The Chinese Healthcare System

1. The Chinese Healthcare System Lecture 10 Tracey Lynn Koehlmoos, PhD, MHA HSCI 609 Comparative International Health Systems

2. Where are we now?

3. A few facts about China • Country name: People’s Republic of China • Government Type: Communist State • Capital: Beijing • 23 provinces (including Taiwan); 5 autonomous regions and 4 municipalities • Fourth largest country in the world • Mount Everest—in the Tibetan Autonomous region shares a border with Nepal

4. Updated information • Population: 1,313,900,000 (2006) • Some 900,000,000 in rural areas • Life Expectancy: 70.9 male/ 74.5 female • Infant Mortality: 23.1 per 1000 (2006) • Urban:11 per 1000 • Rural: 37 per 1000 (1999) • Population >65: 7.7%

5. The Chinese Challenge • For the last 30 years China has embraced a new political economy of market socialism. This is a dramatic shift from a health care system that was famously low-cost, bureaucratically controlled, collectivist and emphasized prevention. Now the philosophical, financial and organizational approach to the provision of healthcare is dramatically different from the Maoist/Socialist ideas that served the People’s Republic of China since its inception. • What does this dramatic change mean for the health of the Chinese people? (David & Chapman) • (http://www.yalechina.org/publications/healthjournal/davis.pdf accessed 12 May 2006)

6. Organization of Care • Hierarchical • Ministry of Public Heath: national policy and management • Provinces/Territories/Cities: Large departments of health responsible for local policy and management • Bifurcated • Urban: 2.3 physicians per 1,000 population, about 1/3 of total Chinese population • Rural: 1.1 physician per 1,000 population

7. Four Historical and Economic Steps to a Decline in Population Health Outcomes • 1st: 1978 to 1999, China reduced federal funding of healthcare from 32 to 15%--in favor of provincial/local gov’ts having more “control” (result: disparities & privatization) • 2nd: Gov’t imposed Perverse Price Regulations: hospitals and physicians that generated more income got bonuses; promoted use of new, expensive pharmaceutical products and high-technology services

8. Chinese Federal Health Expenditure as % of Total Health Expenditures

9. Four Steps to Poor Health (Continued) • 3rd: Dismantling of Cooperative Medical System, 900 million rural Chinese became uninsured overnight, barefoot doctors became unqualified peddlers of high cost pharmaceuticals, loss of preventative emphasis • 4th: Reduced gov’t funding for public health efforts, local agencies switched to revenue generating focus (restaurant/food inspection) vs. MCH, epidemic control & health ed. • Blumenthal D, Hsaio W Privatization and Its Discontents — The Evolving Chinese Health Care System. NEJM. Volume 353:1165-1170 (11)

10. Macro Health Finance Health expenditure as % of GDP: 5.8 (2002) • Per capita total health expenditures: $ 63 US (2002) • General Government expenditure on health as % of total expenditure on health: 33.7 • Private expenditures on health as % of total: 66.3 • Private expenditures out of pocket: 96.3% • External resources for health as a % of total expenditures on health: 0.1% 50-70% of ALL healthcare spending is on pharmaceuticals—many of which are counterfeit

11. Privatization • Since 2000: • Hospitals: 15% cooperative ownership, 15% private, for-profit • Rural area clinics and hospitals allowed to privatize

12. Rural Healthcare • Rural residents pay for 90% of their own healthcare (out-of-pocket) • Public Health Campaigns: Government and NGOs/INGOs frequently sponsor immunization or other healthcare campaigns • No opportunity for rural residents to purchase health insurance (no competitive market place for insurers) • In 2002, officials launched several experiment inpatient care insurance plan as a rural health safety net. The government provides $2.50 a year, rural residents must match this with an annual $1.25.

13. Urban Healthcare • Public hospitals: 70%, state mandated charges • Two tier “National” insurance system: based on employer and employee contributions—started in 1998 • 1st Tier: Personal medical account • 2nd Tier: Universal fund available when the personal account is exhausted • A “young” program, not all employers participate, time will tell the impact

14. Informed Patient/Rise of Consumerism • China’s former emphasis on prevention is no longer acceptable • Urban Chinese have knowledge of modern curative approaches and want high technology and superior treatment • With the One Child (One Son?!) policy, today’s Chinese consumer demands the best for the child, a social guarantee for the health and future of the family. Low quality healthcare will lead to parent’s ignoring the one child rule

15. Gender Imbalance • Mexico City Policy, “Global Gag Rule,” which President Bush reinstated as his first act in office • The “Gag Rule” prohibits recipients of U.S. international family planning assistance from counseling women on abortion or engaging in political speech on abortion.

16. Rounding out your global health system cultural vocabulary • Russian abortion rate: 2 abortions for every live birth (2002) • Chinese abortion rate: 27% overall, 55% for unmarried urban women (a growing statistic—not counted by all agencies) • US: 24.5 per 100 pregnancies (2002) • Decline in Chinese abortion rate • Distrust of birth control pill

17. Gender Imbalance • 120:100 male to female births overall • In some areas, 360 to 100 for second children • Abortion: RU 486 prescribed & black market • Female Infanticide • Suspiciously high FEMALE infant mortality

18. Rural Urban Disparity • Some poor rural areas have seen an increase in infant mortality • Rural areas have fewer trained providers • Rural areas have lower access to high quality care, low access to new technology • Schistosomiasis, an infectious, parasitic disease—previously eliminated has re-emerged and contributed to mortality rates

19. Schistosomiasis !?! • Classic public health problem, previously “cured” or eliminated by extensive, collective public works programs • Caused by parasitic worms, passed through feces into water, snails are the vector, caught through skin exposure • 200 million people are infected worldwide—with a rapid increase in China • Causes cirrhosis, causes death

20. More on Schistosomiasis • Previously endemic along the Chang Jaing River (this is a long river, almost all of Southern China) • Mao and Communist Party vowed to eliminate Schisto • Came to power started collective public works program—dug hundreds of thousands of new canals, buried old canals—snails eliminated—except for in the mountains, source of the Chang Jaing

21. More about Schistosomiasis • Since 1978, shift away from collectivism toward private economy • Disappearing emphasis on public works • No new canals, INVADER SNAILS! • Schistosomiasis is on the rise • Cannot be prevented—but can be held in a steady state through an annual dose of praziquantel (campaigns are common in affected areas)

22. Compared to US • Both China and the US must struggle to reform inefficient and poorly organized health care systems • Rural-urban disparities exist and must be successfully tackled in both countries

23. Summary • China’s enormous size both in land mass and in population demand enormous attention both from within its borders and beyond them • SARS, avian flu, and HIV/AIDS mean that no country’s health problems, health status or health system exist in a vacuum • A decentralized Chinese system with a waning emphasis on public health must prepare to deal with on-going and in-coming epidemics