Mhc 720 Jh01 Health Care Systems Health Care In China 121307

December 13, 2007 Donna Doherty Leslie Pirtle Jeanne Ulmer

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Health Care In China

MHC 720 Health Care Systems


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The IronyWhile ruled by one of the most authoritarian regimes of the century and while being one of the poorest countries in the world China saw tremendous health improvements….

…As it has become freer, some of the advances in health have been reversed. (Hesketh & Zhu)


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Rural Cooperative Medical System (RCMS) 1950s to the 1970s

• 1st Large Nation to develop rural health insurance system

• Priority was prevention

• Financing relied on pre-payment

• Universal access to health care

http://www.nature.com/nature/journal/v441/n7092/images/441392a-i1.0.jpg


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Rural Cooperative Medical System (RCMS) 1950s to the 1970s

• Life expectancy jumped from 35 to 65

• Brothels and opium dens closed

• Elimination of flies, mosquitoes, rats, and sparrows

• Sexually transmitted diseases, schistosomiasis, and leprosy virtually eradicated

• Declines in recorded cases of tuberculosis & hepatitis B

• Training of a million “barefoot doctors”

http://www.destination360.com/asia/china/forbidden-city.php


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Barefoot Doctors

• An army of paramedics trained in western disease control & traditional Taoist medicine

• Hygiene and infectious disease control educators

• Focus on the poor, rural peasant


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Late 1970’s – Early 1980’s

• Urban living standards improved

• Rural-urban disparity in health care emerged

• Fee-for-service replaced barefoot docs

http://www.frbatlanta.org/publica/econ_south/2005/q2/images/china-one.jpg


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• Rural cooperatives abolished

• Doctors and health authorities were encouraged to find private sources of income

• In 25 years, the share of medical spending individuals jumped from 20% to 60%

• Disproportionate investment in cities and high-tech equipment.


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• State Council Controlled 30 Provinces– 71 Counties

• 25 Townships– 14 Villages

http://www.jephc.com/ewebeditpro3/upload/china_map.jpg


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1980’s – 1990’s

• Chinese with access to state health facilities– 71% in 1981– 21% in 1993

• 1978-99: Central govt.’s share of health spending fell 32 to 15%

• 1999-China ranked # 144 out of 191 WHO member countries


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Rise in Government Health Care Spending

•($499 billion U.S. dollars)

(1 trillion U.S. dollars)


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Chinese Government's Share of National Health Care Spending, as % of Total Health Care Expenditures.


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Current Crisis

http://www.bbc.co.uk/worldservice/specials/1543_ruling_china/index.shtml


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Causes of Current Crisis

• Decreased government support

• Government imposed price regulation

http://www.bbc.co.uk/worldservice/specials/1543_ruling_china/page2.shtml

• Government privatized agriculture

• Decentralization of public health system


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Urban Health Care• Escalated health care costs

– 15 percent increase a year– Urban care consumes 80%

medical resources

• Average length of stay increase

• Hospital-based spending

– 75 percent of health spending goes to hospital-based care

– 60 percent goes to pharmaceuticals



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Urban Health Care• Most urban hospitals receive

only about 10% of operational funds from the state

• Remainder is generated by own revenues– Drug sales

• Cost and willful over-prescription is biggest grievance of patients

– Medical Testing / Technology


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Rural Health Care• Rural hospitals are in

worse financial shape.• Most basic hospitals are

run by governments at the township level

• Source of funding – Higher level of

government funding– Taxes– Fees paid by

farmers and businessmen.

http://www.economist.com/research/backgrounders/displaystory.cfm?story_id=3104423


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Rural Health Care

• “A peasant saying has it that a pig must be taken to market every time an ambulance siren wails, a year's work is ruined as soon as you sleep in a hospital bed, and if you are struck with a serious disease, 10 years of savings go up in smoke.” (Watts 5-07)

http://iftf.typepad.com/photos/uncategorized/homeless_1.jpg


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Rural Conditions• Surmang is among poorest of rural China

• No running water, electricity or roads

• 30% infant mortality rate

• Estimated maternal mortality rate is 3000/100,000 live births

• All births are unattended

• Women give birth alone with animals

• Umbilical cords are severed with an old rusty knife

• Newborns are bathed in powdered yak dung

• Illiteracy rate is nearly 100%

http://www.ratnafoundation.org/images/surmang/Gary's%20Surmang%20photos%20for%20Ratna%20011.jpg

http://www.surmang.org/intro.php


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Rural Health Care

• Preventive medicine relies on fees

• China is the only country in the Western Pacific region which relies on patients to finance childhood immunizations (World Health Organization)

http://www.chinaembassy.org.ro/rom/xw/W020070829607486880149.jpg


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Urban/Rural Disparity

• Guizhou's 37 million people - most of whom are peasants - can expect to live 13 years less than Beijing counterparts

• Mothers have a 10 times greater risk of dying during childbirth

• Infants are 5 times more likely to perish before the age of five

http://cache.viewimages.com/xc/52255392.jpg?v=1&c=ViewImages&k=2&d=17A4AD9FDB9CF193CC300C081D9F47003ABB457FB89A6DA009EE3D65BCA33BAFA55A1E4F32AD3138


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Urban/Rural Disparity

• Despite having only 35% of the population cities currently enjoy 80% of health resources

• More than half of China's 1.3 billion population live in the countryside.



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Urban/Rural Disparities

•Funds are disproportionately invested in the cities and on hi-tech equipment

http: /www.guardian.co.uk/china/story/0,,2168522,00.html http: /www.guardian.co.uk/china/story/0,,2168522,00.html


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Who Pays?

• Government healthcare spending doubled between 1998 -2004

• Health Insurance Covers

– Government employees– College communities – State enterprises with

> 100 employees

• “56 % of the nation's health care costs are paid directly by patients…”

http://english.people.com.cn/200703/02/images/yuan.jpg


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Insurance Coverage

• Gongfei yiliao– Government Employee

Health Insurance

• Laobao yiliao– Labor Health Insurance– Self paying

• Uncovered– Unemployed


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Consequences

• 90% of rural population is uninsured

• Nearly 60% of urban population have no coverage

• Some 60% of rural residents avoid hospitals altogether because of the expense

• Out-of-pocket spending on health care is soaring.


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Consequences

• Lack of Health Coverage– Elderly– Rural Dwellers

• Over 1/3 who fall ill do not seek care due to inability to pay

• TB, syphilis and rabies on the rise again

• Hong Bao– “Red Packets”


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Current Conditions

• Doctors and nurses poorly paid

• Level of training varies greatly

• Specialists well-trained – No national standardization body to

assess competency such as American Boards or a Royal College

• Hospital director earns about the same as a company sales representative

http://www.jokes.org.au/useimages/user756_1179386167.jpg

www.gac-china.com


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Current Conditions

• 17,000 major hospitals in China

• 48,000 smaller "township" hospitals

• 3.6 million hospital beds nationwide 170 medical schools and educational institutions

• 120 biomedical research institutions

• Variety of national organizations representing hospitals and physicianshttp://english.people.com.cn/200501/06/images/0105_C91.jpg


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Hospital Conditions

• 1/2 babies born in China are delivered by caesarean section, partly because doctors make more money that way.

• China is one of the few countries in the world with more doctors than nurses, despite research suggesting nurses provide more cost-efficient services.

http://www.guardian.co.uk/china/story/0,,2168522,00.html


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http://www.guardian.co.uk/news/gallery/2007/jul/10/internationalnews?picture=330175082

Guiyang city, Guizhou province: A woman extracts a client's tooth at her stand offering dentistry services on a pedestrian overpass in Guizhou's capital. Dental health is not a high priority to many low-income Chinese people, who are not covered by medical insurance

Care for the Uninsured


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Prescription Drug Sales


Barefoot Doctor Hua Wanxiang recently shut his clinic and opened a shop selling groceries alongside medicines

The sale of medication now accounts for half of hospitalincomes, which has led to suspicions of over prescribing



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Prescription Drug Sales

• Privatized medicine is blamed for rampant over-prescription

• New strains of TB and other diseases that are resistant to antibiotics

• "I prescribe penicillin more than any other drug," says Hua, who charges 2 yuan for each injection.

– “I mostly recommend it for rheumatoid arthritis. A lot of villagers suffer from that."

http://www.patentdocs.us/photos/uncategorized/2007/08/13/prescription_drugs.jpg


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Disparities Causing Anger• “5,500 medical

workers were injured last year in assaults and protests”

(Watts)


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The Positive

• Response to SARS• Life expectancy continues to increase

http://chinadigitaltimes.net/thumbnail/xin_50120327083115505441.jpg


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Comparison With United States

CHINA U.S.

Total population 1,323,350,000 298,213,000

Gross national income per capita $6,600 $41,950

Total expenditure on health as percentage of gross domestic product

4.7% 15.4%

Per capita total expenditure on health at international dollar rate $276.7 $6096.2

http://www.who.int/countries/chn/en/


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“Americans have a huge stake in the wisdom and ingenuity with which China’s leaders approach their country’s health care challenges. In an age of terrorism, SARS, avian influenza, and HIV, no country is a health care island unto itself.” (Blumenthal and Shiao, p. 170)



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Questions


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Blumenthal, David, M.C., M.P.O. and William Hsiao, Ph.D. (2005, September 15) The New England Journal of Medicine.Privatization and Its Discontents – The Evolving Chinese Health Care System. http://content.nejm.org/cgi/content/full/353/11/1165

The Economist. Where are the patients? (2004August 19) http://www.economist.com/research/ backgrounders/displaystory.cfm?story_id=3104423

Hesketh, Therese. & Zhu, Wei Xing. Effect of Restricted Freedom On Health in China. BMJ Publishing Group Ltd. (2004 December 18) http://www.bmj.com/cgi/content/full/329/7480/1427

Liu, Yuanli (2004) Development of the Rural Health Insurance System in China. Health Policy and Planning. http://www.heapol.oxfordjournals.org/cgi/reprint/19/3/159.pdf

Sources


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Meng-Kin Lim, Hui Yang, Tuohong Zhang, Wen Feng and Zijun Zhou. Public Perceptions Of Private Health Care In Socialist China. Health Affairs, 23, no. 6 (2004): 222-234. http://content. Health affairs .org/cgi/content/abstract/23/6/222?ijkey=e0c45d2d9c36b85b7d bcd35f4f69bd9213bbcd8&

keytype2=tf_ipsecsha

Moreton, MD Michael J Healthcare in China (retrieved December 1, 2007) http://www.med hunters.com /articles/healthcareInChina.html

Powell, Alvin. Vice minister Huang details advances, problems, reforms; Health care reform in China discussed. Harvard Gazette Harvard News Office (2005 September 15) http://www.hno.harvard.edu/gazette/2005/09.15/09-china.html

Watts, Jonathan. Ailing system leaves sick to pay up or die (2007 September 14) Guardian Unlimited. http: //www.guardian.co.uk/china/story/0,,2168522,00.html

Sources, 2


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Watts, Jonathan. Chinese hospital staff face attacks amid high prices and dubious care. Guardian Unlimited(2007 May 12) http://www.guardian.co.uk /china/ story/ 0,,2078 004,00.html

Wong, B. & Gabriel S. The Influence of Economic Liberalization on Urban Health Care Accessin the People’s Republic of China. (retrieved November 21, 2007) http://www.mtholyoke.edu /courses/ sgabriel/chinahealth.htm

World Bank Group, Curing China’s Ailing Health Care System. Beyond Transition. The Newsletter About Reforming Economies (2001)http://worldbank.org/html/prddr/trans/aprmayjun03/pg9.htm

Xingzhu Liu1, Yuanli Liu2 and Ningshan. The Chinese experience of hospital price regulation Chen Health Policy and Planning. Oxford University Press (2000 June15) http://heapol.oxfordjournals .org/cgi/content/abstract/15/2/ 157?ijkey =f1c8fea548077429a8e35288812b2943fb3aaa93&keytype2=tf_ipsecsha

Sources, 3

Health & Medicine

Mhc 720 Jh01 Health Care Systems Health Care In China 121307