The document provides information on healthcare delivery in China. It begins with definitions of healthcare delivery systems and their components. It then provides demographic profiles of China and India, comparing various metrics like population size, density, health outcomes, expenditures, and common health problems. The profile sections of China and India are quite extensive. It also provides historical background on China's healthcare system, from the pre-revolutionary era to the establishment of the basic health insurance system in recent decades. It describes the key reforms to China's healthcare system over time that aimed to decentralize control and increase coverage. It outlines China's current universal healthcare system, which utilizes a mix of public health programs, primary care facilities, hospitals, and basic medical insurance schemes to cover

1. Healthcare delivery
in CHINA
Dr. Jenifer Florence Mary J,
Postgraduate
Department of Community Medicine
Sri Manakula Vinayagar Medical College and Hospital
Pondicherry, India.

2. Healthcare delivery
system:
It consists of all organizations, people and
actions whose primary intent is to
promote, restore or maintain the health
and includes efforts to influence
determinants of health as well as more
direct health - improving activities.
It is more than the pyramid of publicly
owned facilities that deliver personal
health services. It includes inter-sectorial
action by health staff e.g., encouraging
the Ministry of education to promote
female education, a well-known
determinants of better health.
(WHO)

3. Demographic profile of CHINA and
INDIA
Profile China India
Politics
Socialist consultative democracy – Chinese
Communist Party
Parliamentary secular democratic
republic
Country name People’s Republic of China Republic of India
Politics
Socialist consultative democracy – Chinese
Communist Party
Parliamentary secular democratic
republic
Government type Communist Party led state Federal parliamentary republic
Administrative
divisions
23 provinces, 5 autonomous regions and 4
municipalities
29 states and 7 union territory

4. Profile China India
Total land area (km2) 9,388,211 (3,624,807 sq. mi) 2,973,190 (1,147,955 sq. mi)
Population density (per
km2)
153 (397 people per mi2) 464 per (1,202 people per mi2)
Climate
Extremely diverse; tropical in
south to subarctic in north
Varies from tropical monsoon in
south to temperate in north
Population ranking 1 2
Total population 1,441,736,995 (Dec 7, 2020) 1,385,863,914 (Dec 7, 2020)
Urban population (% of
total pop)
60.8 (875,075,919 people in 2020) 35.0 (483,098,640 people in 2020)
Rural population (% of
total pop)
39.0 (564,247,857 people in 2020) 65.0 (896,905,745 people in 2020)

5. PROFILE CHINA INDIA
Population ages 65 and above (% of total pop) (2019) 11.5 6.4
Human Development Index (2018)* 0.758 (+7 – 2013-2018) 0.647 (+1 – 2013-2018)
Poverty index (2018)* 0.016 0.123
Illiteracy rate (15 +)** (2018) 97 74
Life expectancy at birth total (yrs.) 77.5 70.4
Life expectancy at birth male(yrs.) 75.4 69.2
Life expectancy at birth female (yrs.) 79.7 71.8
Median age (years) 38.4 28.4
GDP public health expenditure (%) (2019) 2.9 1.29

6. Profile China India
Under 5 mortality rate (per 1000 live birth) 9.8 32.9
GDP / capita growth (annual %) 6.90 6.68
Household expenditure on health greater than 10% of total household
expenditure or income (%)$
19.72 (2013) 17.33 (2011)
Infant mortality rate (deaths per 1,000 live births) 8.4 26.6
Maternal mortality ratio (per 1,00,000 live births) (2017) 29 145
Total fertility rate (live births / woman) 1.7 2.2
Contraception prevalence of women aged 15-49 years (%) (2015) 84.5 53.5
Unmet need for contraception of married women ages 15-49 (%) 2.3 (2001) 13 (2016)

7. Profile China India
Common health
problems!
1. Stroke
2. Ischemic heart disease
3. COPD
4. Lung cancer
5. Alzheimer’s disease
6. Liver cancer
7. Stomach cancer
8. Hypertensive heart
disease
9. Road injuries
10. Esophageal cancer
1. Heart disease
2. COPD
3. Stroke
4. Diarrheal diseases
5. Lower respiratory infection
6. Tuberculosis
7. Neonatal disorders
8. Asthma
9. Diabetes
10. Chronic kidney disease

8. Profile China India
Major infectious
disease!
Food or waterborne disease: Bacterial
diarrhea, hepatitis A and typhoid fever
Vector borne: Crimean-Congo hemorrhagic
fever, JE
Soil contact disease: Hanta viral hemorrhagic
fever with renal syndrome
Food or waterborne diseases: Bacterial
diarrhea, hepatitis A and E, typhoid fever
Vector borne disease: Dengue, JE, malaria
Water contact diseases: Leptospirosis
Sources:
Elaboration of data by United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects: The 2019 Revision.
World Development Indicators 2020.
*Human development report office 2019
** Population Census of the People’s Republic of China. Beijing: China Statistics Press.
#The global health observatory data repository and OCED 2019 data
$World Bank, 2019
!GBD compare 2018

9. Historical background
• Pre-revolutionary China / Pre-Mao era
Traditional Chinese Medicine
Peking Union Medical College
• Mao-era
Centrally planned and managed
managed health services
Soviet model

10. China
Soviet
model
Bureaucratic
Economy
managed by
bureaucratic and
reports
No health
insurance
Health care was
affordable and
accessible to all
Collectivization of
agriculture
Innovation
difficult
No reward for
taking risk and
creating
something new
Inefficient firms
practiced
Firms not allowed
to fail
Restriction of
geographic
motility
Hukou
Co-operative
controlled price
Ownership of
industry by
government
Centrally
planned
economy

11. First national health
congress (Aug 1950)
Medicine should serve the
workers, peasants & soldiers
Preventive medicine to be
emphasized over curative
services
Integration of traditional
medical practices with
western medicine
Health related works to be
combined with mass
movements, in controlling
infectious diseases

12. 1950-1957
•Three-pronged
healthcare
insurance system
1950
•Epidemic
prevention
station
1951
•Labor insurance
regulation
1953-58
•First five-year
plan – Agriculture
dependence
1955
•Cooperative
medical scheme
(CMS)
1957
•Three-tier of
rural health care
system
1959 - 61
•The Great Leap
forward / Second
5-year plan
1966 - 75
•Cultural
revolution
1976
•Barefoot doctors
1979
•One-child policy
•Surveillance
system
1978 - 2000
•Economic
reforms
>2000
•Health reforms

13. Early health system reforms
• China managed to build a basic health system between 1949-
1979 despite low economic development and limited
resources (1.2%)
• Emphasis on grassroots care:
90% of all counties had medical institution by 1952
Every village had at least 1 barefoot doctor
• Free services to control communicable diseases: smallpox
• Centralized control: service cost, drug markups
• Initial medical security system: rural cooperative, government
and employee insurances
Centralized control
Communicable disease
reduction
Rural and primary health
care development
Barefoot doctors
Basic medical security
system established

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 charger reliance
1994
• Combined risk pooling government, employer/employee expenditure
1997
• Decision on re-establishment of rural CMS, UEBMI deepening
1998
• Implementing the UEBMI scheme nationally
2002
• Launch of NRCMS

15. 2003
• Shift to
developmental
aims including
person-centered
health care
2004
• China – Centre
for Disease
Control and
Prevention
(CDC)
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 five-year
plan
2013
• Essential
medicine system
reform, service
industry
2015
• Health reforms
for achieving
UHC
2016
• Two-child policy
Recent health reforms

16. Healthy China 2030
• HC 2030, which is the Chinese
• vision of health care, is built on four core
principles.
• The first is health priority.
• The second core principle is innovation.
• The third principle is scientific
development.
• The fourth principle is fairness and
justice.

17. Framework of the HC 2030 vision

19. Health system
Mixed health financing / Universal Health Coverage
1. Health legislative system (financing, service
delivery and health supervision system)
2. Central Government control and regulation
3. Dominant public hospitals, including
traditional medicine hospitals
4. Constitution includes the right of citizens to
state assistance for health care including
disability and ageing
5. Basic public health equalization
programmed
• Historical grassroots health
facility focus
• Growing private sector and
NGO involvement
• Social health insurance with
UHC focus by 2020

21. Level of healthcare in CHINA and INDIA

22. China’s Healthcare system
Healthcare
system
Public
health
Prevention centers
(dedicated to different
areas)
Health education on
1. Basic diseases prevention and control
2. Family planning, MCH care
3. Mental health
4. Blood donation
5. Special disease and emergencies
Medical
services
Primary hospitals
1. Basic medical care
Rural areas: Township health centers and village clinic
3. Urban areas: Community health centers and community
health stations
Secondary and tertiary
hospitals
1. High quality services and more advanced medical supplies
2. Generally preferred by patients as better qualified doctors
and even for less serious treatments
3. Typically located in urban areas
Pharmace
utical
services
Pharmacies (afflicted
by medical institutions )
Usually locate in a hospitals
Supplies prescription medicine
Independent
pharmacies
Located in cities and villages
Provides general medicine that is freely available

23. 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

24. Financial flow
Created by Dr. Jenifer J

25. Universal healthcare
insurance system
Urban residence
Urban workers and
retiring workers
Urban workers
Children, students,
unemployed and urban
residence
Rural residence Farmers
Other healthcare
insurance
Civil servants and
soldier

26. Health legislation
Chinese government upholds the following
principles in health:
• Highlight rural areas
• Preventive care first
• Aligning positions of traditional Chinese
medicine and western medicine
• Relying on science, technology and education
• Encouraging the participation of whole
society
• Serving for people’s health
• Serving for China's socialistic modernization

27. Essential drug list
• Drug is made by manufacturers
• Sold to patients by distributors
• Raise the price for drugs in order to gain margin.
• Expensive fees for medical services in China
• It aims to lower the price by reducing the middleman
• Sets ceiling price for drugs in the list which is updated
every 3 years
• The government tried to extend the zero mark up for
drug sales in basic level hospitals with no profit and
the lost margin would be reimbursed by the
government

28. Input and processes outputs outcomes impact
Policy changes
Insurance
Essential drugs
Public health
Process or implementation
Health workers
PHC service packages
Hospital standards
MRs prices
Service reorganization
Results
Coverage
Behavior change
Result
Financial
protection
Patient satisfaction
Financial changes
Investments follow
New policies
Better quality
Efficiency in service
delivery
Health status
TIME
2009………………………2010…………………………….2011………………2012………………………………2020

29. Challenges in Healthcare system in CHINA
• Uneven economic growth
• Urban and rural disparities
• Technological barriers
• Human resources
• Overcrowding at tertiary hospitals
• Needs for the growing elderly population
• Market-oriented financing mechanisms to
fund for both curative and preventive care
• Services became unaffordable and
inaccessible for disadvantaged populations
• Rapid rise of medical costs and the
inefficiency of state-owned enterprises
collapsed rural health insurance and crippled
urban health insurance
• Lack of coverage provided by the health
system and inadequate government support
are the main obstacles to universal coverage

30. Learning
• Continue political support is most important enabling condition for achieving UHC
• Increasing health financing is necessary and investment from both government and private
sector to be considered
• Strong PHC system should be regarded as a core component in realizing UHC
• Increase spending on health, especially infrastructure, providers and necessities
• Better control of communicable diseases and improvement in maternal and infant mortality
• Though, there is no strong and proper evidence for the healthcare system, it is
to interrupt

31. Reference
• Detels R. McEwen J. Beaglehole R. Tanaka H. Oxford textbook of Public health. 4th ed. New York: Oxford University Press;
2004.
• WHO. China’s village doctors take great strides. Bulletin of the World Health Organization. 2008 [cited on 2020 Dec 7]; 86
(12) Available from URL: www.who.int/bulletin/volumes/86/12/08-021208/en/
• Qingyue M, Hongwei Y, Wen C, Qiang S, Xiaoyun L. People’s Republic of China Health System Review.2015 [cited on 2020
Dec 8]; 5(7) Available from URL: http://iris.wpro.who.int/bitstream/handle/10665.1/11408/9789290617280_eng.pdf
• WHO (World Health Organization) (2020). Universal Coverage of health care in China: Challenges and Opportunities.
WHO, Geneva.
• H. Yu, “Universal Health Insurance Coverage for 1.3 Billion People: What Accounts for China's Success?” Health
Policy 119, no. 9 (Sept. 2015): 1145–52.
• The State Council, The State Council’s Suggestion on Merging Urban-Rural Resident Basic Health
Insurance (2016), http://www.gov.cn/zhengce/content/2016-01/12/content_10582.htm

32. Thank you