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