The Chinese Healthcare System

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The Chinese Healthcare System

• Lecture 10
• Tracey Lynn Koehlmoos, PhD, MHA
• HSCI 609 Comparative International Health Systems

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Where are we now?
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A few facts about China

• Country name Peoples 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 Everestin the Tibetan Autonomous region
  shares a border with Nepal

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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)
• Urban11 per 1000
• Rural 37 per 1000 (1999)
• Population gt65 7.7

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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 Peoples 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/healthjourn
  al/davis.pdf accessed 12 May 2006)

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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

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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 govts having more control
  (result disparities privatization)
• 2nd Govt imposed Perverse Price Regulations
  hospitals and physicians that generated more
  income got bonuses promoted use of new,
  expensive pharmaceutical products and
  high-technology services

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Chinese Federal Health Expenditure as of Total
Health Expenditures
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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 govt 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 3531165-1170 (11)

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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
  pharmaceuticalsmany of which are counterfeit

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Privatization

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

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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.

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Urban Healthcare

• Public hospitals 70, state mandated charges
• Two tier National insurance system based on
  employer and employee contributionsstarted 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

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Informed Patient/Rise of Consumerism

• Chinas 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, todays
  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
  parents ignoring the one child rule

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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.

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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 statisticnot
  counted by all agencies)
• US 24.5 per 100 pregnancies (2002)
• Decline in Chinese abortion rate
• Distrust of birth control pill

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Gender Imbalance

• 120100 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

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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
  diseasepreviously eliminated has re-emerged and
  contributed to mortality rates

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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 worldwidewith a
  rapid increase in China
• Causes cirrhosis, causes death

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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
  programdug hundreds of thousands of new canals,
  buried old canalssnails eliminatedexcept for in
  the mountains, source of the Chang Jaing

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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 preventedbut can be held in a steady
  state through an annual dose of praziquantel
  (campaigns are common in affected areas)

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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

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Summary

• Chinas 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
  countrys 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