So the New York Times posted an article by David Leonhardt called In China, Uneven Progress in Health. It’s essentially a “they’re doing great but…” China article. This time it was: the economy has been great and all, but success has been distributed unevenly and healthcare has not been improving concomitantly. Well, duh. I’m not sure what the news is here. My theory is that this guy just came back from a China trip and felt like writing this up; he just about says as much in the article. All of his other articles are related to U.S. economics and fiscal policy, nothing China related at all.

In any case, the real point of the article is to set up China as a counterpoint (or a straw man, if we want to be cynical about it) to the United States, which he calls out in the final paragraph (if you can call them that, as I was counting I was struck by how short journalism paragraphs are):

There is, after all, another large country with unimpressive recent gains in life expectancy, even smaller than China’s. That’s right: the United States. Since 1990, we have been passed by Chile, Denmark, Slovenia and South Korea, among others. China is still five years behind us, but it’s gaining.

I was curious to see what the comments on this article thought, and I did a little survey:

There were only 20 comments on the article after two or three hours, and I divided them up into categories. The hash marks count comments and the numbers in parentheses count the total number of “Likes” attached to the comments in each category.

There were a couple off point comments which either reiterated some point in the article or brought up some totally irrelevant fact.

There were relatively few China Bashers, and their comments were mainly a grab bag of “communism blows,” “serves the baby poisoners right,” and then criticism of the one-child policy.

The China apologists were split between people who missed the point of the article slightly, or perfectly rational people explaining China’s mitigating circumstances. The former group seized on the article’s following “omission”:

The article began by saying that the rates of all these other countries (minus the U.S., which I just put there for reference) had increased their life expectancy at a faster rate than China, but the apologists faulted the author for not pointing out that China has nearly a decade on the other third world countries. Of course, those apologists consequently ignore the fact that the author also notes that some countries which started with higher life expectancies than China also improved at faster rates, see below. The latter group of apologists simply brought up points about population size and the like. Nothing earth-shattering.

(Isn’t google cool? That’s the World Bank data visualized.)

Finally, the self-deprecators, in the great majority, certainly got the point that was being made. It’s too bad it had to be made at China’s expense, but they do focus on criticizing domestic policy at least. But that’s not what China Bio Law is about so I don’t feel any obligation to go into it.

One thing I did particularly like about the article was the author’s little historical aside into the “Mortality Revolution,” which basically discussed how economic growth following the Industrial Revolution did not bring immediate health benefits along with it. I’ve put the book on this on my reading list.

Oh, and I suppose here’s the section that was most relevant to this blog; there’s nothing new and there’s already plenty of material out there on this stuff:

Finally, there is the medical system itself. The dismantling of state-run industrial companies over the last two decades has ended the cradle-to-grave benefits system known as the iron rice bowl. In its place was a market-based medical system many Chinese could not afford. Even in emergencies, people sometimes had to bring cash to the hospital to get treatment.

Early last year, the Chinese government began expanding health insurance coverage, with the goal of making it universal by 2020. The initial signs look pretty good. The World Bank does not have data past 2008, but numbers published by the C.I.A. suggest that life expectancy has risen in the last two years. In my travels, I visited a simple, clean clinic in rural northern China that seemed to be providing the kind of basic care that could make a huge difference.

China’s current health care goal was first stated in October 2006, when Hu Jintao announced that all Chinese people should have access to “affordable essential health services” and committed a working group of fourteen ministries (led by the Ministry of Health and the National Development Reform Commission) to develop a plan for health care reform.  It took them three years to develop it, and after its unveiling in April of 2009, the deadline set for universal coverage of basic healthcare was 2020.

The upcoming reforms will focus on five areas:

• The public health system;
• The medical care delivery system;
• The health security system;
• The pharmaceutical system; and
• Pilot hospital reform.

Financing and budget allocation is going to be a huge issue, because the central government cannot simply cut check and get the money to the right place.  Public resource allocation is highly decentralized, and governments below the central level actually administer 90% of all government healthcare spending.  Local health departments and other health care providers are also expected to generate their own funding, which seriously distorts the provision of health care because those providers then focus on more profitable curative care and medicines and start increasing fees for public health goods.  In 2007 health expenditures totaled 4.5% of China’s GDP (estimate of total GDP in 2007 was $7.332 trillion USD, meaning ~$330 billion USD would have been spent on healthcare; compare that with the U.S.’s $2.2 trillion spent on healthcare, 16.2% of our GDP) , and 45% of those expenditures were paid for out of pocket by private citizens (compared to the U.S.’s 12%!), a percentage that has been growing relative to the government’s own portion.

China’s health care problems broadly separate out into two often-related areas: cost and quality of care.

Cost is in fact the main barrier to health care in China.  Fees and required expenditures are increasing faster than the average income, and health insurance coverage is spotty at best.  The problem is greatly exacerbated in rural and poor areas, making the issue of even greater concern as great portions of the Chinese population are either rural or poor citizens, and usually both.  Rural governments are often unable to implement the government’s medical financial assistance schemes because of cost, and specialized care is difficult to come by in more remote areas.  Payment schemes tend to disadvantage poor and rural citizens, and their health insurance will frequently be limited to catastrophic illness and reimburse patients for only a third of a treatment’s cost at most.  Many rural enterprises operate without sufficient safety regulation, and generate most of China’s occupational diseases, disabilities, and deaths.

As for quality of care, most problems arise out of a lack of comprehensive regulation and thorough implementation.  Hospital accreditation isn’t linked to comprehensive safety records, doctors and health institutions are unrestricted in their pursuit of commercial incentive programs, and there is a severe deficit of clinical treatment guidelines.  The government wants to better define its role in the health sector by creating consistent health and safety regulation across the country and streamlining the administrative end of things.  The government also wants to improve the quality of care by altering the current composition and distribution of human resources.  Currently, only 14% of the nation’s health professionals have bachelor’s degrees or higher, and poorer regions are often unable to attract and retain qualified medical staff.  There are also imbalances within the health care profession; for instance, with a ratio of 1.3 to 1, China is one of the few countries where doctors outnumber nurses.

So China certainly has a long road ahead of them, and their first step comes in the form of a $124 billion USD commitment to the first three-year implementation program.  Along the way they will have to deal not only with problems endemic to the rational structuring of any nation’s health care system, but uniquely Chinese ones as well.  Traditional Chinese Medicine (TCM) is one of these indigenous issues; the majority of the Chinese population seeks out TCM and the government actively promotes it and integrates it into the national health care system.  So a portion of the government’s reform efforts will center around acknowledged issues in the TCM industry, such as the absence of standardized regulations for assessing TCM treatments and medicines, a lack of standards for applying TCM in clinical trials, and a great amount of evidence-based testing and research yet to be done.  There are also issues with the overall quality of TCM professionals and institutions.

And while the WHO report I have been analyzing did not mention the role of emerging technologies, such as stem cell treatments, in China’s healthcare system, I will be very interested in finding a source on that or doing some original research on it.

Continued from the last post.

What are the current problems that China’s health care system has to cope with?

Thanks to China’s publicly financed health programs providing basic care in the 1960s and 70s, over the course of the last half of the century many of China’s health indicators (e.g. life expectancy, maternal mortality, malnutrition) have steadily improved.  But while China is in a much better health situation than most developing countries, problems still loom large.

In terms of mortality, China’s disease profile is similar to developed countries, meaning that 85%-90% of the deaths in China are caused by noncommunicable diseases and injuries.  Stroke, chronic obstructive pulmonary disease, and heart disease account for nearly 50% of all deaths, and much of this could be reduced by curtailing many of the risk factors in China, such as air, water, and sanitation quality; tobacco and alcohol consumption; diet and nutrition problems; and exercise deficiency.  I will be very interested in seeing how the Chinese government deals with these things.  I’ve seen concerted exercise efforts at least, but I know attempts to curtail smoking have been difficult to implement.  As for the injury deaths, 28% are due to suicide, 25% due to road traffic injuries, and 11% due to drowning.

Compare some of these to the United States’ statistics (in 2006).  The US’ top three killers are heart disease, cancer, and stroke; accidental injuries beat out suicide; and homicide actually sneaks into the top 15.

On the disease front, the major worries are:

• Tuberculosis: China is one of 22 high-burden countries, causing the death of 200,000 people yearly, with multidrug-resistant tuberculosis becoming an increasing public health threat (66,000 new cases every year).
• HIV: At the end of 2007, there were about 700,000 people living with HIV.
• Pandemics: China is also seriously concerned about diseases with a high epidemic potential, such as SARS, H5N1 (bird flu), and H1N1 (swine flu).  It was the SARS scare at the beginning of the century which touched off the increased concern with public health among Beijing’s leadership.
• Certain preventable diseases: Diseases such as malaria and cholera continue to occur, especially in the tropical border provinces and poorer regions of the country.

The government has an Expanded Programme on Immunization, which covers TB, poliomyelitus, diptheria, tetanus, pertussis, hepatitis B, Japanese encephalitis, meningococcal meningitis, hepatitis A, rubella, mumps and measles, leptospirosis, anthrax, and epidemic hemorrhagic fever.  The 11th Five Year Plan is seeking an immunization rate of more than 90% by 2010.

Next time I’ll get to the meat of this section, the actual steps taken by China to resolve their health care woes.

I’ve decided to devote a section of my blog to maintaining up to date profiles of certain aspects of Chinese Biolaw.  My first will be the reform of the Chinese public healthcare system.  I recently read a book called China: Bioethics, Trust, and the Challenge of the Market, which I have mixed feelings about, but it nevertheless had a wealth of information about the history and current status of China’s developing healthcare system.

There is currently no shortage of journal articles written on this topic.  However, information gets dated fast and the language barrier can also act as an impediment to the dissemination of information.  So I hope to create an easily accessible online index of valuable English and Chinese resources for doing research on China’s healthcare system, and continuously input any major updates.

I’m first looking at the WHO‘s current (2009) country profile for China.

Demographically and socioeconomically, it’s the same old story:

• The largest population, 1.3 billion people (although by 2025 India’s population is projected to be roughly commensurate with China’s);
• An aging population, by 2035 a quarter of the country will be more than sixty years of age; 
• An urbanizing population, by 2030 fully half of China’s population will live in urbanized areas (although the rural population as of 2007 was already 56%);
• A population lifted out of poverty, over the past 30 years ~400 million people have been lifted above the international poverty line (US $1) (accounting for ~75% of the developing world’s poverty reduction!);

Politically, healthcare is part of the vanguard of China’s new policy direction.  China’s 11th Five Year Plan (2006-2011) is seeking to introduce “five balances,” and among them is a balance between social and economic development.  The portion of social development that interests us here is the push to support medical care and public health.

This is a no-brainer for the Chinese; solving China’s health care problems will be a key part of resolving social unrest in China.  There are clearly existing and emerging trends in threats to the people’s health that are distributed primarily into environmental, workplace, and lifestyle problems.  The divide between rural and urban health and income continues to grow and is another one of the targets of China’s newest Five Year Plan.  Up to 30% of China’s poor state that health is the primary cause of their poverty (it leads to reduced earning capacity on top of potentially financially-catastrophic medical expenses).  The economic recession also presents dangers for China, because reduced local government earnings may interfere with local governments’ budgetary allocation for healthcare or even encourage them to seek extra revenue by increasing fees or otherwise reducing costs in the healthcare system.  Worse, despite the central government’s social development policy, countervailing economic considerations may encourage the promotion of consumption (e.g., unhealthy food, alcohol, tobacco) at the expense of health considerations.

This is the brief background presented by the WHO report.  I do not think I adequately presented the key link between China’s healthcare status and social unrest, but that’s really a topic in itself.  In the next post I will start giving the nitty gritty on health specific statistics and a description of the development of China’s healthcare infrastructure.