Elsevier

Public Health

Volume 125, Issue 1, January 2011, Pages 9-14
Public Health

Minisymposium
Emerging issues in public health: A perspective on China’s healthcare system

https://doi.org/10.1016/j.puhe.2010.10.009Get rights and content

Summary

China’s expenditure on healthcare has increased dramatically over the last 20 years, and three broad trends are seen in the associated health outcomes. First, limited improvements have been achieved to aggregate high-level health outcomes, e.g. infant mortality. Second, development of large and widening health inequalities associated with disparate wealth between provinces and a rural–urban divide. Finally, the burden of disease is shifting from predominantly communicable diseases to chronic diseases. Reasons for the limited gains from investment in healthcare are identified as: (1) increased out-of-pocket expenditure including a high proportion of catastrophic expenditure; (2) a geographical imbalance in healthcare spending, focusing on secondary and tertiary hospital care and greater expenditure on urban centres compared with rural centres; and (3) the commercialization of healthcare without adequate attention to cost control, which has led to escalation of prices and decreased efficiency. Recently, the Chinese Government has initiated widespread reform. Three key policy responses are to establish rural health insurance, partly funded by the Government (the New Rural Co-operative Medical Care System); to develop community health centres; and to aspire to universal basic healthcare coverage by 2020 (Healthy China 2020).

Introduction

China’s economy has experienced unprecedented growth over the last 30 years. These vast increases in wealth have allowed expenditure on healthcare to rise at even faster rates. Total health expenditure increased from 1.1 billion Yuan in 1978 to 1128.9 billion Yuan in 2007, equating to approximately a 75-fold increase in health expenditure per head.1 It is likely that this represents the biggest single increase in per capita health expenditure at any point in history. It is therefore of interest to consider what benefits such investment has delivered, why this is the case, and what could and should be done differently.

Over the last 20 years, China’s health outcomes have exhibited three broad features: relatively small improvements in aggregate outcomes, large inequalities and a changing burden of disease.2, 3, 4 In the last 5 years, the Chinese Government has launched a number of major new policy initiatives.4, 5

This paper describes the patterns of health outcomes in China, and summarizes the extent to which policies within China’s health system and broader society have been responsible for this pattern of disease. In particular, the effects of healthcare expenses born by households, the geographical imbalance of healthcare spending and the commercialization of healthcare will be considered. The paper also outlines the Government’s current approach to healthcare reform, and considers how far these new policies are likely to address existing and future challenges.

Section snippets

Health outcomes in China following economic liberalization

In the period prior to economic liberalization, China had unusually good health outcomes for its level of economic development (as measured by income level). For example, in 1972, China’s life expectancy for gross domestic product (GDP) was significantly better than the global trend, but in 2002, it was in line with its peers (Fig. 1).6, 7 Furthermore, China’s infant mortality rates fell massively from 250 deaths per 1000 births in 1952 to 40 deaths per 1000 births in 1980; a period

The role of China’s public health system and primary care in China’s health

The impressive health outcomes of the pre-liberalization period have been attributed to the earlier emphasis on strong preventative and public health initiatives and basic healthcare services, reaching 90% of the population.14 As outlined above, between 1978 and 2003, total spending on health increased by 11.5%, compared with the already substantial 9.6% increase in GDP.5 On the face of it, it seems surprising that health outcomes have exhibited such limited gains following massive increases in

Policy responses

Since 1997, the Chinese Government has initiated widespread reform coupled with substantial investment in the healthcare system. For the first time, basic medical services in China have been defined as one of the ‘essential rights of the people’. Most reforms to date have tended to be tested in pilot programmes prior to nationwide roll out. In line with other areas of policy, broad policy has been defined by central government, with local tiers of government responsible for the practicalities

Conclusion

It is clear that building a basic healthcare system to cover all Chinese residents will be a long-term task.29 Many regions, especially the poorer areas, are lagging behind in terms of standards of care, training and resources. The policy adjustments that will determine the success of the healthcare reform need to address the re-alignment of financial incentives to health providers, both in terms of the role of hospital commercialization and the detrimental effects of high out-of-pocket

Ethical approval

None sought.

Funding

Grants from the Chinese Government. Major grants administrated under the Eleventh 5-year Plan (2008ZX100[01-003] and 2009ZX10004-903), the Innovation Research Group of Beijing Municipal Commission of Education (PHR201007112), the National Basic Research Programme-973 of China (2011CB503806) and the National Natural Science Foundation of China for Young Scholars (30901239).

Competing interests

None declared.

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