Health care in China
Feb 21st 2008 | BEIJING
From The Economist print edition
An orthodox approach to fixing the unavailability of decent health care
STARTLING economic growth in China has not been matched by similar improvements in health care. The cost of treatment is becoming ever more prohibitive for the poor. Government spending is meagre. But nearly three years after declaring the system a failure, officials are at last getting ready to unveil a plan to fix it.
Some Chinese press reports say the long-awaited and much-debated reform plan is likely to be revealed at the annual session of China's parliament, which opens on March 5th. The outline is already clear: a stronger role for government, including more money from the central budget, and a drive towards universal health insurance. Changes are already in train.
The reforms reverse the market-driven policies of much of the past two decades. The outbreak in 2003 of SARS, an often fatal respiratory disease, made the government realise what a mess the health-care system had become. Government hospitals and clinics, starved of funding, had turned to raising money (and boosting ill-paid doctors' salaries) by prescribing ever more expensive treatment and diagnostic procedures. With the collapse and privatisation of state-owned enterprises, the vast majority of citizens had been left with no insurance. Many began avoiding even desperately needed treatment.
In 2003 the government introduced a new medical-insurance scheme in the countryside. This involves contributions from rural residents as well as local governments and, for the first time, the central government. The number of people taking part rose from 80m that year to more than 730m now. This month Wu Yi, a deputy prime minister, said all rural residents (about 800m is the usual official figure) should be insured by the end of this year.
The scheme is only a slight relief, if at all, for the poor. It often does not cover routine outpatient treatment. The average reimbursement rate is only 30-40%, and bills have to be paid in full first. So hospital stays are beyond the means of many. There is also a big loophole: those insured can get benefits only in their own localities. Many younger people from the countryside are working in cities where they have to pay all of their treatment costs. A new labour-contract law introduced this year requires employers to pay medical insurance for such workers. But migrants are often hired informally, making it easy for employers to evade such requirements.
Even though urban health care receives a disproportionate share of total government spending on health, many urban residents fare just as badly. Li Ling of Peking University estimates that more than half of the urban population has no insurance. Those who do are mostly civil servants and the staff of state-owned enterprises. At least until the labour-contract law was enacted, many private enterprises provided nothing. Last year the government introduced an urban insurance scheme (similar to the rural one) aimed at non-working residents, including children and university students. The aim is to have every urban citizen covered by 2010.
Much detail, however, is still unclear. A big issue is how to wean hospitals off their dependence on revenue from user payments. Policymakers and academics have been furiously debating whether the emphasis should be on government subsidies for hospitals or on reimbursements for patients. No target has yet been set for the maximum share of health expenditure to come from patients' own pockets. Ms Li, who has been advising the government on health reform, suggests a goal of 20% compared with over 50% at present.
Unlike for education, Chinese officials have also yet to set any specific targets for government spending as a percentage of GDP. The government spends a mere 0.8% of GDP on health (it was more than 1% in the 1980s). Henk Bekedam of the World Health Organisation says it could easily afford around 2.5%. But the government is being cautious. Reform, said Ms Wu last month, would be complicated. “Patience is needed,” she said. Patients would say they have shown more than enough already.