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The Chinese Healthcare System. Lecture 10 Tracey Lynn Koehlmoos, PhD, MHA HSCI 609 Comparative International Health Systems. Where are we now?. A few facts about China. Country name: People’s Republic of China Government Type: Communist State Capital: Beijing

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The chinese healthcare system l.jpg

The Chinese Healthcare System

Lecture 10

Tracey Lynn Koehlmoos, PhD, MHA

HSCI 609 Comparative International Health Systems



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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


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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)

    • Urban:11 per 1000

    • Rural: 37 per 1000 (1999)

  • Population >65: 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 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)


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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 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



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Four Steps to Poor Health (Continued) Expenditures

  • 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)


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Macro Health Finance Expenditures

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


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Privatization Expenditures

  • Since 2000:

  • Hospitals: 15% cooperative ownership, 15% private, for-profit

  • Rural area clinics and hospitals allowed to privatize


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Rural Healthcare Expenditures

  • 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 Expenditures

  • 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


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Informed Patient/Rise of Consumerism Expenditures

  • 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


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Gender Imbalance Expenditures

  • 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 Expenditures

  • 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


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Gender Imbalance Expenditures

  • 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


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Rural Urban Disparity Expenditures

  • 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


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Schistosomiasis !?! Expenditures

  • 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


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More on Schistosomiasis Expenditures

  • 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


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More about Schistosomiasis Expenditures

  • 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)


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Compared to US Expenditures

  • 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 Expenditures

  • 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


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