China s Health System: Achievements and Challenges Qingyue Meng School of Public Health China Center for Health Development Studies Peking University The Asia Health Policy Program at Stanford University Nov 17, 2015
WriIen by MENG Qingyue, Peking University YANG Hongwei, Health Development Research Center CHEN Wen, Fudan University SUN Qiang, Shandong University LIU Xiaoyun, Peking University Edited by: Anne Mills, Viroj Tangcharoensathien Topics on: Context Organiza[on and governance Financing Resources Delivery Health reforms Assessment h#p://www.wpro.who.int/ asia_pacific_observatory/hits/series/ china_health_systems_review.pdf?ua=1
Background High economic growth; More resources available for health; Continuously increasing demand for health and health care by the people; More complicated health challenges from pollutions, popu ageing, NCDs, and food safety
Economic indicators Indicators 1990 2000 2013 Gross domespc product (GDP, 360.0 1198.5 9240.3 billion US$) GDP at PPP (current internaponal $, billion US$) 1110.0 3616.3 16161.7 GDP per capita (US$) 314.4 949.2 6807.4 GDP per capita at PPP (current internaponal $) 1006.6 2864.1 11906.5 Annual GDP growth (%) 4.1 7.6 7.7 Public expenditure (% of GDP) 14.1 15.8 14.1 Data source: World Bank 2015
Health system indicators Indicators 1990 2000 2013 ProporPon of total health expenditures in GDP (%) ProporPon of out-of-pocket payment in total health expenditures (%) Number of health professional workers per 1,000 populapon Number of hospital beds per 1,000 populapon 4.0 4.6 5.6 35.7 59.0 33.9 3.4 3.5 5.2 2.6 2.5 4.5 Data source: China NaPonal Health and Family Planning 2015
Health expenditure as a share (%) of GDP in China and selected countries, 1995 2012 % 10 8 6 4 2 7.4 7.3 7.1 6.7 5.5 5.4 4.0 3.7 3.5 3.4 3.2 2.8 10.3 8.3 8.8 9.3 8.8 7.6 8.4 7.8 8.2 7.5 7.2 5.5 6.7 6.2 6.3 5.4 5.6 5.5 5.4 5.2 5.1 4.6 4.7 4.3 4.2 4.4 4.0 3.4 3.9 3.2 3.5 3.9 3.0 3.3 0 1995 2000 2005 2012 Brazil China Hungary India Malaysia New Zealand Philippines Poland Republic of Korea Romania Russian Federa[on South Africa Thailand From: China HiT 2015
7000 140 6000 GNI per capita U5MR 120 GNI per capita (US$) 5000 4000 3000 2000 100 80 60 40 Child mortality per 1000 live births 1000 20 0 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Year 0 Source: World Bank, World Development Indicators (2014) hip://data.worldbank.org.cn/country/china#cp_wdi
Achievements A national goal for universal health coverage; Rising role of health in political and economic agenda; An institutional arrangement in health financial protection; Increased public funding for health; and Capacities in health care delivery.
China s health systems reform -One gaol Universal coverage to basic health care -Four systems (si liang) Systems of public health, medical care, health security, and essential medicines -Eight strategies (ba zhu) Concrete strategies and policies, covering areas such as financing, human resources, regulation, and information
Coverage of the three health insurance schemes Population coverage (%) 100.0 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Figure 2 Population coverage by the three health insurance schemes, 2003-2011 2003 2004 2005 2006 2007 2008 2009 2010 2011 NCMS coverage UEBMI coverage URBMI coverage Year Data source: China health sta[s[cs year book, 2007-2012 [12]; China Sta[s[cs 2010-2012 [13]; China Labor Sta[s[cs 2010-2011
Meng and Xu, WHO Bull, 2014
% out-of-pocket payment Percentage of OOP (%) 65 60 55 50 45 40 35 30 25 20 15 10 5 0 Figure 3 Percentages of out-of-pocket payment (OOP) in total health expenditures, 1978-2011 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Data source: Report on China s Health Account Study, 2012
Change in out-of-pocket spending as a share of total expenditure on health, 2000-12 Source: World Health OrganizaPon and OECD, 2014
QuanPty of health insptupons in China, 1978 2012 25000 20000 InsPtuPon quanpty 15000 10000 5000 0 1978 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 All hospital General hospital Year Source: Ministry of Health, 2013
Changes in total health professionals in China, 1949 to 2012 Source: Ministry of Health, 2013
Health care uplizapon Driving forces: -Availability of financial protec[on mechanisms -Income -NCDs -Popu ageing -Others 16 14 12 10 8 6 4 Number of outpatient visit per person and hospitalization rates, 2003 2014 4.69 5.12 5.45 6 7.4 8.7 3.07 3.13 3.4 3.57 3.69 9.98 10.54 4.11 4.35 11.33 4.65 13.18 5.09 14.12 14.9 5.38 5.6 2 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 诊 Data source: China Health StaPsPcs Yearbook 2014 and Digest 2015
Challenges Inequalities in health; Inequitable coverage of health programs; Hospital-centered health delivery system; Inefficiency in use of health resources; and Low quality of health care.
Life expectancy years at birth by province in 2010 -Gap of life expectance years between the richest and poorest provinces: 9 years old (2010) -Ra[o of IMR (rural/urban): 2.4 (2005)
Fragmented health insurance schemes verpcally and horizontally Data source: Meng et al. Lancet, 2015
2010-2013: -% of health professionals of community health facili[es in total health professionals decreased from 32.6% to 29.7% -while increased from 19.9% to 25.3% in 3 rd level hospitals 18.00% 16.00% 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% Annual increase rate of health professionals in health facilipes, 2010-2013 16.08% 4% 3.75% 0.00% 3rd level hospitals 2nd level hospitals PHC providers Data source: China Health StaPsPcs Yearbook 2014
Growth of health facili[es has concentrated in large hospitals (hospital beds >=800, 243 hospitals in 2004 and 1212 in 2013 0-49 50-99 100-199 200-299 300-399 400-499 500-799 Annual growth rate of number of hospital by number of hospital beds, 2004-2010 1.50% 3.20% 3% 4.20% 7.90% 8% >=800 19.60% -5.00% 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% Data source: China Health StaPsPcs Yearbook 2014
Distribution of the inpatient care, 2003-2013 DistribuPon of the uplizapon: -Stagnated growth in primary health ins[tu[ons; -The turning point of 3 rd level hospitals and PHC providers in 2011; 20000 18000 16000 14000 12000 10000 8000 6000 4000 2000 0 19120 17840.3 15264.8 14138 13929 13312.5 12706 11550.8 10724.2 9777.2 9477.9 6061.5 6656.9 7128 7890.6 8454.3 7373.4 6451.2 4110.4 4667.1 5075.1 5545.6 4726 5450 3771.2 4203.6 3593.8 3962 2811.1 2668 3097 3717 4257.8 4288 1661.2 1640.2 1658.1 1910.6 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 总住院人数医院三级医院基层医疗卫生机构 Data source: China Health StaPsPcs Yearbook 2014
Impoverishment rates due to diseases Income quintile (I: the poorest; V: the richest) Figure 4 Percentage of households below poverty line due to medical expenditrues (%) All I II III IV V 0 2 4 6 8 10 12 2003 2008 Impoverishment rate (%) Data source: Meng and Xu, PLOS Medicine, 2014
Both cost and quality of care are much concerned Top four reasons of papents complaints 45% 40% 35% 30% 25% 20% 15% 40% 16.10% 13.80% 10% 7.10% 5% 0% High medical fees Poor quality of care Bad artudes of providers Unreasonable prices Data source: NaPonal health service survey, 2013
The way forward A people- and PHC-centred health care system; Consolidation of the health financing systems; Integration of the health care delivery system; Strengthening of human resources in health; and Improvements in governance and regulation.
Thanks for your attentions!