China has done well in expanding the coverage of health insurance to 96% of the population since it launched nationwide health-care reforms in 2009, but poorly in reforming the "wasteful and inefficient" health-care delivery system. These substantial challenges, together with a new policy to promote private hospitals is endangering China's goal of providing affordable and quality basic health care to all by 2020, according a Review published as part of a Lancet themed issue on China.
"Chinese health care still faces considerable challenges to transform from a poorly governed, hospital-centred system that puts profit above patient welfare, to a primary care-based delivery system that is cost effective and better able to respond to a population increasingly affected by chronic diseases and disabilities associated with ageing", explain authors Winnie Yip, Professor of Health Policy and Economics at the Blavatnik School of Government, University of Oxford, UK, and William Hsiao, research Professor of Economics at Harvard School of Public Health, Boston, USA.*
Despite the government almost doubling annual health spending to ¥836.6 billion (£1 is roughly equal to ¥10) between 2009 and 2012, with substantial investment in primary health care, most visits and admissions continue to take place in hospitals. As a result, primary health-care facilities have not been able to perform their key functions of prevention, case-detection, gate-keeping, and referral - essential for chronic disease prevention and control.
Take hypertension (high blood pressure) as an example. Despite being the second largest risk factor causing disability and death (the first being tobacco), only 42% - 57% of adults with hypertension are aware they have the condition, whilst just a third to half of patients with hypertension receive treatment. What is more, admission rates for complications from diabetes in China are more than five times the rate in countries of the Organization for Economic Cooperation and Development (OECD) countries - a sign of poor primary health care.
Worryingly, say the authors this might only be the tip of the iceberg: "The government's latest strategy to promote private investment for hospitals, with the target of private hospitals meeting a 20% market share by 2015, would result in escalating health-care expenditure, with patients bearing increasing costs; a two-tiered system in which access and quality of care are decided by ability to pay; and poor population health outcomes."*
They conclude that to steer China back on course to achieve its health goals an alternative strategy is needed to reform public hospitals to pursue the public interest and be more publically accountable, with public hospitals as the benchmarks against which private hospitals would have to compete. They add, "China should assess how the entry of private hospitals affects its health-care system before it makes any decision to further expand their market share. Otherwise, China might not be able to rein in a runaway delivery system plagued with inequity and cost escalation."