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.

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.