Focus on China
I’m Sophie Ratcliffe, student intern here at The Lancet and Lancet Student. I’m a final year medical student at Cardiff university and over the coming week I will be helping Rhona and Hannah post your blogs and articles and with the general running of the Lancet Student website. This week sees the launch of the Lancet’s China series, which focuses upon the key issue of Health System Reform in China. China is currently debating an ambitious strategy of reforms with the aim of universal health insurance provision, under the Healthy China 2010 Plan. The Lancet, in a series of scientific collaborations with Peking University Health Sciences Centre and the China Medical Board, examines the major health challenges China faces, and the implications these are set to pose for future global health.
Photo from www.sxc.hu
Over the past few years, China has undoubtedly taken the world’s centre stage. Whether talking about its huge natural and human resources (accounting for over a fifth of the global population), its culture, its human rights record, its rapidly expanding economy or, most recently, the Beijing Olympics, the media has been alive with debate about China. Though China is now feeling the pinch of the global recession, many commentators have predicted that it would pass through the current market turmoil more unscathed than most. Much less attention has been given to public health in China, though events such as the SARS outbreak, the Sichuan earthquake and the melamine-in-baby-milk scandal have highlighted the strengths and weaknesses of the health system there.
The lead comment explains why the Lancet decided to commission this series and the importance of Chinese health both domestically and internationally. They note four particular points; the sheer size of the population and the challenges they face from infectious and increasingly non-communicable disease, the fact that China is both historically and currently a source of health innovation (indeed the number of academic papers on medicine, as well as other sciences, originating from China has risen exponentially in the last few years), China’s role in ameliorating or exacerbating global public health risks (be it SARS or TB) and China’s increased involvement in international politics, including those related to public health
Article six in the series identifies the major challenges to be addressed in the way health-care is paid for in China, most noticeably; rapid cost increases; high levels of out of pocket payments; and insufficient insurance; together with widespread inefficiencies in health facilities and inefficient use of scare resources; uneven quality; extensive inequality and perverse incentives for hospitals and doctors. Health-care equality represents a major political issue and public complaint in China, with significant deficits in appropriate access or affordability to many of its 1.3 billion population. In a WHO report into equality in the provision of medical treatment, China ranked 187th of the 191 countries surveyed. The poor and those in rural areas have been the worst hit, often having to travel large distances to the cities to receive healthcare at excessively high out of pocket cost. The average cost of a single hospital admission is now almost equivalent to China’s annual income per head, sparking public concern at the exponential increase in fees, now more than 18 times what they where in the 1990s. These rising fees coupled with collapsing coverage have come to represent healthcare as a notable source of impoverishment for many households.
Today the old system is set to be dismantled as the government attempts to spread the cost of healthcare in a bold, new step to provide universal insurance cover by the year 2010 and accelerate improvement in the way healthcare is delivered. The outcome of these reforms remains uncertain, but there are reasons for optimism; central government spending on health is being increased substantially after stalling at exceptionally low levels for many years; with the commitment for 100% coverage by 2010, represents an ambitious step in the right direction, but still much more remains to be done to tackle inequality in China’s healthcare.
Money also needs to be directed towards preventative medicine, with an increasingly elderly and urbanised population as China continues to develop, chronic disease rates are also on the rise. Rapid social changes together with shifts in diet and lifestyle pose new medical problems requiring further investment. There has been a rapid epidemiological shift in China from infectious to non-communicable diseases, in fact the latter now accounts for more than three quarters of deaths. A paper in the series discusses the reasons behind this and the public health step-up needed. Part of this can be explained by measures to tackle infectious diseases and the ageing population but there are many other contributing factors. Smoking, for instance, is a big problem, with China the largest producer and consumer of tobacco in the world. Changes in nutrition (for instance an increase in meat consumption and overall fat intake) and levels of physical activity have, as in other countries, led to an increase in obesity and hypertension. 177 million people in China are hypertensive, the largest number of people in any one country, demonstrating the sheer scale of the challenge faced by the healthcare system. Measures to combat these and other chronic diseases are lacking and need to be put in place rapidly, in the same way that China was able to harness its resources to tackle infectious disease in a much shorter time frame than other industrialising countries.
Despite the great successes China has had against infectious diseases, they remain a problem, as detailed by another paper. Emerging infectious diseases and zoonoses, such as SARS and avian influenza, are a big concern for the international community as well as for China. Good monitoring and epidemic strategies are essential to contain these risks. Also of great importance is HIV/AIDS, spurred on by a rapid growth in the sex industry and changes in sexual attitudes, and schistosomiasis, both of which are highlighted in comments.
Hannah and Sophie