In the battle against the outbreak of COVID-19, if the city is "the main battlefield ", the grassroots are one by one "preparation units". On one hand, there are concentrated and crowed returning people is the during Spring Festival period, on the other hand, there is a relative shortage of quality medical resources, how to face the challenge at the grass-roots level?

In Zhejiang, both the "double sinking and two promotions" work and the county-level medical community construction which has been fully spread out in the whole Province manifest that a more reasonable, relatively balanced urban and rural medical and health system is being relocated.

Looking back at this battle against the epidemic, we find that it is a big test of the basic level treatment and public health system, and also a test of the periodic effect of the reform of the medical and health system in Zhejiang Province.

According to the list of hospitals for the diagnosis and treatment of COVID-19 released on February 8, of the 100 designated hospitals, more than 60% are county-level. Can these primary medical and health institutions deal with the important task of clinical treatment?

Presently, Zhejiang Province is quite confident about the improvement of the capacity of county-level hospital medical services. At the end of 2012, the Provincial Party Committee and the Provincial People’s Government pushed forward the policy of "double sinking and two promotions ", aiming for challenges such as weak grass-roots hospital, weak technology and skills and insufficient talents, closing the health gap between cities and townships for decades. For more than 7 years, 54 municipal 3A Hospitals and 122 county-level hospitals in Zhejiang Province have been implementing close cooperation, with more than 600 experts from urban hospitals are regular-stationed in county-level hospitals.  

Jinyun County People's Hospital, managed by the First Affiliated Hospital of Zhejiang University Medical School, quickly opened up a life channel after the outbreak: it vacated the isolation ward at the first time and opened the fever clinic strictly and leading the fever patients according to the standard of Infectious Disease Department of the Hospital; After the patients were tested confirmed, the Hospital successively contacted on line the Infectious Diseases Department of the First Affiliated Hospital of Zhejiang University and decided treatment solution for the patient by remote-consultation.

The Infectious Diseases Department of First Affiliated Hospital of Zhejiang University accumulated rich experience in the battle against SARS in 2003. After the incurring of the COVID-19, nine county-level hospitals in Beilun, Shengzhou, Yiwu, Jingning, Sanmen, Pujiang, Jinyun, Changshan, and Anji which are under the management of the Hospital have imported the above said treatment experience of the Hospital.

"Over the past seven years, a rational and orderly pattern of medical treatment, forming a provincial-municipal-county-rural medical network platform has been gradually constructed in Zhejiang Province, so that quality medical resources can serve all kinds of people at all levels," said Dong Hengjin.

More than four years after the work of "double sinking and two promotions " was advanced, the construction of county-level medical community also started in Zhejiang Province again, which is the reform of "sinking" medical resources of county-level hospitals to towns and villages again, is also known as "upgrade version" of "double sinking ".

In September 2017, the Project of the pilot building of county-level medical community launched in 11 counties (cities and districts); 2019, the Project was fully pushed forward in the whole Province. At present,70 counties (cities and districts) in Zhejiang Province have set up 161 medical communities consisting of 208 county hospitals and 1,063 township health centers or community health service centers.

With the sudden outbreak of COVID-19, how can the county medical community mechanism keep "small doors " of grass-roots hospitals?

Back to the afternoon of January 17, 2020, namely 6 days before Zhejiang launched a major public health emergency level response. Ma Yuefeng, president of the Medical Community Group of Changxing County People's Hospital, shared the grim situation of epidemic prevention and control with relevant personnel in Changxing, a small town after he had attended the meeting from Hangzhou.

On the same day, the eight townships (street) branch hospitals under the jurisdiction of Changxing County People's Hospital launched the “wartime mechanism” synchronously. On January 17th, more than 600 employees of the General Hospital and branches of the Medical Community Group gave up their leave. Eight townships (street) health centers adhered to the front line and followed up every day to monitor the health status of the local residents in quarantine. They entered the village to publicize the knowledge of prevention and control and even participated in the work of environmental elimination giving full play to the role of grass-roots public health and epidemic prevention.

"Without a well-established county medical community, a county-level hospital cannot play a leading role, and nor can township hospitals which are distributed in the towns quickly response as one." Ma Yuefeng said with emotion.

Now, in the critical stage of post-epidemic, namely labor and school resuming, economic and social recovery, the importance of the role of grass-roots doctors as "health gatekeeper" is more obvious.

Chen Lina, president of Traditional Chinese Medicine Hospital of Keqiao District, said:" A total of 43 medical workers have been deployed by the Medical Community as health instructors in enterprises. They inspect the health guidance work in enterprises on a regular basis and find that the hidden dangers of safety are reported in time, keeping the "small doors" at the grass-roots level.

In Zhejiang, the County Medical Community moves forward the epidemic prevention & control and medical treatment passes and leads the hospital intervened in the first time to realize the integration of epidemic situation monitoring, reporting, and treatment.

The linkage mechanism brought about by the reform of the medical and health system breaks the barriers between urban and rural areas and realized the "interconnection" between medical personnel and medical technology.

The small town of Rui’an withstood the "big test" of the epidemic. As the only county-wide new designated COVID-19 diagnosis and treatment hospital, Rui’an People's Hospital Treatment task is very heavy.

During this special period, the effect of up-and-down cooperation between hospitals and 20 medical community departments under their jurisdiction was very obvious. At the time of the most serious situation of the epidemic, the beds in the observation ward of the General Hospital were in serious shortage, and the inpatient wards of Feiyun and Ma Yu two branches were urgently transformed into isolated wards, which were used as reserve treatment hospitals. "The hospital has also undertaken a large number of cases screening work, namely when patients were diagnosed as suspected cases, they were transferred to the General Hospital by special ambulances for isolation treatment; the hospital has also transferred more than 50 medical workers from the branch hospital for support."

The internet has also become a very important link between the city and township. Family doctors help local patients with chronic diseases contact the general hospital experts for remote consultation through the internet diagnosis and treatment booking process, allowing villagers do not go out can also achieve home diagnosis and treatment.

Graded diagnosis & treatment system is one of the objectives of medical and health system reform. In Zhejiang Province, a pattern of "perform their respective duties" is gradually emerging in all kinds of medical and health institutions at all levels.

Another medical community in Rui’an —— General Hospital of Rui’an City Hospital of Traditional Chinese Medicine Medical Services Group takes the unique advantages of traditional Chinese medicine and it is responsible for 14 days of medical observation of the COVID-19 patients. Famous Chinese medicine physicians and other experts give Chinese medicine intervention to improve the physical fitness of the recovered patients according to the specific situation of each person.

The health situation of a recovered person who returned home after the observation period is monitored by each branch of Traditional Chinese Medicine Hospital in Rui’an. The doctors of these hospitals go to the recovered persons’ home every day to complete health condition monitoring of the recovered persons within the community during their quarantine including temperature tests and asking health conditions and so on.  

During the period of prevention and control of COVID-19, county-level hospitals and township health centers have carried out as possible as they can, so that medical resources can be used in an orderly and reasonable manner which finally benefits the people.

在抗击新冠肺炎疫情这场战争中，如果说城市是“主战场”，基层就是一个个“备战单元”。一边是春节期间密集的返乡人员，一边是优质医疗资源的相对稀缺，基层如何直面挑战？

在浙江，无论是 “双下沉、两提升”工作，还是已在全省全面铺开的县域医共体建设，都在重新布局更为合理、相对平衡的城乡医疗卫生体系。

回望战“疫”之路，这是对基层救治、公共卫生体系的一次大考，对浙江医药卫生体制改革阶段性成效的一次检验。

2月8日公布的新冠肺炎诊治定点医院名单中，100家定点医院中，有超过六成是县级医院。这些基层医疗卫生机构，能否应对临床一线的救治重任？

今天的浙江，对于县级医院医疗服务能力的改善，已是颇有底气。2012年底，省委、省政府推进“双下沉、两提升”工作，将“矛头”直接对准基层不强、技术不强、人才不足等痛点，缩小了几十年来城与乡之间的医疗差距——7年多来，全省54家省市级三甲医院与122家县级医院开展紧密型合作，每年有600余名城市医院专家常驻县级医院。

由浙江大学医学院附属第一医院托管的缙云县人民医院，在疫情发生后迅速开辟出一条生命通道——第一时间腾出隔离病房，并严格按照院感要求开设发热门诊、疏导发热病人，患者确诊后，医院也先后多次连线浙大一院感染病科，用远程会诊的形式，为患者制定诊疗方案。

浙大一院感染病科在抗击非典等公共卫生事件过程中积累了丰富经验。疫情发生后，该院已托管的北仑、嵊州、义乌、景宁、三门、浦江、缙云、常山、安吉9家县级医院均成为了这些救治经验的“输入方”。

“7年多来，我省逐步构建了合理有序的就医格局，形成了省-市-县-乡医疗四级网络平台，让优质医疗资源能够服务各级各类群众。”董恒进说。

“双下沉、两提升”工作推进4年多后，我省又启动了县域医共体建设，这项将县级医院医疗资源再“下沉”至乡镇的改革，也被称为是“双下沉”的“升级版”。

2017年9月，我省在11个县（市、区）试点县域医共体建设；2019年，这项工作在省内全面推开。目前，全省已有70个县（市、区）将208家县级医院与1063家乡镇卫生院或社区卫生服务中心组建为161个医共体。

新冠肺炎疫情突如其来，县域医共体机制如何守好基层“小门”？

时间回到1月17日下午——浙江启动重大公共突发卫生事件一级响应前6天。长兴县人民医院医共体集团院长马岳峰从杭州开完会后，把疫情防控的严峻形势带回了小城长兴。

当天，长兴县人民医院下辖8家乡镇（街道）分院同步启动了“战时机制”。1月17日，医共体集团总院和分院的600余名员工全部放弃休假，8家乡镇（街道）卫生院坚守一线，每天随访监测当地居家隔离人员的健康状况，进村入户宣传防控知识，甚至参与环境消杀等工作，发挥基层公共卫生防疫的作用。

“如果没有已经前期构架好的县域医共体，一家县级医院不可能发挥牵头作用，分布在县城各个乡镇的卫生院，也不可能快速拧成一股绳。”马岳峰感慨道。

如今，在疫情“下半场”的复工复产和经济社会复苏关键阶段，基层医生的“健康守门人”作用更为明显。

柯桥区中医医院院长陈丽娜说：“医共体共抽调了43名医务人员担任驻企健康指导员，他们不定期对驻企健康指导工作情况进行巡查，发现安全隐患及时上报，守好了基层‘小门’。”

在浙江，县域医共体将疫情防控和医疗救治关口前移，牵头医院于第一时间介入，实现了疫情监控、上报、救治的一体化。

医药卫生体制改革带来的上下联动机制，打通了城乡之间的壁垒，实现医护人员和医疗技术的“互联互通”。

小城瑞安，经受住了疫情的“大考”。作为县域范围内唯一一家新冠肺炎诊治定点医院，瑞安市人民医院的救治任务十分繁重。

非常时期，医院和下辖的20家医共体分院上下合力的效果十分明显。在疫情最严重时，总院的留观病房床位紧张，飞云、马屿两家分院住院病房紧急改造为隔离病房，作为后备收治医院。“分院还承担了大量的病例初筛工作，患者一经诊断为疑似病例，就安排专用救护车将其转送到总院隔离治疗；医院还从分院抽调了50余人来支援。”

互联网，也成为了非常时期联动城与乡的重要纽带。家庭医生帮助当地的慢病患者，通过互联网诊疗预约流程，联系总院专家远程会诊。村民们不外出也能实现居家诊疗。

分级诊疗制度，是医药卫生体制改革的目标之一。在浙江，各类各级医疗卫生机构“各司其职”的格局正在逐渐显现。

在瑞安的另一个医共体——瑞安市中医院医疗服务集团总院发挥中医药的独特优势，负责新冠肺炎出院患者14天的医学观察。名中医师等专家根据每人的具体情况，因人制宜给予中药干预改善康复者体质。

观察期结束后，康复者回到家中，将由瑞安市中医院各分院“接力”，分院责任医师每天到康复者家中，询问身体状况、测量体温，完成辖区内康复者居家观察期间的健康状况监测。

在新冠肺炎防控期间，县级医院、乡镇卫生院开展力所能及的工作，让医疗资源得到有序、合理利用，最终使百姓受益。

(Executive Editor: Ye Ke)