planning of GP-Focused Primary Health
Care Teams, which consisted of three major tasks of
cultivation, employment and management to have built a
community of 300,000 across the country by 2020 to address
the requirements of primary health care . Hereinto, an
emphasis was placed on the establishment of
ability-andperformance-oriented and social-recognition-focused
mechanism of qualification evaluation targeted at the
primary care personnel, because such an endeavor would
help reduce inequity of health workforce in the provision
of primary health care.
Over the world, more than 50 countries have health care
systems based on the GP model . Some of those
countries such as UK, Germany and USA have developed
advanced GP management system which integrates capacity
evaluation with pre-occupation schooling and
postoccupation training, performance appraisal and incentive
mechanism throughout a GP’s entire career [19–23].
Different from those developed countries in the world, most
countries are just at the beginning, trying to establish such
a management system with its own characteristics. As an
important part of medical practice in China, traditional
Chinese medicine (TCM) plays a vital role in delivering
primary health care. At the CHSC, the GPs who are
engaged in the integration of TCM and western medicine
(WM) can be expected to have routinely a holistic view
and evidence-based skill in diagnosing and treating
common diseases as well as in practicing rehabilitation and
prevention. Technically, these types of GPs are certificated
physicians of general medicine; therefore, they are equally
treated as those counterparts of WM.
Previous investigations have presented multiple
perspectives on GPs’ capacity evaluation [24–27]. In China,
there have been few studies discussing GPs’ necessary
ability elements  and the establishment of evaluation
index system [7, 29]. Obviously, few studies have
empirically evaluated GPs’ capacity in terms of ability and
performance and recognition.
In 2014, a newly developed model of GP qualification
examination, called the GP’s Theoretical and Practical
Examination (GPTPE), was initiated in Pudong New
Area of Shanghai, China, which was characterized by
ability/performance-oriented evaluation so that the
theoretical knowledge and practical capacity of the GPs
could be evaluated at their working CHSC and the ways
of alliance for other existing continuing medical
education (CME) and clinical performance evaluation as well
as GPs’ incentive mechanisms could be explored.
In the current study, we analyzed the first two-year
data of Pudong-New-Area-based GPTPE (2014–2015)
with a view to getting a deep insight into the GP
community so as to identify barriers in particular to its
further development, as empirical evidence for the national
establishment of GP evaluation mechanism as well as for
the promotion of equity in the human resource for the
delivery of primary health care across the country.
The first two-year data of GPTPE were derived from
Pudong-New-Area-based Medical Institutions
Administration Center (MIAC), which runs and manages GPTPE
under the auspice of the Department of Medical
Administration of Pudong New Area Commission of Health
and Family Planning (CHFP). The training center of
Weifang CHSC, exclusively designated as the
examination place, was connected to the database. All the
examinees were informed of the importance and necessity
of GPTPE before they signed up. The managers of each
CHSC could have their independent choice to take the
examination or not. The scoring results would be linked
with their annual performance appraisal.
The agency survey method was applied to exploring
the general picture of Pudong-New-Area-based GPs
based on the two-year database. The whole sample of
the GPs’ self-administered information covered name,
gender, age, working unit, employment span, practicing
category and professional title.
And also the agency survey method was used to
collect the examinees’ test scores, theoretical and practical,
from 2014 to 2015 for evaluation. The theoretical test is
taken within the computer paperless test system, with
100 questions selected at random and each representing
one score, and the questions refer to the disciplines of
general practice, internal medicine, surgery, gynecology,
ophthalmology, otolaryngology, pediatrics and medical
ethics. The practical test is taken by approximately 30%
of the examinees selected randomly, with a maximum
score of 100 for the operation on medical patient
The formative research served to explore the key
elements for developing the new model of GPTPE [30, 31],
which typically refer to such questions as who the target
populations are; how the data are accurately evaluated;
and what the conclusion is after the evaluation. A
formative evaluation was made of the instantiation of
GPTPE, which had been established on the basis of the
mix-method research, through observation, statistics and
The data analysis was performed with SPSS for Windows
(Version 19.0), the threshold of statistical significance set
at P < 0.05 (2-tailed). Based on the descriptive statistics on
the GPs’ overall characteristics such as testing year,
quantity, gender, age, regional distribution, practicing category,
etc., comparisons were made among different groups
using the F test for numerical variables and the χ2 test for
GPs in Pudong new area
As indicated by Table 1, Pudong-New-Area-based GPs
numbered 1227 including the employees after retirement
in 2014, and 1264 excluding employees after retirement
in 2015. By 2015, 45 CHSCs had been in operation with
93 posts across the area. As defined by the degree of
urbanization within the area, the GPs’ regional
distribution could be administratively divided into 4 types: Type
A as the urban area, Type B as the suburban, Type C as
the rural and Type D as the farther rural. The different
types of region were statistical different in sex, age,
professional title, employment span (P < 0.05).
GPTPE in 2014 and 2015
The GPs’ GPTPE scores of 2014 and 2015 were
obtained from the theoretical and practical, respectively
(Tables 2 and 3). A total number of 1189 and 1234
examinees took GPTPE in 2014 and 2015, respectively,
except the managers of CHSCs who chose not to take it
and those who had asked for maternity leave, sick leave or
personal leave in advance. A random selection of 325 out
of 1189 examinees (27.33%) and of 427 out of 1234
examinees (34.60%) was designated to take the practical test in
2014 and 2015, respectively.
In different types of region, the theoretical scores of
GPTPE were statistical different in 2014 (F = 13.86; P <
0.05), showing a sloping trend of Type A & B > Type
C > Type D, as indicated by further LSD-t test (P < 0.05),
while the practical scores of GPTPE showed no
significant difference (χ2 = 3.70; P > 0.05). In the theoretical
GPTPE, the female scores were higher than the male ones
(F = 8.19; P < 0.05), and a decline was observed there with
an increase in age, as indicated by F test (F = 22.44; P <
0.05) and LSD-t test (P < 0.05). A trend of employment
span was observed as follows: −10 & 11–20 years > 21–30
years > 31+ years, as indicated by F test (F = 22.39; P < 0.05)
and LSD-t test (P < 0.05). As to the different practical
categories, GPs of western medicine scored significantly
higher in the theoretical GPTPE than the counterparts of
TCM (F = 91.71; P < 0.05). Furthermore, the theoretical
scores of GPTPE increased with the escalating professional
title, as indicated by F test (F = 6.90; P < 0.05) and LSD-t
test (P < 0.05), respectively.
Similar data were found in 2015; the theoretical
scores of GPTPE were statistical different in different
types of region (F = 7.76; P < 0.05), showing the same
sloping trend as that in 2014, as indicated by LSD-t test
(P < 0.05), and the GPs of WM scored higher there than
the counterparts of TCM (F = 22.11; P < 0.05).
Development of GPTPE Model
On the basis of the initial model of GPTPE, the
formative evaluation of the instantiation was performed from
2014, and after an analysis-remodification cycle, the
model was improved in 2015 (Fig. 1).
In 2014, the practical GPTPE contained 2 items so that
a possible score was 0, 50 or 100; therefore, it didn’t show
any differences between groups. The post-retirement
employees complained that it was of extreme pressure for
them to take GPTPE and that the test results would have
little incentive effect on them. A total number of 221
TCM examinees (17.5%) took GPTPE in 2014, who in
reality composed an important part of primary health care
at CHSC and reported that it was unfair because the test
bank did not contain any well-targeted questions for them.
In the seasonality of GPTPE, it was relatively late for the
GPs to take the examination in the fourth quarter of the
male 134 (32.8) 78 (29.1) 104 (38.9) 117 (41.3)
female 275 (67.2) 190 (70.9) 163 (61.1) 166 (58.7)
~ 35 137 (33.5) 84 (31.4) 54 (20.2) 78 (27.5)
36 ~ 45 198 (48.4) 137 (51.1) 171 (64.1) 161 (56.9)
46 ~ 55 53 (13.0) 37 (13.8) 30 (11.2) 37 (13.1)
56~ 21 (5.1) 10 (3.7) 12 (4.5) 7 (2.5)
mean 38.9 38.9 39.94 39.24
SD 8.05 7.08 6.98 6.23
median 38 37 39 38
minimum 25 26 25 26
maximum 66 61 66 60
WM 323 (79.0) 224 (83.6) 225 (84.3) 241 (85.2)
TCM 86 (21.0) 44 (16.4) 42 (15.7) 42 (14.8)
junior 76 (18.6) 50 (18.7) 51 (19.1) 77 (27.2)
intermediate 306 (74.8) 195 (72.7) 209 (78.3) 199 (70.3)
senior 27 (6.6) 23 (8.6) 7 (2.6) 7 (2.5)
~ 10 years 121 (29.6) 72 (26.9) 40 (15.0) 56 (19.8)
11 ~ 20 years 186 (45.5) 128 (47.8) 141 (52.8) 136 (48.1)
21 ~ 30 years 65 (15. 9) 48 (17.9) 61 (22.8) 74 (26.1)
31 ~ years 37 (9.0) 20 (7.4) 25 (9.4) 17 (6.0)
mean 16.09 16.71 18.42 17.87
SD 9.48 8.65 8.09 7.73
median 15 17 18 17
minimum 1 1 1 1
maximum 46 46 44 43
WM western medicine, TCM traditional Chinese medicine, SD standard deviation
*P < 0.05 (2-tailed)
F = 1.34
F = 4.87*
F = 3.69*
F = 10.82*
Table 2 GPs’ Scores in Theoretical Exam from 2014 to 2015
Year Category Number Mean SD
Type-A 393 57.42 10.57
Type-B 261 57.7 10.95
Type-C 260 55.83 10.68
Type-D 275 52.72 9.39
male 412 54.84 9.96
female 777 56.68 10.86
~35 344 57.81 9.65
36 ~ 45 651 56.35 10.71
46 ~ 55 151 53.89 10.24
56~ 43 44.91 9.64
WM 979 57.36 10.24
TCM 210 49.92 10.05
junior 247 54.44 10.81
intermediate 887 56.25 10.51
senior 55 60.00 9.83
~10 years 284 57.02 10.51
11 ~ 20 years 573 57.50 10.29
21 ~ 30 years 243 54.18 10.43
31 ~ years 89 48.69 9.50
Total 1189 56.05 10.59
Type-A 412 55.34 8.11
Type-B 268 55.16 8.73
Type-C 273 53.56 8.51
Type-D 281 52.61 7.86
male 425 53.05 8.16
female 809 54.94 8.38
~35 332 57.40 7.61
36 ~ 45 708 53.84 8.04
46 ~ 55 173 51.23 8.86
56~ 21 45.48 7.10
WM 1013 54.80 8.51
TCM 221 51.91 7.13
(53.88 ~ 55.81)
(55.92 ~ 57.45)
(56.72 ~ 58.00)
(48.56 ~ 51.29)
(52.27 ~ 53.83)
(54.36 ~ 55.51)
(54.28 ~ 55.33)
(50.97 ~ 52.86)
Table 3 GPs’ Scores in Practical Exam from 2014 to 2015
(73.39 ~ 77.97)
(72.68 ~ 76.48)
(72.94 ~ 76.30)
(73.47 ~ 79.38)
Fig. 1 Flowchart of GPTPE model development (2014 ~ 2015)
year as their performance appraisal and as part of their
According to the empirical evidence of GPTPE in
2014, some improvement were made in some aspects of
the model in 2015: 1) The practical GPTPE was
expanded from 1 to 4 disciplines covering 7 items totally
scored 100; 2) The test bank of theoretical GPTPE grew
to contain 1040 questions, which were separately
arranged for the examinees of WM and TCM; 3) The
post-retirement employees did not have to take the
examination; 4) The number of randomly selected
examinees for the practical GPTPE was increased to be over
30% so that all GPs could take it in 3 years; and 5) In
case of system failure or other temporary problems, a
whole day was scheduled for the examinees to make up.
In 2015, a total number of 1234 out 1264 GPs
(97.63%) took GPTPE, the rate higher than that in 2014
(1189/1227; 96.90%). The TCM examinees’ average score
was 51.91 ± 7.13 in the theoretical GPTPE, which was
higher than that (49.92 ± 10.05) in 2014 (t = 2.38; P <
0.05), while it was significantly lower than that (54.80 ±
8.51) of the WM ones (F = 22.11; P < 0.05). Additionally,
in 2015 the total average score of the theoretical
GPTPE was as low as 54.29 ± 8.35, which the examinees
blamed for the unsuitable questions from the test bank,
and meanwhile the practical GPTPE was expanded to cover
4 disciplines with 7 questions, which was still so insufficient
that no significant differences were observed between
GPs in Pudong new area
Pudong New Area is located in the east of Shanghai,
covering an area of 1429.67 km2, 22.55% of the total area
of the metropolitan city, and by 2015, the area had had a
population of 5.47 million . As revealed by the
current study, there were 1264 GPs there, with the
coverage of 2.25 and 2.31 per 10,000 residents in 2014
and 2015, respectively. As required by the Guidance of
the State Council General Office on Promoting the
Construction of Stratified Medical System, the nationwide
staffing objective is to ensure 2/3 qualified GPs per
10,000 residents for primary care and first-contact
services . As reported in 2014, the national average
numbered 1.27 GP per 10,000 residents , and
accordingly Pudong New Area has been above the average.
To address the growing demand for the routine work
of GPs at CHSC, however, the proportion should have at
least 5 GPs per 10,000 residents in Shanghai . In
USA, UK, Canada, Australia, etc., every population of
2,000-3,000 can have a GP; in UK as a case in point, the
proportion ranged from 6.1 in Northern Ireland to 8.2
per 10,000 population in Scotland in 2011 .
Definitely, it is imperative that further investigations be
conducted on ensuring the standard and quality services
on the part of GPs.
As evidenced by the current study, the GPs working in
Type C and D of region were significantly older, with
longer employment span and lower professional title
than those working in Type A and B of region (P < 0.05),
which suggested a relative inequality of quality GP
resource in the different socioeconomic developing
regions. According to the human capital theory, human
capital with high quality can improve the output of
medical services . Compared with the urban areas, the
existing problems such as insufficient number,
underqualified skill and frequent turnover were reported to be
the bottleneck in improving the medical care system
. And the higher level of inequitable distribution of
qualified health workers in those disadvantaged areas
might have lower densities of the professionals .
Indisputably, there are growing needs for qualified and
stable grass-roots health employees to deliver rural
primary care; Pudong New Area is no exception. To meet
the great challenge and achieve real fairness, the central
government of China should keep an eye on the issue of
“quality fairness,” directing further investigations on
equity in quality.
Nowadays in China, most of the GPs working for
CHSCs used to be specialist practitioners before
jobtransfer training; they are not so qualified due to their
limited general medicine training [39, 40]. As evidenced
by the scores of the theoretical examinations, the
majority of the GPs was knowledgeable about such a discipline
as internal medicine or gynecology, but did not have
comprehensive medical knowledge as a qualified GP
should possess. The shortage of qualified GPs cultivated
by the “5 + 3” mode is a common phenomenon in China
[41, 42], which is composed of 5 years of undergraduate
medical education plus 3 years of GP standardization
training. This is also true of Pudong New Area, where
less than 10% of the GPs working at CHSCs were
cultivated as required by the mode. Therefore, one of
GPTPE’s strategic goals is to build qualified GPs to be
real gatekeepers. The current study suggests that the
first two-year evaluating results of developing GPTPE
can provide valuable reference information for the actual
construction of qualified GPs in China.
Development of GPTPE Model
In theory, GPTPE is of profound importance in building
qualified GPs in China. As evidenced by the data
comparison between 2014 and 2015, efforts were made to
improve Pudong-New-Area-based model of GPTPE in
the aspects of discipline, content and management.
However, there sure exist the issues of improvement and
perfection in its further development so that the model
of GPTPE can be institutionalized and normalized in a
In 2015, the theoretical item bank of GPTPE grew to
possess 1040 questions specifically targeted at TCM
GPs; thus the examination was separately scheduled for
the TCM examinees. This change is not alone; in some
other countries, the delivery of services requires
differently skilled and different types of health professionals
working in general practice . In reality, as an
important part of medical practice in China, TCM can be
applied as the effective means of disease prevention and
health-keeping behavior, deeply rooted in the Chinese
residents who are willing to seek TCM for their health
problems, as evidenced by some reports that the
approach of TCM can meet the demand of the growing
CHS [33, 44, 45]. In the current study, TCM GPs’
average score was still lower than that of WM GPs in 2015
theoretical examination (P < 0.05), which could be
explained by their different professional competences
and/or by their different testing competences due to the
designing of the questions themselves. Such a phenomenon
needs further investigations to verify.
Despite the expansion of the item banks of GPTPE from
2014 to 2015, the total average score was still lower than
60/100 in the theoretical and no differences were observed
between different groups in the practical. This indicated
that the item bank still remains to be desired, which was
derived from the item bank of GP standardization training
in the tertiary hospitals of Shanghai, and was improved by
consulting experts. After the two-year implementation in
Pudong New Area of Shanghai, it was found in the current
study that the problem of feasibility and reliability still
existed for the GPs working for CHSCs. According to the
examinees’ feedbacks, the item banks of GPTPE were
reported to be unsuitable for them.
In order to make the GPTPE model more conducive
to qualified GP construction, further research is needed
to explore ways to combine the evaluating scores with
the on-going regional GP-based continuing medical
education, performance appraisal and incentive mechanism.
As to the social recognition and patient-physician
harmony, there is still a need to explore appropriate and
effective means to improve GPs’ real competence and
promote CHS for their local contracted residents. On an
administrative level, much needs to be done to take the
advantage of the GPTPE model to inspire GPs’
enthusiasm and their work initiative, as well as to make full use
of the washback effect on GPs’ academic and skillful
The current study was of a tentative research, which
had much to be desired in evaluating the
PudongNew-Area-based GPs’ theoretical competence and
practical performance. As one of assessments, GPTPE can
be insufficient for a comprehensive evaluation; further
studies need focus on exploring multiple dimensions of
GPs’ evaluation. Additionally, the two-year data could not
be sufficient enough to be an effective and valuable
evaluation for intervention policies; therefore a bigger database
based on a long-term observation is needed to better
evaluate the newly developed model of GPTPE.
As empirical evidence for the national establishment of
GP evaluation mechanism as well as for the promotion
of equity in the human resource for the delivery of
primary health care across the country, the newly developed
GPTPE in Pudong New Area is of profound importance
in building qualified GPs in China. It can be concluded
from the current study on the GPTPE to empirically
evaluate GPs’ competence and performance, the resource
of qualified GPs was not sufficient at CHSCs, which
reflected the urgency of building qualified GPs to address
the growing demand for CHS. As a preliminary study, it
needs further research to explore ways of alliance for the
existing CME, evaluating model and incentive mechanism
in building qualified GPs.
CHFP: Commission of Health and Family Planning; CHS: Community health
service; CHSC: Community health service center; CI: Confidence interval;
CME: Continuing medical education; GP: General practitioner; GPTPE: GP’s
Theoretical and Practical Examination; ME: Ministry of Education; MF: Ministry
of Finance; MHRSS: Ministry of Human Resources and Social Security;
MIAC: Medical Institutions Administration Center; NDRC: National
Development and Reform Commission; NHFPC: National Health and Family
Planning Commission; SCOPSR: State Commission Office of Public Sectors
Reform; SD: Standard deviation; TCM: Traditional Chinese medicine;
WM: Western medicine
We would like to thank all involved in the study.
This study was funded by National Natural Science Foundation of China
(#71503170), Shanghai Municipal Commission of Health and Family Planning
(#201440036 & #2016HP009) and supported by the Technology Development
Special Fund of Pudong New Area Health and Family Planning Commission (#
PW2016A-4). The funders had no role in the study design, data collection,
analysis and interpretation, or preparation of the manuscript.
ML, XH, LMJ and ZQS contributed to the conception and design of the
study. ZHD, JW, QSX and JQL were involved in data acquisition. ZQS and
QSX conducted the data analysis, and all other authors participated in the
interpretation of the data. ZQS, LMJ and KL draft the manuscript and revised
it with input from all other authors. All authors read and approved the final
version of the manuscript.
The authors declare that they have no competing interests.
Ethics approval and consent to participate
Ethics approval by the Academic Ethics Committee of Shanghai Pudong
Institute for Health Development (# PDWSL2013-4) was acquired prior to the
current study which did not involve any ethical issue.
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