china ’ s healthcare reform ling li peking university
TRANSCRIPT
China’s Healthcare Reform
Ling Li
Peking University
Time line of China’s healthcare reform
2003 2006 2007 2009 2014
SARS Crisis
Public Health Development
New CMS
The Political Bureau of the Central
Committee workshop
（ Oct 23, 2006）
Text
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The State Council collected health reform proposals worldwide
Healthcare Reform phase I
Healthcare Reform
Phase II
Why Need Reform?
Rapid increase in health care expenditure Increase share of personal income spent
on health care Decrease in government spending Decrease in health insurance coverage
Limited access to health care service High medical expenses Poor service qualities
Health Inequality Regional Economic
Chinese healthcare system During the period between 1950 to 1978, China had
many achievements in health field to be proud of rapid and large reductions in mortality rate, despite
China’s low income per capita at the time create a low cost, wide coverage primary health care
model
Chinese healthcare system After 30 years of economic reform, China’s healthcare
system has not improved as well as the economy has. Instead, it has deteriorated in many aspects Medical costs are escalating rapidly The relationship between patients and doctors are
deteriorating
The GHE decreased since the late 1980s and has returned to increase since the early 2000s ( SARS in 2003).
Source: Chinese Health Statistics Yearbook 2011
Market reform in health sector: 1985
SARS, New govt. (NCMS): 2003
Healthcare reform in China
10
Life Expectancy and Per Capita GDP in 1980
Far Super economic level
数据来源：世界银行
Life Expectancy and Per Capita GDP in 1990
数据来源：世界银行
Life Expectancy and Per Capita GDP in 2000
Normal Country
数据来源：世界银行
Life Expectancy and Per Capita GDP in 2009
略好于 2000 年
数据来源：世界银行
Children Mortality Rate and Per Capita GDP in 1960
数据来源：世界银行
超越经济发展水平
回归正常
China’s unbalanced development—1960-80 vs. 1980-2000
30
67.9 68.6 71.4
01020304050607080
before 1949 1973-1975 1981 1990 2000
Life Expectancy in Selected Years
total
male
female
Source: Health Statistic Yearbook, 2006
Life Expectancy （ year）
under-five mortality（‰）
Increase of Life Expectancy
Decrease of under-five mortality
1980 2003 1980 2003
China 68 71 42 37 3 -5Australia 74 79 11 6 5 -5Hong Kong
74 79 11 3 5 -8
Japan 76 82 8 4 6 -4Korea 67 76 26 5 9 -21Malaysia 67 72 30 7 5 -23New Zealand
73 79 13 6 6 -7
Singapore 71 80 12 3 9 -9Sri Lanka 68 73 34 15 3 -19
Source: World Bank. World Development Indicators 2005. Washington DC
Big city
Middle-size city
Small city
Rural 1 Rural 2 Rural 3 Rural 4
inpatient
1993 34.09 33.87 53.47 47.95 63.15 61.14 67.72
1998 53.12 58.43 70.77 63.80 54.12 70.26 69.38
2003 64.4 35.6 74.8 77.6 74.9 75.5 73.6
Outpatient
1993 3.21 2.40 9.58 15.10 21.36 19.55 24.421998 36.69 23.48 42.96 30.09 31.67 42.29 38.72
2003 30.8 32.7 47 29.2 33.9 41.2 49.1
Source： The national health service survey, 1993 、 1998 、 2003
% of people who should see a doctor choose not to do so because of the cost
China’s Healthcare Reform Plan
The plan, issued on April 6, 2009 by the State Council, promised to provide a universal primary health service to the country's 1.3 billion people.
“The goal is for everyone to enjoy basic health care services”
Government has responsibility to build a safe, effective, convenient and inexpensive health care system covering both urban and rural residents
Healthcare System
Financing
Healthcare Delivery
Management & Regulation
Drugs & Equipment
Health Personnel
22
Health
China’s Healthcare Reform Phase I
Speed up the establishment of a universal healthcare system
Set up an essential drug system Improve the primary health service
network Provide equal access to public health care
for urban and rural residents
From 2009-2012
Expand the coverage of health insurance. Increase the amount of rural and urban
population covered by the basic health insurance system or the new rural cooperative medical system to at least 90 percent by 2012
up to now, more than 1.27 billion urban and rural Chinese have been covered by basic health insurance, coverage rate is 96%
From 2009-2012 Build an essential drug system that includes a
catalogue of drugs that mostly needed by the public
Identified 307 essential medicines for common and frequently-occurring diseases. Government guidance on prices of these medicines has
been published. The government has included all the essential
medicines into the health insurance reimbursement list.
By the end of 2012, this policy had been implemented in all urban and rural primary health care institutions throughout the country
From 2009-2012
Improve health service delivery systems government increase funding to primary
health care institutes set up family doctor training system,
emphases on human resources education government has invested 60 billion yuan to
build 5,169 clinics at the township level, 2,000 hospitals at the county level, 2,400 urban community clinics, and 11,250 village clinics in remote areas
From 2009-2012
Gradually provide equal public health services in both rural and urban areas in the country
Government has offered all the urban and rural residents 10 types of free public health services.
Promote health maintenance by setting up personal health archives for urban and rural residents
Restructuring the primary healthcare system a comprehensive reform of primary care
system increasing government investment in primary care
centers Eliminating medicine-subsidized healthcare Paying for performance New regulation and incentive for hospitals and doctors “Two-Envelope” bidding procedure for procurement of
essential medicines• “Technical Bid” ensures the qualification of pharmaceutical firms;• “Business Bid” limits drug prices.
改革成效举例
Healthcare and Social Development
Leading the government’s role and development pattern towards emphasizing social development
Experimenting the creative and open approach for the government’s policymaking
Learning by doing social experiment Integrating top-down and bottom up
Challenges of China’s Healthcare Reform
Li Keqiang called for deepened health care reform, speeding up the reform of public hospitals
Health service delivery in China
1980s reform reduced budget support to providers
Providers paid fee-for-service Regulated prices are distorted
Low (or negative) margin on basic care High margin on high- tech care and drugs
Providers shift demand to high-tech care and drugs
From 2009-2012
Push forward reform trials in public hospital 70% of Chinese hospitals are publicly owned. due to low government investment, the public
hospitals are “for profit” "over treatment" and "doctors make living on
prescribing medicines“ are popular phenomena
17 pilot cities are reforming the public hospitals
Structure of Hospital revenue per patient （ general hospitals within health sector ）
Source: Health Statistic Yearbook
Revenue per outpatient（ yuan）
Revenue from medicine（ % ）
Revenue from medical examination （ % ）
Revenue per inpatient （ yuan）
Revenue from medicine（ % ）
Revenue from medical examination （ % ）
1990 10.9 67.9 19.3 473.3 55.1 25.71995 39.9 64.2 22.8 1667.8 52.8 30.41998 68.8 62.1 16.4 2596.8 49.2 28.12000 85.8 58.6 19.6 3083.7 46.1 31.72002 99.6 55.4 28 3597.7 44.4 36.72004 118.0 52.5 29.8 4284.8 43.7 36.6
2005 126.9 52.0 29.8 4661.5 43.9 36.0
2010 173.8 50.7 30.9 6525.6 43.4 25.9
2011 186.1 49.6 31.2 7027.7 41.8 26.7
36
Sanming ( 三明） model
Magt. & Regulation
Delivery
Financing
Availability+
Affordability=
accessibility
Health Personnel
Drugs &Equipment
Public hospital
New incentive for doctors
New incentive for doctors
Magt. & Regulation
Magt. & Regulation
New payment system (FFS,DRGs)
New payment system (FFS,DRGs)
Drugs & Equipment
Drugs & Equipment
Single Payer by combining all the insurances
Single Payer by combining all the insurances
Restructuring the system
Sanming model
合计 17091. 04 - 0. 58% 5691. 14 - 29. 24% 4975. 66 19. 32% 6859 - 9. 49% 129. 01 101. 89 -1. 81% 4. 39
三明市第一医院 7332. 45 8. 46% 2435. 63 - 10. 19% 1976. 02 15. 59% 8322 - 8. 09% 138. 63 118. 33 6. 03% 5. 40
三明市第二医院 2703. 36 - 0. 18% 911. 07 - 29. 28% 832. 53 23. 30% 7797 - 17. 71% 126. 04 100. 80 -20. 82% 4. 99
三明市中西医结合医院 1592. 59 - 5. 81% 495. 86 - 36. 57% 506. 15 17. 03% 7463 - 6. 83% 111. 26 97. 44 -22. 46% 4. 57
三明市第五医院 322. 08 - 30. 93% 102. 24 - 59. 27% 135. 11 3. 64% 4736 - 24. 43% 123. 67 97. 84 4. 58% 3. 22
梅列区医院 95. 28 12. 50% 19. 12 - 34. 93% 24. 25 13. 66% 3083 - 26. 82% 90. 22 79. 02 -52. 92% 2. 99
永安市立医院 1090. 40 - 1. 63% 360. 77 - 37. 19% 384. 60 32. 00% 6153 - 10. 96% 130. 82 79. 72 -10. 74% 3. 97
大田县医院 307. 90 - 25. 98% 106. 33 - 58. 66% 83. 53 34. 39% 5115 6. 48% 135. 80 100. 15 8. 37% 5. 92
次均普通门诊费用（元）
次均门诊总费用
（元）
检查化验费
( )万元
住院总费( )用 万元
药品收入（万元）
每百门急诊住院人次(住院率)
同比增长
次均普通门诊同比增
%长
同比增长%
次均住院费用（元）
同比增长%
同比增长%
三明医改实现了药品收入、总费用、次均费用同时下降医改主要措施： 1. 医生实行年薪制 2. 按照核定任务发放工资 3. 公示制度等
Future Directions
• China Dream• Healthy China
•Improve people's health and happiness
• 12th five-year plan•HiAP
Future Directions
Integrated Health with Social and Economic Development
Health care not Disease care system With information technology, big
data• Unified information platform• Overall process • Universal population
Future Directions
Great opportunity for information tech applications Unified information platform Integrated public hospital system Restructure payment system and incentive
system
Health information system in China
A national public health information system• Direct reporting system of infectious disease
and public health emergency A regional community health network
• Beijing Dongcheng District Community health network
An integrated Health Information System• Shanghai Min Hang District’s Integrated Health
Information System
The administration center
GPs Households
Health Management
Comprehensive health recordIn-time management
Lifetime Seamless Health Maintenance System
maternity
palliative
care
Birth Lifetime Death
physical examination Health promotion
immunization Long-term care
Thank You!H
Healthy World
Thank You!