Healthcare in China

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Healthcare in China has undergone basic changes over the

chronic illnesses. Under the "Healthy China 2020" initiative, China has undertaken an effort to cut healthcare costs, requiring insurance to cover 70% of costs by the end of 2018.[2][3] In addition, there are policies such as critical illness insurance and medical assistance. China's commercial health insurance is also proliferating. In 2020, the country's commercial health insurance premium income amounted to 817.3 billion yuan, with an average annual growth rate of 20%. China's coverage of maternity insurance has continued to expand, by the end of 2020, 235.673 million people were insured under maternity insurance.[1]

The country maintains two parallel medical systems, one for modern or Western medicine, and one for

Merck entered the Chinese market and have experienced explosive growth. China has also become a growing hub for healthcare research and development.[4] According to Sam Radwan of ENHANCE International, China's projected healthcare spending in 2050 may exceed Germany's entire 2020 gross domestic product.[5]

The above only applies to

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History

Traditional and folk medicine served as the basis for health care in China. Western-inspired evidence-based medicine made its way to China beginning in the nineteenth century. When the Chinese Communist Party (CCP) took power in 1949, national "patriotic health campaigns" and local governments successfully introduced basic sanitary measures and preventative hygiene education. Health care was provided through the place of work, such as the government bureaucratic unit, the enterprise, factory, school, or, in the countryside, the cooperative or commune. Larger danwei might have their own in-patient clinic on premises.[7]: 310  During the Cultural Revolution (1966-1976), Mao Zedong's followers attacked medical professionals as elitists. Basic primary care was dispatched to rural areas through barefoot doctors and other state-sponsored programs. Urban health care was also streamlined.[8]

Mao era

Free medical treatment was practiced in areas controlled by the CCP before 1949. In February 1951, the industrial and mining departments began to try out labor insurance regulations and solve workers' medical problems. In the same year, free medical treatment was also tried in northern Shaanxi and some ethnic minority areas. On June 27, 1952, the Instructions of the Administration Council on the Practice of Free Medical Treatment and Prevention for State Functionaries of People's Governments at all levels, parties,[9] organizations and affiliated Institutions were issued. After that, the CCP government gradually communized the medical and health system and modernized it in imitation of the Soviet Union. During the period of planned economy, a tertiary hospital structure was established: a tertiary medical service and epidemic prevention system consisting of municipal and district hospitals and outpatients from sub-districts, factories, and mines. A three-level medical prevention and health care network is established in rural areas, with county hospitals as the leader, township (town) health centers as the hub, and village clinics as the basis.[8]

Before the Cultural Revolution, the Ministry of Health focused on the delivery of health care in urban hospitals.[10]: 304  Mao criticized Minister of Health Qian Xinzhong for promoting this health care model, arguing that an urban hospital-focused health care model failed to treat peasants and focused on cure rather than preventative medicine.[10]: 304  Mao also described the Ministry itself as the Ministry "of urban overlords."[10]: 105 

The Cultural Revolution brought a greater focus on rural health care. In his June 26 Directive, Mao prioritized healthcare and medicine for rural people throughout the country.[11]: 362  As a result, clinics and hospitals sent their staff on medical tours of rural areas and rural cooperative healthcare expanded.[11]: 362  Barefoot doctors brought healthcare to rural areas where urban-trained doctors would not settle. They promoted basic hygiene, preventive healthcare, and family planning and treated common illnesses.[12]

Deng's economic reform

However, beginning with economic reforms in 1978, health standards in China began to diverge significantly between urban and rural areas and coastal and interior provinces. The barefoot doctor system was put in free fall in 1981, as the "commune" system was shut down.[13][14] By 1984, village cooperative healthcare coverage had dropped from 90% to 4.8%.[15] The barefoot doctor model officially ended during the Chinese Medical Reformation of 1985, when the term 'barefoot doctor' was removed from the healthcare system and replaced with the term and concept of 'village doctors'.[16][17] Though most village doctors are former barefoot doctors, they started charging for their services as private entities.[18]

Urban residents also faced healthcare privatization as they were laid off from state-owned enterprises and lost much of their social security and health benefits. As a result, the majority of urban residents paid almost all health costs out-of-pocket beginning in the 1990s, and most rural residents simply could not afford to pay for healthcare in urban hospitals.[11]

In 1989, the Chinese government decided to try and reverse the fall of rural healthcare coverage, but they were not very successful: coverage was only up to 10% by 1993.[15] In 1994, the government decided to fund a revival of the co-operative system,[15] though they would not be successful until the 2005 NRCMCS project.[19]

Despite the consequences of privatization, the economic reforms did bring in money and new technology for building new hospital infrastructure. Modern hospital infrastructure expanded significantly in China beginning in the 1990s.[20]: 101 

21st century

The 2003 SARS epidemic resulted in substantial public criticism, prompted government statements that privatizing health care in rural China had been a failure, and brought rural reform to the top of the policy agenda.[21]: 104–105  The government launched the New Rural Co-operative Medical Care System (NRCMCS) in 2005 in an overhaul of the healthcare system, particularly intended to make it more affordable for the rural poor. Under the NRCMCS, some 800 million rural residents gained basic, tiered medical coverage, with the central and provincial governments covering between 30 and 80% of regular medical expenses.[19]

Since 2009, China has been undertaking

Mao era.[22] The availability of medical insurance has increased in urban areas as well. By 2011 more than 95% of the total population of China had basic health insurance, though out-of-pocket costs and the quality of care varied significantly,[4] particularly when it came to serious illnesses among children.[23] The health infrastructure in Beijing, Shanghai, and other major cities was approaching developed-world standards and is vastly superior compared to those operating in the rural interior.[citation needed
]

Current healthcare system

Life expectancy in China

The Chinese healthcare system maintains

V.I.P. wards typically charge higher prices than other hospital facilities, but are still often cheap by Western standards. In addition to modern care, traditional Chinese medicine is also widely used, and there are Chinese medicine hospitals and treatment facilities located throughout the country. Dental care, cosmetic surgery, and other health-related services at Western standards are widely available in urban areas, though costs vary. Historically, in rural areas, most healthcare was available in clinics providing rudimentary care, with poorly trained medical personnel and little medical equipment or medications, though certain rural areas had far higher-quality medical care than others. However, the quality of rural health services has improved dramatically since 2009. In an increasing trend, healthcare for residents of rural areas unable to travel long distances to reach an urban hospital is provided by family doctors who travel to the homes of patients, which is covered by the government.[25][26][27][28][29]

Reform of the health care system in urban areas of China has prompted concerns about the demand and utilization of Community Health Services Centers; a 2012 study, however, found that insured patients are less likely to use private clinics and more likely to use the centers.[30]

A cross-sectional study between 2003 and 2011 showed remarkable increases in health insurance coverage and inpatient reimbursement accompanied by increased use and coverage. The increases in service use are particularly important in rural areas and at hospitals. Major advances have been made in achieving equal access to insurance coverage, inpatient reimbursement, and basic health services, most notably for hospital delivery, and use of outpatient and inpatient care.[31]

A 2016 report from the World Bank Group, the World Health Organization, the Ministry of Finance, the National Health and Family Planning Commission, and the Ministry of Human Resources and Social Security of China recommended health care reforms to reduce healthcare spending in China by shifting away from a hospital-centric model towards a system that focuses more on primary care, health service equality, and cost-efficient health services.[32] The report found that the greatest health threat to the Chinese population is from non-communicable diseases which replaced infectious diseases as most common threat. The threat from non-communicable disease is worsened by behaviors like sedentary lifestyles, high alcohol consumption, and smoking as well as air pollution. The report suggests that without health care reforms the spending on health care in China will increase to 9% of China's GDP by 2035 which is an increase from the 5.6% of China's GDP in 2014.[32]

With substantial urbanization, attention to

Communicable infections should also be re-focused on.[33] In 2022, the BBC's chief international correspondent Lyse Doucet said China had a very good healthcare system including at the provincial level.[34]

As of 2022, enrollment in China's nationwide healthcare system is almost universal. However, these plans generally provide low levels of benefits.[35]: 202 

Resources

In 2005 China had about 1,938,000 physicians (1.5 per 1,000 persons) and about 3,074,000 hospital beds (2.4 per 1,000 persons).[36] Health expenditures on a purchasing power parity (PPP) basis were US$224 per capita in 2001 or 5.5 percent of the gross domestic product.[37] Some 37.2 percent of public expenditures were devoted to health care in China in 2001.[38] However, about 80 percent of the health and medical care services are concentrated in cities, and timely medical care is not available to more than 100 million people in rural areas. To offset this imbalance, in 2005 China set out a five-year plan to invest 20 billion renminbi (RMB; US$2.4 billion) to rebuild the rural medical service system composed of village clinics and township- and county-level hospitals.[39] By 2018 this goal had been completed and the country had a total of 309,000 general practitioners or 2.22 per 10,000 people.[40]

There is a shortage of doctors and nurses in China. More doctors are being trained, but most aim to leave the countryside in favor of the cities, leaving significant shortages in rural areas.[41]

In 2016 it was reported that ticket resale was widely practiced at Beijing Tongren Hospital and Peking University First Hospital. Advance tickets for outpatient consultation are sold by the hospitals for 200 yuan but sold for as much as 3,000 yuan. An eye doctor commented that the appointment fees did not reflect the economic value of doctors' skills and experience and that the scalpers were selling the doctor's appointment at a price the market is prepared to pay.[42]

Medical training

In 1956, in the midst of China's education reform modeling Soviet practices, the Ministry of Hygiene embarked on standardizing medical education and organizing medical colleges in China. Taking an April, 1955 Soviet curriculum as reference, the resulting curriculum would offer a tertiary higher medical education at a maximum of 12 years. By 1958, traditional Chinese medicine was included in the curriculum. Beginning in 1962, a six-year course for medical education and a five-year course in pharmacology came into effect. Despite these early standardizations, the Cultural Revolution saw a halt in higher medical education and a preference for "barefoot doctors" with little to none formal medical education. Higher medical education was revived in 1977 on orders of the Ministry of Education and the State Department to resume higher education; starting February, 1978, students are enrolled in a five-year course for medical school and a four-year course for pharmacology at the undergraduate level. [43]

In 2012, the Chinese Ministry of Education proposed again to standardize medical education in China into "5+3" programs: five years of undergraduate medical school training and three years of residency. Meanwhile, the same proposal also suggested a "3+2" program for graduates of higher vocational colleges: a three-year vocational medical degree and two years residency. [44] The indetermination of this departmental opinion displayed how various tracks of higher medical education coexist in contemporary China. Previously, a 1998 State Department regulation established professional clinical medicine degrees of Master of Medicine (M.M) and Doctor of Medicine (M.D). Applicants to these degrees require three years of experience as resident physicians as well as supervised training of at least six months; a M.M holder may advance to M.D with three years of further residency, bring the potential length of the most advanced medical degree in China to 11 years. [45] Neither of these regulations, though theoretically still in effect, reflect the full reality of undergraduate and postgraduate degree programs in the early decades of the 21st century. By 2019, Chinese medical education features tracks of three-year (vocational or no degree), five-year (Bachelor of Medicine), "5+3" (Masters degree in Medicine or in Clinical Medicine), eight-year (MD), etc. Postgraduate degrees are further categorized into research degrees and professional degrees.[46]

The National Health Commission of the People's Republic of China certifies practitioner qualification through annual qualification examinations managed by its subsidiary National Medical Examination Center (NMEC). The 2021 Law on Doctors of the People's Republic of China (《中华人民共和国医师法》) rules that physicians satisfying the following criteria may enter qualification exams, catering to three types of practitioners, those with a bachelor's degree or above, with a junior-college or vocational degree, and those engaged in Traditional Chinese and ethnic Medicine practices: [47] [48][49]

has obtained a bachelor's degree or above in a medicine-related major from an institution of higher education and has completed at least one year of medical work practice at a medical and healthcare institution under the guidance of a practicing doctor.(Article 9, subsection 1)

has obtained a junior college degree in a medicine-related major from an institution of higher education, and has practiced with a medical and healthcare institution for at least two years after obtaining a practicing certificate of practicing assistant doctors.(Article 9, subsection 2)

has obtained a junior college degree or above in a medicine-related major from an institution of higher education and has completed at least one year of medical work practice at a medical and healthcare institution under the guidance of a practicing doctor may take the examination of practicing assistant doctors' qualifications. (Article 10)

Notably, Article 11 specifies how Traditional Chinese Medicine practitioners may obtain qualification: "has studied TCM for at least three years through master-disciple education or who has acquired special medical skill after many years of practice may, after passing the assessment of and being recommended by a professional TCM organization or a medical and healthcare institution authorized by the health department of the people's government at or above the county level, take the examination of TCM doctors' qualifications."

Traditional and modern Chinese medicine