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APO People's Republic of China Health System Review (Health in Transition)


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The People’s Republic of China has made great achievements in improving health status over the past six decades, mainly due to the government’s commitment to health, provision of cost effective public health programmes, growing coverage of health financial protection mechanisms and investments in an extensive health-care delivery network.

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APO People's Republic of China Health System Review (Health in Transition)

  1. 1. Health Systems in Transition People’s Republic of China Health System Review
  2. 2. Health Systems in Transition: China Health System Review 2 Authors: Qingyue Meng Hongwei Yang Wen Chen Qiang Sun Xiaoyun Liu Editors: Anne Mills Viroj Tangcharoensathien Suggested citation: Qingyue M, Hongwei Y, Wen C, Qiang S, Xiaoyun L. People's Republic of China Health System Review. Vol.5 No.7. Manila: World Health Organization, Regional Office for the Western Pacific, 2015.
  3. 3. China: Socio-demographic profile  Overview of health system  Service delivery network  Governance and administration  Health financing  Infrastructure  Human Resources  Major reforms  Main findings  Progress made  Remaining challenges  Future prospects 3 Presentation outline: This map is an approximation of actual country borders Source:
  4. 4. 4 Socio-demographic profile Area 9.6 million sq. km 3rd largest country by land area Population • 1350.7 Million (2012) • 51.8% Urban population • 1.7 TFR (2012) Life expectancy at birth m/f 73.9/76.5 (2012) GDP per capita: $10944.5 (PPP, current international $) HDI 19 Expenditure on health % GDP 5.4 (2012) Source: World Bank, World Development Indicators, 2014 Social demographics of China
  5. 5. 5 Mixed Health Financing/Universal Health Coverage 1.1. Health legislative system (financing, service delivery and health supervision system) 2.2. Central Government control and regulation 3.3. Dominant public hospitals, including traditional medicine hospitals 4.4. Constitution includes the right of citizens to state assistance for health care including disability and ageing 5.5. Basic public health equalization programme Health system 1. Historical grassroots health facility focus 2. Growing private sector/NGO involvement 3. Social Health Insurance with UHC focus by 2020
  6. 6. Service delivery Outpatient care: PHC institutions offer services including basic medical, public health services to local residents Expensive medical equipment is concentrated in secondary and tertiary hospitals 117 expensive medical equipment pieces, compared to 0.47 in PHC institutions Inpatient care All three basic medical insurance systems cover inpatient expenses across rural and urban areas Inpatient and outpatient integration: Hospitals offer both inpatient, outpatient and PHC services Two way patient referral regulation launched in 2006, to promote higher tier medical facility utilization when necessary Patient pathways: Ineffective gate-keeping as two-way referral yet to be fully rolled out, patients often self refer to hospitals resulting in overcrowding 6
  7. 7. 7 Central • National Health and Family Planning Commission – lead health development planning and administrative manager Local (Provincial, Municipal, County) • Service delivery, some funding Other • Professional Associations: CMA, NACTM – professional management inc. in-service training, middleman between workforce and government • Private sector – actively promoted by government to encourage more players in market Governance and Administration
  8. 8. 8 Health Financing Trends in health expenditure in China Source: China National Health Development Research Center, 2014; World Health Organization NHA Indicators, 2013 • Tax-based, social health insurance, private insurance and OOP payment • Government health expenditure has increased 37-fold from 1995-2012 • 3 basic medical insurances cover 95% of the population • OOP payments decreased from 59% in 2000 to 24.3% in 2012 • USD $241.5 billion was spent between 2009-2011 with USD $68.76 billion spent on URBMI and NCMS
  9. 9. 9 Health Financing – Basic medical insurance schemes 3 basic insurance schemes •95% population coverage UEBMI (mandatory for urban employed) URBMI (urban unemployed) NRCMS (rural) Financing •UEBMI: employer/employee contributions URBMI and NRCMS: premiums, government subsidy Overall decrease in OOP payments from 59% to 34% in 2012 Breadth •UEBMI: inpatient, outpatient, some pharmacies URBMI and NRCMS: inpatient and limited catastrophic diseases
  10. 10. 10 Health Financing – Vulnerable groups • Revenue-sharing, financial transfer payment systems est. to help vulnerable access health insurance • Government funded financial assistance • MFA target group: low- income, covers OOP payments for health insurance | 58.78m beneficiaries • Other assistance schemes cover progressively severe illnesses including Insurance Program for Catastrophic Diseases MFA: Medical Financial Assistance for the Poor NRCMS: New Rural Cooperative Medical Scheme URBMI: Urban Resident Basic Medical Insurance UEBMI: Urban Employee Basic Medical Insurance PMI: Private Medical Insurance Financial Flows
  11. 11. Growth of health institutions in China Operational size of hospitals by bed numbers Infrastructure Source: MOH, 2013a Source: MOH, 2013a • Hospitals numbers have grown 2.5 times to 23170 in 2012 • 53% of hospitals are in urban areas reflecting general population distribution • 4.24 beds per 1000 population in 2012. An increase of 50% from 2007 • NDRC responsible for major infrastructure and private health-care institution development • Local government funding for infrastructure accounted for 70% of total public fiscal expenditure between 2009-2011 11
  12. 12. Human resources for Health  4.94 health professionals/1000 population  84.8% of health professionals in public sector. No dual practice for physicians  Grassroots medical care in rural areas delivered by ‘barefoot doctors’: short- term training; public health care services provided.  Historic periods of rapid health personnel growth: over 100,000 annually in the 1950s, 150,000 in the 1970s and 1980s and 200000 post-2005  Comprehensive medical education system from pre-training to continued professional development 12 Growth in total number of health professionals Source: MOH, 2013a Note: From 2007, health professionals do not include apothecaries, inspectors or other types of technician
  13. 13. Early health system reforms 13 Centralized control Communicable disease reduction Rural and primary health care development Barefoot doctors Basic medical security system established • Emphasis on grassroots care: • 90% of all counties had medical institutions by 1952 • Every village had at least 1 barefoot doctor • Free services to control communicable diseases: smallpox and tuberculosis • Centralized control: service cost, drug mark- ups • Initial medical security system: rural cooperative, government and employee insurances China managed to build a basic health system between 1949-1979 despite low economic development and limited resources
  14. 14. Initial reforms 1985 • Decentralization of financial and decision-making for public hospitals 1989 • Central role of user charges in financing emphasized 1992 • Greater autonomy for public hospitals, increasing user charge reliance 1994 • Combined risk pooling for government, employer/employee expenditure 1997 • Decision on re-establishment of rural CMS, UEBMI deepening 1998 • Implementing the UEBMI scheme nationally 2002 • Launch of NRCMS 13
  15. 15. Recent reforms 15 2003 • Shift to developmental aims including person-centred health care 2006 • Aim to establish basic health system for all 2006 • NRCMS refinement and planned expansion 2007 • URBMI established (National coverage of basic health insurance system achieved) 2009 • Aim of achieving UHC by 2020 set 2011 • Guidelines for establishing GP system 2012 • Deepening health reform during 12th 5 year plan 2013 • Essential medicine system reform, service industry
  16. 16. 16 Achievements and progress made More than doubled life expectancy Dramatic improvement in child and maternal health indicators Substantial decrease and control of major communicable diseases Universal population coverage via basic medical insurance schemes
  17. 17. 17 Achievements and progress: Equity focused reforms Cross-government coordination Universal population coverage National essential medicines system Addressing rural shortfalls Focus on vulnerable groups
  18. 18. 18 Achievements and progress: Decreased OOPE Change in OOP payments as a proportion of THE Source: WHO and OECD, 2014 • Significant drop in OOP expenditure from 59% in 2000 to 34% in 2012 • Government interventions include greater health system funding, expansion of social health insurances • Social welfare programs also set up to address vulnerable groups, e.g. poor • Biggest decline in OOP payments as proportion of THE in all of Asia-Pacific
  19. 19. 19 Achievements and progress: Health Information Systems • HIS development for hospital management, finance and pharmacy2000 • Post-SARs: Largest online reporting system for communicable diseases set up. Online reporting mandatory: avg. reporting time decreased from 5 days to 4 hrs 2003 • HIS for MCH, immunization established • NRCMS insurance funds managed online and in real time 11th Five Year Plan: 2006-2010 • Regional HIS development based on electronic medical records2009 • Three-tier platform covering national, provincial and country hierarchy to strengthen HIS application across health system 12th Five Year Plan: 2011-2015 Timeline of achievements
  20. 20. 20 Achievements and progress: Family planning services • Highly successful population control intervention since 1982 • Policies include controlling rapid population growth, reducing birth defects, encouraging later marriages, later births, fewer babies, and famously ‘the one child policy’. • Intervention measures to reduce birth defects include government support for annual physical examinations targeting women of childbearing age screening for major diseases. 104 million women served in 2012 • Population implications • TFR has dramatically decreased: 5.43 to 1.6 between 1971 and 2012 • World population reaching 7 billion delayed by 5 years • National level implications: Economic development, higher quality of life, eliminating poverty, conserving the environment and natural resources
  21. 21. 21 Achievements and progress: Intersectoral collaboration National Patriotic Health Campaigns ‘Health in all policies’ Long history of multisectoral collaboration • NHFPC often jointly coordinates through equal cooperation with other departments, e.g. Ministry of Agriculture. • Areas of cooperation include: food safety, occupational health, pro-poor health programmes • ‘Patriotic health campaigns’ are delivered by cross-sector agency utilized to promote health nationally across public health, sanitation, disease control and treatment. • ‘Health in all policies’ focuses on environmental impacts on health. Now used for development of healthy cities
  22. 22. 22 Achievements and progress made: Vaccines and pharmaceuticals • China can produce and supply all of its vaccine needs. It is now the world’s biggest vaccine-producer. • Smallpox and newborn tetanus eradicated in China • Domestic drug production valued at $256 billion USD • Challenges: • Pharmaceuticals account for: 50.3% of outpatient costs, 41.1% of inpatient costs • Drug safety and irrational drug use are still key issues Vaccines Output: 1 billion doses per year Vaccines to protect against 15 communicable diseases provided free Medicines All medical institutions nationally have their own pharmacies National Essential Medicines policy
  23. 23. 23 • NCDs: 85% of 10.3 annual deaths and 70% of total disease burden • 260m+ NCD patients in China • Risk factors: • High smoking rate (54% of male adults, aged 18-69) • Low exercise rate among adults and high per-capita salt and cooking oil intake • Ageing population: 8.7% of population older than 65 Remaining challenges: NCDs and risk factors Major risk factors for NCDs Source: China Centre for Disease Control and Prevention, 2012b
  24. 24. 24 • Socioeconomic differences: rural areas have lower levels of economic development, health input and demand • Leading causes of mortality are converging between rural and urban areas (select figures below) Implications • Human resources, bed concentration skewed to urban areas • Higher financial inequity in rural areas, including health access • Higher rates of infant and maternal mortality in rural areas Remaining challenges: Geographic disparities Rural-Urban Causes of death in China Source: weighed proportions of and cause-specific mortalities in urban and rural populations based on information in China Health Statistical Yearbooks
  25. 25. 25 • Equipment is mainly funded by local governments • On average, there were 2.87 pieces of expensive equipment in higher-level facilities in 2012 but none in primary healthcare institutions • Primary health care institutions only have 1 piece of equipment between two facilities. A lack of technicians may also mean underutilization of these. • Major medical equipment is lacking: 3 MRIs, 9.4 CT and 0.7 PETs per million people Remaining challenges: Growing demand for technology Average number of pieces of medical equipment in one health institution, 2012 Source: MOH, 2013a
  26. 26. 26 • Health-care professionals with higher education (19.1%) are more likely to be in urban areas compared to rural areas (5.9%) • Lack of qualified health professionals and high turnover slows down primary healthcare institution development Remaining challenges: Human resources Viet Nam Thailand South Africa Philippines Japan India China Doctors 1.224 0.298 0.758 1.153 2.1 0.65 1.456 Nurses 1.006 1.524 0 6 11.5 1 1.512 Dentists 0 0.065 0.192 0.564 0.74 0.08 0.039 Pharmacists 0.324 0.117 0.369 0.886 2.153 0.541 0.26 0 2 4 6 8 10 12 14 Number of health personnel per 1000 population, selected countries Source: WHO, World Health Statistics, 2013 Note: Data on Dentists in Viet Nam and Nurses in South Africa not provided
  27. 27. 27 Remaining challenges: Migrant health Up to 236 million floating migrants Eligibility for health insurance tied to registered geographic zone Migrants forced to pay full cost up-front, delayed reimbursement – higher OOP payments • Rapid industrialization, urbanization: large population movement from rural to urban areas • ‘Hukou’ or place of registration dictates access to social welfare, inc. health to geographic zone • Lack of insurance coverage: full up-front payments, 15-25% lower reimbursement • Targeted interventions: NEPHSS providing peasant workers and children access to free public health services| URBMI developing policies to create continuity of care
  28. 28. 28 Future prospects: China 2020 UHC establishment 2020 Harmonize insurance schemes Coordinate reform components Person- centred, primary care focused system Speed up public hospital reform Strengthen Human Resources and HIS Encourage NGO investment
  29. 29. Based on the Health Systems in Transition People’s Republic of China Health Systems Review, 2015 29
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