V People’s Republic of China Health System Review

Health Systems in Transition Vol. 5 No. 7 2015

People's Republic of China Health System Review

Health Systems in Transition

Vol. 5 No. 7 2015

People's Republic of China Health System Review

Written by: MENG Qingyue, China Center for Health Development Studies, Peking University YANG Hongwei, China National Health Development Research Center, National Health and Family Planning Commission CHEN Wen, School of Public Health, Fudan University SUN Qiang, Center for Health Management and Policy, Shandong University LIU Xiaoyun, China Center for Health Development Studies, Peking University

Edited by: Anne Mills, Viroj Tangcharoensathien

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WHO Library Cataloguing-in-Publication Data

People's Republic of China health system review (Health Systems in Transition, Vol. 5 No. 7 2015)

1. Health care reform. 2. Health expenditures. 3. Health system plans ? organization and administration. 4. China. I. Asia Pacific Observatory on Health Systems and Policies. II. World Health Organization Regional Office for the Western Pacific.

ISBN 978 92 9061 728 0 (NLM Classification: WA 540 JC6)

? World Health Organization 2015

All rights reserved. Publications of the World Health Organization are available on the WHO website (who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; email: bookorders@who.int).

Requests for permission to reproduce or translate WHO publications?whether for sale or for non-commercial distribution?should be addressed to WHO Press through the WHO web site (who.int/about/licensing/copyright_form/en/index.html). For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines (fax: +632 521 1036, email: publications@wpro.who.int).

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

The named authors alone are responsible for the views expressed in this publication.

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Contents

Preface................................................................................................................. viii Acknowledgements.............................................................................................. x List of abbreviations........................................................................................... xii Abstract................................................................................................................. xv Executive summary.......................................................................................... xvii 1 Introduction.................................................................................................. 1 Chapter summary.................................................................................................. 1 1.1 Geography and sociodemography............................................................. 2 1.2 Political context............................................................................................ 3 1.3 Economic context......................................................................................... 5 1.4 Health status................................................................................................. 8 2 Organization and governance................................................................. 16 Chapter summary................................................................................................ 16 2.1 Overview of the health system................................................................. 17 2.2 Historical background............................................................................... 22 2.3 Organization................................................................................................ 26 2.4 Decentralization and centralization........................................................ 34 2.5 Planning....................................................................................................... 39 2.6 Intersectorality .......................................................................................... 44 2.7 Health information management............................................................ 49 2.8 Regulation .................................................................................................. 51 2.9 Empowerment ........................................................................................... 62 3 Financing..................................................................................................... 66 Chapter summary................................................................................................ 66 3.1 Health expenditure.................................................................................... 67 3.2 Sources of revenue and financial flows.................................................. 75 3.3 Overview of the statutory financing system........................................... 78 3.4 Out-of-pocket payments........................................................................... 95 3.5 Private medical insurance........................................................................ 97 3.6 Payment mechanisms............................................................................. 100

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4 Physical and human resources............................................................106 Chapter summary.............................................................................................. 106 4.1 Physical resources................................................................................... 106 4.2 Human resources for health.................................................................. 116

5 Provision of services...............................................................................130 Chapter summary.............................................................................................. 130 5.1 Public health............................................................................................. 131 5.2 Patient pathways...................................................................................... 137 5.3 Primary health care services................................................................. 139 5.4 Medical services provided by secondary and tertiary hospitals....... 140 5.5 Emergency medical services................................................................. 142 5.6 Pharmaceutical care............................................................................... 144 5.7 Rehabilitation care................................................................................... 146 5.8 Long-term care........................................................................................ 147 5.9 Services for informal carers................................................................... 149 5.10 Palliative care........................................................................................... 149 5.11 Mental health............................................................................................ 149 5.12 Dental care................................................................................................ 151 5.13 Complementary and alternative medicine.......................................... 152 5.14 Health services for specific populations.............................................. 153 5.15 Family planning services........................................................................ 155 5.16 Clinical blood supply and management............................................... 156

6 Major health reforms.............................................................................159 Chapter summary.............................................................................................. 159 6.1 Historical perspective.............................................................................. 160 6.2 Analysis of recent reforms..................................................................... 173 6.3 Future developments............................................................................... 183

7 Assessment of the health system........................................................187 Chapter summary.............................................................................................. 187 7.1 Stated objectives of the health system................................................. 187 7.2 Financial protection and equity in health financing........................... 188 7.3 User experience and equity of access to health care........................ 192 7.4 Population health and service quality.................................................. 198 7.5 Health system efficiency......................................................................... 199 7.6 Transparency and accountability.......................................................... 203

8 Conclusions..............................................................................................205

9 Appendices...............................................................................................209 9.1 References................................................................................................ 209 9.2 Useful web sites....................................................................................... 215

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9.3 Health Systems in Transition methodology and production process........................................................................... 216

9.4 About the authors.................................................................................... 217

List of Figures

Figure 1.1 Correlation between life expectancy at birth and regional GDP per capita in 2010.......................................8

Figure 2.1 Organization of Chinese health system................................ 21 Figure 3.1 Health expenditure as a share (%) of GDP in China

and selected countries, 1995?2012....................................... 72 Figure 3.2 Health expenditure in US$ PPP per capita in China

and selected countries, 1995?2012....................................... 73 Figure 3.3 Public (general government) health expenditure

as a share (%) of THE in China and selected countries, 1995?2012.............................................................................. 73 Figure 3.4 Percentage of THE according to source of revenue (domestic classification), 2012.............................................. 77 Figure 3.5 Financial flows....................................................................... 77 Figure 3.6 Change in out-of-pocket spending as a share of total expenditure on health, 2000?12............................................ 96 Figure 4.1 Quantity of health institutions in China, 1978?2012........... 109 Figure 4.2 Size of hospitals in China by bed size, 2012........................ 111 Figure 4.3 Numbers of ward beds in health institutions in China, 1978?2012............................................................................ 111 Figure 4.4 Ward beds per 1000 people, selected countries................. 113 Figure 4.5 Hospital bed occupancy rate, 1980?2012............................ 114 Figure 4.6 Changes in total health professionals in China, 1949 to 2012......................................................................... 120 Figure 4.7 Number of doctors per 1000 population, selected countries.............................................................................. 122 Figure 4.8 Number of nurses per 1000 population, selected countries.............................................................................. 123 Figure 4.9 Number of dentists per 1000 population, selected countries.............................................................................. 123 Figure 4.10 Number of pharmacists per 1000 population, selected countries.............................................................................. 124 Figure 5.1 Framework diagram of health service provision in China................................................................................ 133

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Figure 5.1 Patient pathways and their probability, urban and rural residents.............................................................................. 138

Figure 6.1 GNI per capital and child mortality rate in China............... 163 Figure 7.1 Health spending as a share of total household

consumption expenditure (%, average)............................... 191 Figure 7.2 Proportion of households with catastrophic health

expenditure (%, average)..................................................... 191 Figure 7.3 Physical accessibility to a health-care institution

(%, average)......................................................................... 194 Figure 7.4 Geographic density of registered (and assistant)

physicians (density per 1000 population)............................ 194 Figure 7.5 Utilization of outpatient services (%, average)................... 195 Figure 7.6 Outpatient visits in the past two weeks, according

to income group................................................................... 195 Figure 7.7 Hospital admission in the past year, according to income

group.................................................................................... 196 Figure 7.8 Proportion of prenatal care (5+ visits) (%, average)............ 196 Figure 7.9 Proportion of in-hospital service delivery (%, average)...... 197 Figure 7.10 Trend in average number of outpatient and emergency

admissions in different medical institutions, 2005?2011... 200 Figure 7.11 Trend of average number of hospitalization admissions

in different medical institutions, 2005?2011....................... 201 Figure 7.12 Daily average rate of outpatient visits and inpatient

bed days per doctor in China, 2000?2012........................... 202 Figure 7.13 Average inpatient length of stay (days) in general

hospitals in China, 2000?2012............................................. 202

List of Tables

Table 1.1

Table 1.2 Table 1.3 Table 1.4 Table 1.5

Table 1.6 Table 2.1

Demographic structure and social demographics of China, 1980?2012................................................................................ 3 Macroeconomic indicators of China, selected years..............6 Major health indicators, selected years..................................9 Top ten causes of death in China in selected years.............. 10 Top ten causes of death in China by rural and urban population in 1990 and 2010.................................................. 11 Major risk factors for noncommunicable diseases.............. 13 Main health laws in China..................................................... 19

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