Healthcare in China

Healthcare in China consists of both public and private medical institutions and insurance programs. About 95% of the population has at least basic health insurance coverage. Despite this, public health insurance generally only covers about half of medical costs, with the proportion lower for serious or chronic illnesses. Under the "Healthy China 2020" initiative, China is currently undertaking an effort to cut healthcare costs, and the government requires that insurance will cover 70% of costs by 2017.^[1][2][2] The Chinese government is working on providing affordable basic healthcare to all residents by 2020.^[3]

China has also become a major market for health-related multinational companies. Companies such as AstraZeneca, GlaxoSmithKline, Eli Lilly, and Merck entered the Chinese market and have experienced explosive growth. China has also become a growing hub for health care research and development.^[4]

The above applies to Mainland China. The Special Administrative Regions of Hong Kong and Macau maintain their own separate universal healthcare systems.

History

Traditional Chinese Medicine (TCM) has been practiced for years, and served as the basis for health care in China for much of its history. Western-inspired evidence-based medicine made its way to China beginning in the 19th Century. When the Communist Party took over in 1949, health care was nationalized, a national "patriotic health campaign" attempted to address basic health and hygiene education, and basic primary care was dispatched to rural areas through barefoot doctors and other state-sponsored programs. Urban health care was also streamlined. However, beginning with economic reforms in 1978, health standards in China began to diverge significantly between urban and rural areas, and also between coastal and interior provinces. Much of the health sector became privatized. As state-owned enterprises shut down and the vast majority of urban residents were no longer employed by the state, they also lost much of the social security and health benefits. As a result, the majority of urban residents paid almost all health costs out-of-pocket beginning in the 1990s, and most rural residents simply could not afford to pay for health care in urban hospitalities.

System reform

Since 2006, China has been undertaking the most significant health care reforms since the Mao era. The government launched the New Rural Co-operative Medical Care System (NRCMCS) in 2005 in an overhaul of the healthcare system, particularly intended to make it more affordable for the rural poor. Under the NRCMCS, some 800 million rural residents gained basic, tiered medical coverage, with the central and provincial governments covering between 30-80% of regular medical expenses.^[5] Availability of medical insurance has increased in urban areas as well. By 2011 more than 95% of the total population of China had basic health insurance, though out-of-pocket costs and the quality of care varied significantly.^[4] The health infrastructure in Beijing, Shanghai and other major cities were approaching developed-world standards, and are vastly superior compared to the rural interior.

Current healthcare system

All major cities have hospitals specializing in different fields, and are equipped with some modern facilities. Residents of urban areas are not provided with free healthcare, and must either pay for treatment or purchase health insurance. The quality of hospitals varies. The best medical care in China is available in foreign-run or joint venture Western-style medical facilities with international staff available in Beijing, Shanghai, Guangzhou and a few other large cities. They are highly expensive; treatment there can often cost up to ten times more than a public hospital.^[6] Public hospitals and clinics are available in all Chinese cities. Their quality varies by location; the best treatment can usually be found in public city-level hospitals, followed by smaller district-level clinics. Many public hospitals in major cities have so-called V.I.P. wards or gaogan bingfang. These feature reasonably up-to-date medical technology and skilled staff. Most V.I.P. wards also provide medical services to foreigners and have English-speaking doctors and nurses. V.I.P. wards typically charge higher prices than other hospital facilities, but are still often cheap by Western standards. In addition to medical facilities providing modern care, traditional Chinese medicine is also widely used, and there are Chinese medicine hospitals and treatment facilities located throughout the country. Dental care, cosmetic surgery, and other health-related services at Western standards are widely available in urban areas, though costs vary.

Historically, in rural areas, most healthcare was available in clinics providing rudimentary care, with poorly trained medical personnel and little medical equipment or medications, though certain rural areas had far higher-quality medical care than others. However, the quality of rural health services has improved dramatically since 2009. In an increasing trend, healthcare for residents of rural areas unable to travel long distances to reach an urban hospital is provided by family doctors who travel to the homes of patients, which is covered by the government.^{[7][8][9][10][11]}

Reform of the health delivery system in urban areas of China has prompted concerns about the demand and utilization of Community Health Services Centres (CHC); a recent study, however, found that insured patients are less likely to use private clinics and more likely to use CHC.^[12]

Despite the introduction of western style medical facilities and the implementation of a National Essential Drug Policy,^[13] the PRC has several emerging public health problems, which include problems as a result of pollution, a progressing HIV-AIDS epidemic, hundreds of millions of cigarette smokers,^[14][15] and the increase in obesity among the population.^[16][17] The HIV epidemic, in addition to the usual routes of infection, was exacerbated in the past by unsanitary practices used in the collection of blood in rural areas.^[18] The problem with tobacco is complicated by the concentration of most cigarette sales in a government controlled monopoly.^[15] The government, dependent on tobacco revenue, seems hesitant in its response and may even encourage it as seen from government websites.^[19] Hepatitis B infection is widespread in mainland China, with about 10% of the population contracting the disease.^[20] Some hepatitis researchers link hepatitis infections to a lower ratio of female births. If this link is confirmed, this would partially explain China's gender imbalance.^[21] A program initiated in 2002 will attempt over the next 5 years to vaccinate all newborns in mainland China.^[22]

Strains of avian flu outbreaks in recent years among local poultry and birds, along with a number of its citizens, have caused great concern for China and other countries. While the virus is currently mainly animal-human transmissible (with only two well documented cases of human-human have been to the present known of to scientists), experts expect an avian flu pandemic that would affect the region should the virus morph to be human-human transmissible.^[23]

A more recent outbreak is the pig-human transmission of the Streptococcus suis bacteria in 2005, which has led to 38 deaths in and around Sichuan province, an unusually high number. Although the bacteria exists in other pig rearing countries, the pig-human transmission has only been reported in China.^[24]

As of 2004, in more undeveloped areas it is advised to only drink bottled water as cholera, among other diseases, is spread through the water supply. As of 2012, food and water safety remains an issue.

Another major problem are the "black ambulances", or illegal, privately run, for-profit ambulance services. As there is a shortage of ambulances belonging to hospitals in major cities, many private businessmen are now operating fleets of unauthorized ambulances, often staffed by untrained personnel and with no medical equipment, and charging the patients. Despite a government crackdown, the number of private ambulances is growing.^[25]

Unaffordable medications are another gaping hole in the Chinese safety net. This forces workers to save as much as possible in order to weather family medical emergencies, which acts to depress domestic consumption, leaving no alternative to the traditional unsustainable export and investment driven economic model.^[26]

A cross-sectional study between 2003 and 2011 showed remarkable increases in health insurance coverage and inpatient reimbursement were accompanied by increased use and coverage. The increases in services use are particularly important in rural areas and at hospitals. Major advances have been made in achieving equal access to insurance coverage, inpatient reimbursement, and basic health services, most notably for hospital delivery, and use of outpatient and inpatient care.^[27]

Nowadays, with substantial urbanisation, attention on health care has been changed. Urbanisation offers opportunities for improvements in population health in China (such as access to improved health care and basic infrastructure) and substantial health risks including air pollution, occupational and traffic hazards, and the risks conferred by changing diets and activity. Communicable infections should also be re-focused on.^[28]

Resources

In 2005 China had about 1,938,000 physicians (1.5 per 1,000 persons) and about 3,074,000 hospital beds (2.4 per 1,000 persons).^[29] Health expenditures on a purchasing power parity (PPP) basis were US$224 per capita in 2001, or 5.5 percent of gross domestic product (). Some 37.2 percent of public expenditures were devoted to health care in China in 2001. However, about 80 percent of the health and medical care services are concentrated in cities, and timely medical care is not available to more than 100 million people in rural areas. To offset this imbalance, in 2005 China set out a five-year plan to invest 20 billion renminbi (RMB; US$2.4 billion) to rebuild the rural medical service system composed of village clinics and township- and county-level hospitals.^[30]

There is a shortage of doctors and nurses in China. More doctors are being trained, but most aim to leave the countryside in favor of the cities, leaving significant shortages in rural areas.^[31]

In 2016 it was reported that Ticket resale was widely practised at Beijing Tongren Hospital and Peking University First Hospital. Advance tickets for outpatient consultation are sold by the hospitals for 200 yuan, but sold on for as much as 3,000 yuan. An eye doctor commented that the appointment fees did not reflect the economic value of doctors' skills and experience, and that the scalpers were selling the doctor's appointment at a price the market is prepared to pay.^[32]

Medical training

The Chinese medical education system is based on the British model, but physicians are trained for five years rather than six. While some medical schools run three-year programs, hospitals tend to recruit physicians who graduated from five-year programs, while big-name hospitals only accept MDs, which takes seven years of study, including the five years of undergraduate studies, followed by the completion of a PhD in medicine. Once a student graduates from medical school, he or she must work 1–3 years in a university-affiliated hospital, after which the student is eligible to take the National Medical Licensing Examination (NMLE) for physician certification, which is conducted by the National Medical Examination Center (NMEC). If the candidate passes, he or she becomes a professional physician, and is certified by the Ministry of Health. It is illegal to practice medicine in China as a physician or assistant physician without being certified by the Ministry of Health.^[33] Physicians are allowed to open their own clinics after practicing medicine for five years.

Traditional and modern Chinese medicine

China has one of the longest recorded history of medicine records of any existing civilization. The methods and theories of traditional Chinese medicine have developed for over two thousand years. Western medical theory and practice came to China in the nineteenth and twentieth centuries, notably through the efforts of missionaries^[34] and the Rockefeller Foundation, which together founded Peking Union Medical College. Today Chinese traditional medicine continues alongside western medicine and traditional physicians, who also receive some western medical training, are sometimes primary care givers in the clinics and pharmacies of rural China. Various traditional preventative and self-healing techniques such as qigong, which combines gentle exercise and meditation, are widely practiced as an adjunct to professional health care.

Although the practice of traditional Chinese medicine was strongly promoted by the Chinese leadership and remained a major component of health care, Western medicine gained increasing acceptance in the 1970s and 1980s. For example, the number of physicians and pharmacists trained in Western medicine reportedly increased by 225,000 from 1976 to 1981, and the number of physicians' assistants trained in Western medicine increased by about 50,000. In 1981 there were reportedly 516,000 senior physicians trained in Western medicine and 290,000 senior physicians trained in traditional Chinese medicine. The goal of China's medical professionals is to synthesize the best elements of traditional and Western approaches.

In practice, however, this combination has not always worked smoothly. In many respects, physicians trained in traditional medicine and those trained in Western medicine constitute separate groups with different interests. For instance, physicians trained in Western medicine have been somewhat reluctant to accept unscientific traditional practices, and traditional practitioners have sought to preserve authority in their own sphere. Although Chinese medical schools that provided training in Western medicine also provided some instruction in traditional medicine, relatively few physicians were regarded as competent in both areas in the mid-1980s.

The extent to which traditional and Western treatment methods were combined and integrated in the major hospitals varied greatly. Some hospitals and medical schools of purely traditional medicine were established. In most urban hospitals, the pattern seemed to be to establish separate departments for traditional and Western treatment. In the county hospitals, however, traditional medicine received greater emphasis.

Traditional medicine depends on herbal treatments, acupuncture, acupressure, moxibustion (burning of herbs over acupuncture points), "cupping" (local suction of skin), qigong (coordinated movement, breathing, and awareness), tui na (massage), and other culturally unique practices. Such approaches are believed to be most effective in treating minor and chronic diseases, in part because of milder side effects. Traditional treatments may be used for more serious conditions as well, particularly for such acute abdominal conditions as appendicitis, pancreatitis, and gallstones; sometimes traditional treatments are used in combination with Western treatments. A traditional method of orthopedic treatment, involving less immobilization than Western methods, continued to be widely used in the 1980s.

Primary care

After 1949 the Ministry of Public Health was responsible for all health-care activities and established and supervised all facets of health policy. Along with a system of national, provincial, and local facilities, the ministry regulated a network of industrial and state enterprise hospitals and other facilities covering the health needs of workers of those enterprises. In 1981 this additional network provided approximately 25 percent of the country's total health services.

Health care was provided in both rural and urban areas through a three-tiered system. In rural areas the first tier was made up of barefoot doctors working out of village medical centers. They provided preventive and primary-care services, with an average of two doctors per 1,000 people; given their importance as health care providers, particularly in rural areas, the government introduced measures to improve their performance through organised training and an annual licencing exam.^[35] At the next level were the township health centers, which functioned primarily as out-patient clinics for about 10,000 to 30,000 people each. These centers had about ten to thirty beds each, and the most qualified members of the staff were assistant doctors. The two lower-level tiers made up the "rural collective health system" that provided most of the country's medical care. Only the most seriously ill patients were referred to the third and final tier, the county hospitals, which served 200,000 to 600,000 people each and were staffed by senior doctors who held degrees from 5-year medical schools. Utilisation of health services in rural areas has been shown to increase as a result of the rise in income in rural households and the government's substantial fiscal investment in health.^[36][37] Health care in urban areas was provided by paramedical personnel assigned to factories and neighborhood health stations. If more professional care was necessary the patient was sent to a district hospital, and the most serious cases were handled by municipal hospitals. To ensure a higher level of care, a number of state enterprises and government agencies sent their employees directly to district or municipal hospitals, circumventing the paramedical, or barefoot doctor, stage.

See also

• Timeline of healthcare in China
• Health in China

References