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Health Systems: an Introduction

Health Systems: an Introduction. Jin Wen, Ph.D. Institute of Hospital Management West China Hospital. Outline. What is a health system? Categorizing health systems  What is a ‘health systems’ analysis? Selected analytical frameworks C hina health system-an overview. Question:.

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Health Systems: an Introduction

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  1. Health Systems: an Introduction Jin Wen, Ph.D. Institute of Hospital Management West China Hospital

  2. Outline • What is a health system? • Categorizing health systems •  What is a ‘health systems’ analysis? • Selected analytical frameworks • China health system-an overview

  3. Question:

  4. What is a health system?

  5. Definitions of a health system • 卫生体系包括那些旨在促进、恢复或维持健康的所有组织、人和行动。(WHO)

  6. Now list examples you can think of… • A health system... includes, a mother caring for a sick child at home; private providers; behaviour change programmes; vector-control campaigns; health insurance organizations; occupational health and safety legislation, ... inter-sectoral activities, e.g. female education, a well known determinant of better health.

  7. Elements of the Health System

  8. Main functions of Health System (WHO 2000) • 融资 • 业务收入 • 基金池 • 采购 • 提供服务 • 资源分配 (eg. human resources, physical capital, pharmaceuticals) • 监管

  9. WHO卫生体系组成要素 目标/结果 体系构成要素 领导力/管理能力 可及性 覆盖率 改善健康(程度和公平) 医疗融资 反应性 卫生人力资源 降低财务风险 医疗产品和技术 质量 安全 信息和研究 促进效率 提供服务类型

  10. By finance and provision • Donaldson C, Gerard K. 1993. Public/private mix in health care financing and provision 医疗保健的公私混合融资和提供

  11. FINANCING SOURCES •Public: –General tax 普通税 –Payroll taxes (工资税 social insurance) –Other earmarked taxes 其他指定的税收 –Donors 捐赠者 •Private –Insurance –Employers –Voluntary organisations –Direct payments

  12. China Health System —an overview

  13. Outline A few facts Historical review Current challenges 15

  14. Disparities within China Source: Tang et al. The Lancet, 2008

  15. Historical Review (1) • 1949–1979(collective period): • health care organized around the workplace in urban area and commune in rural area • Separate health schemes for farmers,state-owned enterprise (SOE) workers and goverment officials • "Bare foot" doctors and workplace clinics provide first level care as gatekeepers • price (salaries) curbed by the government • almost tax financing and nearly universal coverage

  16. Levels of healthcare provision in pre-1978 rural China Source: Ryan Manue,l China: The Next Twenty Years of Reform and Development

  17. Historical Review (2) • 1980-2003( marketization period): • Loss of safety-net due to dismantle of communes and some SOE (state-owned enterprise) • Insufficient subsidy to the providers result in "profit driven" services • high-tech equipment, over consumption of drugs, the delivery of unnecessary care • Rapid cost escalation, impoverishment • Prevention and public health neglected, SARS

  18. Health expenditure in China since 1978 Source: Shanlian Hu,Reform of how health care is paid for in China: challenges and opportunities

  19. Historical Review (3) • 2003 onwards (Health reform started) • Hot debate on how to finance? UK or US • Increased government spending due to economic growth • Attention paid to public and preventive care

  20. 1. Governnance structure • Five-tier government (central, provincial (municipal) , city (district) , county and township) is in charge of health system development and reform, from Ministry of Health (MOH) to Bureau of Health (BOH) at local level. • Highly decentralization on health financing, health service delivery, social medical insurance schemes and essential medicine policies.

  21. 2. Service delivery structure General Hospitals Special hospitals Inspection& Supervision CDC MCH Tech support and training Referral Information Report Community Health Center s Township Health Centers Clinic Nursing home Other Community Health Stations Village Clinics

  22. Public hospitals/facilities • Government subsidies: 10% of total revenue • Heavy reliance on user fees • Fee for service payment method, exacerbated by: 1) Drug mark up; 2) Distorted price schedule. • Public ownership, private for-profit behaviour

  23. 3. Health financing Enterprise & supplemental insurance Special population insurance Commercial health insurance Multiple-layer Health Insurance System in China supplement New rural cooperative medical system (NCMS) Urban employee basic Medical Insurance Urban resident basic medical insurance Main schemes Safety net Social medical aid in Urban and Rural

  24. 4. HRH 卫生人力资源 • No shortage of health workers. • Misdistributions between urban and rural; • Relatively low quality (in terms of education).

  25. System of nomenclature for health workers in China 卫生工作者命名体系 • Health professionals 卫生技术人员 • Doctors • Licensed doctors • Licensed assistant doctors • Nurses • Technicians • Non-professional 非卫生技术人员 • Other technicians • Management staff Anand et al, Lancet, 2008

  26. Doctors density in comparison with OECD Korea, DPR (2003) 3.29 OECD (2008) 3.22 Australia (2007) 2.97 Mongolia (2005) 2.60 New Zealand (2008) 2.46 Macao - China (2008) 2.4 Japan (2008) 2.15 Korea, Rep. (2008) 1.86 Hong Kong - China (2009) 1.80 Singapore (2008) 1.50 China (2006) 1.40 Philippines (2002) 1.15 Asia - 22 1.11 Pakistan (2005) 0.78 Malaysia (2009) 0.70 Vietnam (2005) 0.60 Sri Lanka (2008) 0.60 India (2004) 0.58 Myanmar (2004) 0.36 Lao PDR (2004) 0.35 Thailand (2005) 0.30 Bangladesh (2005) 0.30 Nepal (2004) 0.21 Cambodia (2000) 0.16 Indonesia (2003) 0.13 0 1 1 2 2 3 3 4 HRH in China • Quantity • Quality • Distribution Distribution of doctors and nurses by education level (Source: Anand,2005) 2008 national statistics Source: Michael Borowitz, 2010

  27. China’sinter-provincial disparities Shanghai Beijing Tianjin Guizhou 2011 statistics

  28. Health System Reform • Since 2009, China has been implementing a large scale health system reform. • The reform aims to establish and improve the basic health care system covering urban and rural residents, and provide the people with secure, efficient, convenient and affordable health care services.

  29. 医疗保健铁三角 • 全世界所有国家医疗费用的增长速度均高于GDP增速 • 考虑角度 费用 及时、有效、安全、满意、效率、经济性、连续性和系统性 时间可及、地点可及、负担得起、网络可及 患者 质量 可及性

  30. Key reforms in the last years 1. Expanding basic medical insurance system 2. Establishing National Essential Medicine system 3. Strengthening the healthcare delivery system at grassroots level 4. Promoting equitable access to essential package of public health services 5. Piloting the Public hospital reform

  31. Early Appraisal of China Health Reform • Increased insurance enrolment • UEBMI: 92.4% • URBMI:92.9% • NCMS:96.6% Question: Universal Coverage?

  32. Dimensions of universal coverage Source:World Health Report 2010

  33. Too expensive and difficult!看病贵，看病难？ 视频：柴进看两会

  34. Problems in quality of services • Quality of services is big concern in China’s health system. • A few examples: • Misuse of antibiotics • Misuse of intravenous injection • High proportion of Caesarean Section

  35. Misuse of antibiotics • In China, the use of antibiotics in hospitals is very popular, antibiotics become the main source of revenue in the hospitals. • The share of antibiotics revenue in tertiary hospital is almost 30% of total drug revenue, in secondary hospital the proportion is 40%.

  36. Misuse of intravenous injection • Global data in 2004 showed that 5 out of 16 billion injections (31%) were occurred in China, China is the biggest number of intravenous injection country in the world • In average, 8 bottles of intravenous injection fluid were used per annual per capita. Much higher than the average number of 2.5-3.3 bottles per capita according to the international standard.

  37. Health outcomes 1. China has made remarkable progress in health outcomes in the past decades (life expectancy, MMR, IMR). 2. NCDs become a growing burden. 3. However, there are great disparity between urban/rural, east/west:

  38. MMR of permanent and migrant population in 2005 (1/100,000 people, China • (Meng, 2011: “One China, Two world”) MMR=maternal mortality rate

  39. 第三次上课(2016年3月14日周一)小组汇报作业 文献查阅：国内外医院管理模式或经验分享 要求： 1.分为9个组，分别查阅美国、英国、法国、日本、澳大利亚、新加坡、台湾、加拿大、中国大陆 9个国家或地区 2.制作成PPT 3.课题随机抽取小组中的一个成员上台汇报，代表所有小组成员成绩 4.每组汇报时间5-8分钟 Thanks!

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