care has to be accessible, affordable
Dr Henk Bekedam
Over the past month or so, health care reform in China has been
the subject of much discussion and public debate in the wake of
a report issued by the Development Research Centre (DRC) of the
State Council with the support of the World Health Organization
(WHO) and the UK Department of International Development.
The report takes a long, hard look at China's health care reform
process - and candidly lists the challenges of the past, the present
and the future.
Health care reform has been firmly on the government's agenda
for some time now. The DRC study has elevated the discussion to
a new level - and, at the same time, narrowed the debate to defining
more clearly the role of the government when it comes to reinvesting
in health. The question remains: how to do this? Where should
government funding be focused? What should the levels of expenditure
be? What are the mechanisms that need to be created and strengthened?
How can these best be implemented?
Many of the health challenges relate to the major transitions
that are taking place in China. Rapidly increasing urbanization,
an ever-widening gap between the rich and the poor, an ageing
population. All these factors contribute to a range of health
challenges - from tuberculosis to HIV/AIDS, from emerging infectious
diseases like SARS and avian influenza to the fast-growing, silent
epidemic of non-communicable diseases.
It's important to recognize that China achieved significant health
gains before economic reforms took hold. China's health picture
in 1980 - with a life expectancy of 65 years - has been recognized
as a major contributor to sustained economic growth. Decades of
economic reforms have made China a powerhouse. But economic reforms
have also made citizens the main financiers of health services
through the introduction of user fees - thereby making it very
expensive to be sick.
The SARS outbreak of 2003 and the cracks it revealed really brought
home the fact that the government had to reinvest in health across
the spectrum. The health care system - once a model of its kind,
especially in rural areas - has crumbled. The government has realized
that public health is indeed a public good, integral to the nation's
Post-SARS, health systems such as disease surveillance and reporting
are being modernized and strengthened. Still, for much of China
today, what is available is not affordable - and hence not accessible.
As medical costs continue to escalate, health care has become,
for all practical purposes, a luxury for millions.
Sadly, surveys confirm that health care costs are ultimately
the main single reason for people falling into poverty - and for
those already poor to sink even deeper into financial and personal
Policymakers urgently need to address this crisis of inequity
in health care and the spiralling of health care costs. There
are fears that health care spending, which is currently at 5.5
per cent of GDP, might exceed 8 to 10 per cent within the next
five years without actually improving the quality of services.
That is a truly disturbing picture, with potentially dire economic
consequences for China and its people.
Privatization is seen by some as a solution to curb government
expenditures for health. However, privatization can lead to increased
expenditures for society as a whole if no proper cost control
mechanisms are put in place. Health insurance systems can play
an important role both in controlling costs and ensuring that
hospital services remain affordable and accessible. A strengthened
regulatory framework to ensure cost control, quality control and
safety pertaining to both public and private health care services
will be essential.
Another factor that requires an urgent review is the current
incentive structure. In China, essential health services are under-funded,
and hospitals and their staff need to supplement their incomes.
This leads to an increased demand for health services, including
diagnostics and drugs, instigated by the provider - or, in other
words, supplier-induced demand.
Identifying problems, of course, is the easy part. Fixing these
problems is the challenge. China is a big country, and one solution
might not fit all, so to speak. But there are clear markers -
accessibility, safety, quality and cost control - which are applicable
across the board.
The WHO believes that an overall vision is needed to guide health
care reform, and provide direction to the many ministries and
institutions involved in public health. This vision includes the
need for the government to define the appropriate scope and nature
of its own involvement in addressing concerns of equitable access,
safety and cost. Improved and increased government funding and
investment will need to follow.
(August 31, 2005)