The National Health Commission of the People’s Republic of China, in collaboration with the National Development and Reform Commission, the Ministry of Finance, the National Healthcare Security Administration, the National Administration of Traditional Chinese Medicine, and the Chinese Center for Disease Control and Prevention, has issued the document titled “Guiding Opinions on Strengthening Community-Based Chronic Disease Health Management Services” (Document No. 15, 2025). This comprehensive policy framework aims to reinforce the country’s primary-level healthcare system by optimizing chronic disease prevention, detection, treatment, and ongoing management, thereby ensuring better health outcomes for the population and improving residents’ access to integrated and continuous care.

I. General Requirements

Guided by Xi Jinping’s Thought on Socialism with Chinese Characteristics for a New Era, this policy fully implements the principles outlined by the 20th National Congress of the Communist Party of China and the second, third, and fourth plenary sessions of the 20th Central Committee. It emphasizes a people-centered approach to health, advocating for a combination of prevention and treatment strategies, balanced integration of traditional Chinese medicine and Western medicine, and coordinated service delivery through closely integrated medical consortia and family doctor contracting services. By leveraging existing basic public health service projects and integrating all stages of chronic disease management—including prevention, screening, diagnosis, treatment, follow-up, and rehabilitation—these guidelines aim to provide comprehensive, systematic, and continuous services, thereby enhancing the quality and effectiveness of chronic disease management at the community level.

By 2027, counties, cities, and districts implementing closely integrated medical consortiums are expected to achieve basic full-process chronic disease health management services at the grassroots level. Utilization of these services by patients with chronic diseases is projected to increase gradually, and the health behaviors and literacy related to chronic diseases among urban and rural residents are expected to improve. By 2030, a continuous service model for chronic disease management will be widely applied at the grassroots level, expanding the coverage of services and significantly enhancing residents’ satisfaction and sense of well-being.

II. Integration of Community-Based Chronic Disease Health Management Functions

Role of Township Health Centers and Community Health Service Centers as Hubs

Township health centers and community health service centers are designated as primary hubs for chronic disease management. They should focus on general medical departments, integrated chronic disease clinics, and other core functional areas to consolidate prevention, diagnosis, treatment, and follow-up services, including traditional Chinese medicine. Ideally, these centers will establish one-stop chronic disease health management centers with rational zoning and smooth patient flow. Their responsibilities include organizing chronic disease prevention and management programs for local residents, coordinating referral services for both incoming and outgoing patient transfers, compiling and analyzing health information for chronic disease patients, and guiding patients in need to sign contracts with family doctors.

Role of Village Clinics and Community Health Service Stations as Foundations

Village clinics and community health service stations serve as foundational points for chronic disease health management. In accordance with basic public health service standards, they are responsible for health education, patient assessments, follow-ups, stratified interventions, and consultations. Practical measures include equipping facilities with medical devices such as electronic blood pressure monitors, weighing scales, portable blood glucose meters, and waist circumference tapes to encourage self-monitoring among residents. High-risk individuals identified through these assessments should receive targeted health guidance and education, with referrals to township or community chronic disease health management centers when necessary.

Support Role of Lead Hospitals in Integrated Medical Consortiums or Higher-Level Hospitals

Lead hospitals within closely integrated medical consortiums or other higher-level hospitals are responsible for coordinating specialized departments, managing patients experiencing acute episodes or severe complications, and streamlining both intra-hospital and inter-hospital referrals. They should actively consolidate and transmit patient information to the corresponding grassroots institutions according to patients’ preferences. Additionally, they are tasked with guiding and supporting community health centers through personnel training, quality control, and outcome evaluation. Experts dispatched from these hospitals to townships and communities are expected to participate in local diagnosis, treatment, and follow-up services, providing timely care to patients in proximity.

Technical Guidance from Professional Public Health Institutions

Centers for disease control and other professional public health institutions are expected to provide strong technical guidance for grassroots chronic disease management. This includes conducting disease and risk factor surveillance, promoting comprehensive prevention and treatment measures, disseminating suitable medical technologies, and evaluating the effectiveness of health management initiatives.

III. Promotion of Full-Process Community-Based Chronic Disease Health Management

Early Identification of High-Risk Populations

Grassroots medical institutions should strengthen chronic disease prevention publicity, implement healthy weight management campaigns, and promote the simultaneous prevention of multiple diseases. Through public health services, routine health check-ups, and individual self-assessment, high-risk populations should be identified promptly and referred to community-based chronic disease centers for comprehensive health evaluations. Guidance on non-pharmacological interventions, including maintaining a healthy weight, balanced diet, adequate physical activity, smoking cessation, and alcohol moderation, should be provided, alongside the offer of family doctor contracting services.

Stratified and Graded Management of Chronic Disease Patients

Chronic disease management centers should implement stratified care according to patients’ conditions. Patients with stable conditions should receive continuous long-term management in line with national public health service standards and relevant chronic disease prevention and treatment guidelines. Those with suboptimal control should receive lifestyle interventions, adjustments to medication regimens, and increased follow-up frequencies to achieve effective management. Patients requiring higher-level care should be referred promptly to specialized departments in lead hospitals or higher-level institutions, and once stabilized, returned to grassroots care for dynamic follow-up management.

Integrated Management of Patients with Multiple Chronic Conditions

For patients suffering from two or more chronic conditions, community-based centers should conduct comprehensive assessments and develop individualized management plans. Services and follow-up schedules should be integrated to optimize efficiency. Clinical pharmacists are encouraged to participate in medication guidance for polypharmacy patients, providing consultation and promoting continuous self-recording of medication. Digital information systems should be leveraged to consolidate follow-up records and reduce the workload for healthcare providers.

Incorporation of Traditional Chinese Medicine in Chronic Disease Services

Traditional Chinese medicine (TCM) approaches should be fully integrated throughout the chronic disease management process. TCM preventive methods should be widely promoted through education campaigns, health guidance, and rehabilitation programs. The use of appropriate TCM techniques in grassroots settings should be encouraged to enhance prevention and recovery outcomes.

Patient Self-Management and Community Participation

Community committees and health promotion groups should organize self-management programs for patients with chronic conditions. Health education should encourage self-monitoring, and patients with access to smart devices such as electronic scales and wearable monitors may upload their data—safely and securely—to electronic health records and healthcare insurance platforms. This enables healthcare providers to offer more informed guidance. Local initiatives, such as enhancing family doctor service packages and implementing health points exchange systems, can further enrich chronic disease management and improve residents’ experience and engagement.

IV. Strengthening Supporting Measures

Medication Supply Assurance

The medication lists of integrated medical consortiums should be optimized to ensure the availability of essential drugs for chronic diseases such as hypertension, type 2 diabetes, and chronic obstructive pulmonary disease at grassroots facilities. Long-term prescription services and shortage reporting and distribution mechanisms should be guaranteed. Health insurance policies must be coordinated to cover the costs of medications at grassroots institutions, and innovative payment models combining capitation and chronic disease management should be explored.

Support for Personnel Training and Capacity Building

Local authorities should strengthen support for chronic disease management services as part of the implementation of the Medical and Health System Strengthening Project and the development of integrated medical consortiums. Personnel training programs should prioritize chronic disease prevention and management skills, enhancing the capacity of grassroots health workers. Internal performance-based incentives should reward effort and excellence, ensuring fair remuneration. Expenditures under basic public health services must follow regulations, with proper performance management and evaluation.

Digital and Intelligent Health Empowerment

Integrated medical consortium platforms should enable real-time information sharing between lead hospitals, specialized departments, and grassroots institutions. Interconnection of medical and public health data is crucial to improving the efficiency of integrated services. Artificial intelligence tools should be leveraged to assist in electronic health record management, automatically generating health assessment suggestions for residents to review and use in self-management.

Quality Control Enhancement

National and provincial chronic disease management professional organizations should guide grassroots institutions to ensure standardized, high-quality care. Lead hospitals and higher-level institutions must assume responsibility for quality oversight, and coordination between upper-level and community-level facilities should be strengthened. Internal quality management systems at grassroots institutions should be established, standardizing practices and optimizing service delivery.

Effective Implementation and Evaluation

Health administrative departments are responsible for coordinating and leading the implementation of these measures. Cross-departmental collaboration should ensure smooth execution. Evaluations should focus on improvements in residents’ health and patient satisfaction, incorporating chronic disease indicators into comprehensive monitoring and assessment frameworks. Effective communication and promotion of best practices will foster a supportive environment for the expansion of grassroots chronic disease management services.

Policy Interpretation and Background

The development of these Guiding Opinions responds directly to the directives of the Medical and Health System Strengthening Project, which emphasizes the continuous management of high-risk populations, particularly patients with hypertension, type 2 diabetes, and chronic obstructive pulmonary disease. It also underscores the importance of integrating preventive and clinical care, multi-disease prevention and management, and combining medical and public health efforts. By consolidating lessons from local pilot programs and aligning with community needs and service capabilities, the policy provides a roadmap to enhance systematic, continuous, and high-quality chronic disease management services across urban and rural communities in China.

In summary, the document articulates a multi-faceted approach that integrates:

Community-level service hubs

Foundational village and community clinics

Specialized hospital support

Public health technical guidance

Patient self-management and digital health tools

This comprehensive approach ensures that residents benefit from preventive, curative, and rehabilitative services, fostering better health literacy, behavior modification, and overall well-being.

Issued by:

National Health Commission

National Development and Reform Commission

Ministry of Finance

National Healthcare Security Administration

National Administration of Traditional Chinese Medicine

Chinese Center for Disease Control and Prevention