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RTD info logoMagazine on European Research Special issue - July 2005   
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HEALTH SERVICES
Title  Health report on Chinese cities

Dramatic changes are sweeping across China, of which economic reform and an expanding private sector, a massive rural exodus, the overturning of social structures, and an ageing population are just some of the most striking examples. How are these changes affecting the efficiency of health services and what are the consequences for access to treatment? These are the two questions being posed by a team of European and Chinese experts in the framework of a study co-financed by the INCO programme.

Epidemiological transition is well under way in urban China. This trend, which accompanies development, is marked by a decline in infectious diseases and an increase in chronic diseases similar to those found in the industrialised countries.
Epidemiological transition is well under way in urban China. This trend, which accompanies development, is marked by a decline in infectious diseases and an increase in chronic diseases similar to those found in the industrialised countries.
It all began in the late 1990s when the Chinese Government announced that it was awarding top priority to reforming the urban health care system, judged to be in a pitiful state. A senior official at the Health Ministry, Cai Renhua, today Director of the Chinese Health Economics Institute, enlisted the expertise of the Institute of Development Studies (IDS) at Sussex University (Brighton, UK) and of the Faculty of Medicine in Shanghai, both of which had already participated in studies of the health care system in rural China. The task was to assess the equity and efficiency of health services in Chinese towns and to submit recommendations to health officials.

A research consortium was set up and organised into two groups. The IDS, as study coordinator, teamed up with the Shanghai Faculty of Medicine (which later became the University of Fudan) and sociologists from the University of Hamburg (DE) to study equity of access to health services, while Shandong University’s Institute of Social Medicine and Health Policy worked with the Stockholm School of Economics (SE) on the efficiency of the health system. With co-financing assured from the EU (INCO programme), the British Government and the Ford Foundation, the researchers were able to begin their mission by defining their method. As it is impossible to try and obtain a comprehensive picture in a country as vast as China, they decided to focus on a case study.

Spotlight on Nantong and Zibo
Two cities in eastern China were selected: the port of Nantong (population 2.5 million) which lies on the banks of the Yangtze in Jiangsu Province, and the industrial city of Zibo (population 1.4 million) in Shandong Province. There were also scientific reasons for the choice. “One of the greatest difficulties facing social science research in China is the rate of change. It was to get round this difficulty that we decided to carry out studies that were both very local and very detailed and which would be able to reveal the dynamic of the change in progress,” explain programme coordinators Gerald Bloom (ISD) and Tang Shenglan, formerly a researcher at Fudan University and now at the Liverpool School of Tropical Medicine (UK). 

The authorities in both Nantong and Zibo were enthusiastic participants in the study. They provided medical statistics compiled by the health centres (number of patients, types of pathology, etc.) as well as various economic and social data that are essential to any analysis of a health care system. In addition to collecting these statistics, the researchers also carried out their own in-depth studies in the field. They set up a panel of several thousand families representing the different social classes, issuing each family with a book in which to record, during two weeks, details of any visit to a health care establishment. The researchers also conducted face-to-face interviews with inhabitants, government officials, business managers and hospital directors. 

New illnesses, new patients
What lessons can de learned from this three-year study that combined an economic and sociological analysis with a quantitative and qualitative approach? As space does not permit the presentation of the collected data in any detail – it runs to 250 pages of a book containing about 30 publications in both English and Chinese(1) – we will highlight the most notable findings.  

First of all, the study provides a very precise picture of the health situation of the populations of these two towns. This shows that the six most common causes of mortality are at present chronic diseases of the kind that are found in Western societies (cancers, cardiovascular disease, etc.). Infectious diseases rank seventh, although they remain an important public health issue, especially with the resurgence of tuberculosis and the spread of Aids. The researchers see this as proof that epidemiological transition is well under way in urban China, marked by a decline in infectious diseases and an increase in the chronic diseases that accompany development. 

The second lesson is that access to hospital care is not dependent on sex but on economic status. Employees of public administrations and of profitable state-owned enterprises attend medical centres much more often than employees of loss-making enterprises, private companies or, most notably, the unemployed. There is a simple explanation for this inequality: those who seek most health care are those who benefit from a health insurance policy paid for by their employer. Such systems are very rare. If they do not have sufficient insurance cover, those who suffer from a chronic disease spend a large part of their wages on their treatment. As to the poorest sections of the population, whose situation is often precarious, they find it difficult to meet the cost of health care.

A mixed picture
Group of Chinese girls
Although not egalitarian, are China’s health services efficient? The study offers a mixed response on this point. There was a notable drive for modernisation between the early and late 1990s, when such high-tech devices as medical imaging became generally available, for example. The hospitals took on a lot more staff and the standard of care improved during this period. Unfortunately, there was a down side to this progress. Patients with the means to do so abandoned the clinics and health centres in favour of the modern hospitals, even when their condition did not really require it. The costs of a consultation tripled between 1990 and 1999 (including an adjustment for inflation), while the daily cost of hospitalisation increased fourfold. There also seems to be a certain wastage and bed occupancy fell from over 80% in the early 1990s to around 60% today.

The study therefore provides a mixed picture of the Chinese health care system. On the one hand, the quantity and quality of care services have improved, and the drive for modernisation has brought considerable progress in public health. But on the other, health services provide a less than perfect response to a considerable and largely unsatisfied demand. Millions of Chinese citizens are unable to receive the treatment they need while more and more hospital beds are remaining empty. These observations were presented first at a round table attended by officials from Nantong and Zibo, and then at the Ministry of Health in Beijing at the end of 2001. These meetings were the occasion to present some of the possible areas for public action suggested by the researchers, “and since adopted in part by the Chinese leaders”, as Gerald Bloom and Tang Shenglan like to point out. Among the points stressed were: the need to move towards a system of universal sickness cover that is accessible not only to employees but to all the inhabitants of towns, and possibly of rural areas too; the need to get more patients out of the hospitals and into the clinics and health centres as “establishments that depend on the state today provide 95% of diagnoses, treatment and hospitalisation”(2); the need for a low cost care system for the elderly; and the need to reform hospital management, with an end to state subsidies that are dependent on the number of beds and which have the effect of boosting supply independently of demand. 

In fact, the challenges facing the Chinese health care system are very reminiscent of those facing the European countries. International co-operation is helping the present rapid rate of change as China learns the lessons from experiences in Europe. The recent SARS crisis, which originated in China, provides a timely warning of the importance of this co-operation.

(1) Gerald Bloom and Tang Shenglan, Health Care Transition in Urban China, Ashgate Publishing Limited.
(2) As the study initiator Cai Renhua declared when commenting on the government’s intention to reduce the importance of public hospitals.

    
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