Thursday, 27 December 2012

My take on China's health white paper

by Michael Woodhead, Editor, CMN
China has released a lengthy white paper setting out its current health situation, the state of play on health reforms and setting the ambitious target of establishing 'a sound basic medical and health system covering both urban and rural residents by 2020, so as to ensure that everyone enjoys access to basic medical and health services'.
The white paper cites some mind boggling figures: 2,500 billion yuan spent on health annually and 6 billion outpatient visits a year. The country has  2.5 million doctors and 5 million hospital beds, if the figures are to be believed (many of these doctors are public health doctors not working in front line clinical care).
The white paper has a generally positive spin on the health of Chinese people, saying the health system has contributed to increasing life expectancy and is coping with a large increase in hospital stays. It also makes much of the limited reforms to medical insurance, claiming that 95% of people have basic medical insurance and that out of pocket expenses have decreased from 58% to 35% (of what it is not clear).
At least it is honest in acknowledging that health care reform in China is going to be complicated and  arduous, and faces many barriers. My own take on the white paper is that it cites a lot of figures but doesn't really say exactly how the reforms are going to be implemented.
The challenges for China's health system reform fall into four main area: capacity, structure, funding and standards.

1. In terms of capacity, China (like all countries) is facing a large increase in both usage and expectation for healthcare services. Demographics are especially bad for China, which faces an ageing population that is not supported by a younger generation due to the one child policy. Despite having a million hospitals, China does not have the capacity to provide good healthcare to the whole population - especially in regional and rural areas. One of the main reasons is workforce: there simply aren't enough doctors, nurses and other healthcare staff to provide care for a billion people. It has been estimated that China needs 200,000 extra paediatricians, for example. Therefore workforce training and deployment are major issues for China. The white paper also says little about allowing foreign companies and organisations to set up in China and provide health services - this is one way in which capacity (and workforce) could be supplemented.

2. Structure. China's health system is based around hospitals, and this severely limits its capacity to provide care for people with chronic disease, and also to provide continuity of care. China needs a primary care system, and there are some moves in that direction underway already. However, it remains to be seen whether China can really reform its hospital based health system and wean patients away from hospitals. China also needs to look at using other healthcare professionals in wider roles - not barefoot doctors but at the provision of physiotherapists, pharmacists, extended care nurses etc.

3. Funding. If China is to provide a universal healthcare system for all, it is going to need massive funding. The white paper is not clear on exactly how this will be done. It mentions the moves towards new medical insurance schemes, such as the rural cooperative medical insurance system, and also the new pilot programs to cover catastrophic diseases such as cancer. These are commendable moves in the right direction, but it is very early days yet. As with most things in China, there is little transparency or accountability in the health system. The white paper does not say much on how China will allocate funding funding for health, and exactly where it will go. Will there be more money for rural clinics and hospitals? Who will provide the funding at provincial and county level and ensure that funds are directed to clinical services? How will China balance the mix of public and private health cover and how will it set the levels of cover and premiums? In the white paper, China claims an impressive 95% coverage for basic medical insurance. However, this fails to acknowledge that this cover is broad but shallow - it does not cover basic medical care for anyone with a chronic or catastrophic illness. The Ministry of Health may wish to provide medical cover for all, but the real power lies with the Ministry of Finance and with provincial and local leaders who will provide the funding (or not).

4. Standards and quality. China's health reforms will have to tackle the issues of poor and uneven quality in many areas of the health system - from skill standards of practitioners to quality of drugs and medical products and also the wider issue of quality of environment.
The newly affluent Chinese public have increasing expectations of health services, but these are not being met. Many question the clinical and caring skills of doctors and nurses, and there is huge frustration over the 'no pay no care' situation, as witnessed by the violent attacks on doctors and nurses. China needs to ensure that standards are set and adhered to in all areas of clinical care. This also applies to area such as pharmaceuticals and medical products - there have been many well publicised cases of substandard drugs, blood products and food contamination. Often China's response to failings has been draconian - jailing or even executing those responsible. This is not the way to run a modern health system - there is a need for open-ness, professionalism and accountability. The same applies to public health issues such as pollution and food standards. When air pollution levels are deemed a state secret there is little hope of improving respiratory health!

Well, these are just a few of my initial thoughts on the white paper. It has set a hugely ambitious goal of establishing universal, affordable and good quality care for all Chinese. This is commendable and potentially achievable, given China's track record in 'moving heaven and earth' in other areas. However, it will require huge change and will upset many vested interests in  local government, health institutions and businesses. Health reform will also require huge changes in expectations from the Chinese public - they can no longer expect to receive 'walk in' care at a hospital and be provided with a pill (or infusion) for every ill. If the health reforms can get the Chinese public to start seeing GPs by appointment by 2020 and accepting that antibiotics don't cure all fevers then they will have achieved a huge turnaround.

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