SeriesReform of how health care is paid for in China: challenges and opportunities
Introduction
To implement the ambitious strategy that China is now rolling out to improve its health system,1, 2 several key challenges need to be met. One challenge is already being resolved: the central government's spending on health, after languishing for many years at exceptionally low levels compared with that in other countries, is now being increased substantially.3 Other financial and systemic issues include reversal of the upward spiral in the out-of-pocket payments that households pay to get health services; achievement of adequate financial protection for the entire population through insurance or other prepaid coverage; control of the rapid escalation of health-care costs; curtailment of inefficiencies and reducing waste; improvement of the quality of care; and enhancement of equity, including addressing disparities among China's diverse regions.
These challenges affect global health, not only because China's 1·3 billion people comprise a fifth of the world population, but also because its innovations and experiences will be helpful and influential for other countries. China's renewed quest to modernise its health system is part of a larger process worldwide. If the 20th century was transformed by two great health-related transitions (the demographic revolution that increased longevity and reduced fertility and the epidemiological revolution that reduced the incidence of many infectious diseases), the 21st century may be fundamentally changed by a third great transition in how health care is financed, provided, and organised. Some countries are well advanced in this third transition, having already replaced arrangements in which the cost of health care is borne mainly by the few who get sick, with policies by which cost is shared by all, equitable access to services is assured, and protection against financial ruin because of illness is widespread. But many countries still have a long journey ahead, and their citizens are impatient for faster advances.
In China major steps toward this third transition were made in the four decades after 1949 and the formation of the People's Republic, but advances then stalled and were partly reversed in subsequent years.4, 5, 6, 7, 8, 9 Now China is trying to recover lost ground and finish the job, helped by a strong economic base and a new development policy centred on people rather than economic growth alone.
Section snippets
Current challenges
Health care has become the number-one concern of China's population, according to a January, 2008, survey of 101 000 households in 5000 communities.10 A new saying appears frequently in Chinese media: “It's too difficult to see a doctor, and too expensive to seek health care!” And government officials have noted publicly the gap in meeting “the people's new expectations”.1
Lessons from other countries
What does the evidence from elsewhere in the world say about the challenges described above? Although much more needs to be done to assess the experiences of other countries, several lessons can be learned from other countries and insurance schemes.22, 30, 31, 32, 33, 34, 35, 36, 37
Conclusions
China has already taken significant steps to correct one problem: government spending on health is now on the rise sharply, after years at extraordinarily low levels relative to other countries. Further increases may be needed in the years ahead, and pressures to allow spending to stagnate or decrease—as other issues compete for attention—will need to be resisted. Fortunately, China's strong economic growth, fiscal position, and huge financial reserves make it one of the few countries in the
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