China's Newest Revolution: Health for All?
Barry R. Bloom, Jacobson professor of public health, dean emeritus, Harvard School of Public Health (HSPH)
Barry Bloom noted that HSPH had launched a China initiative in 2003 when China’s minister of health sought advice on infectious diseases in the wake of the SARS epidemic. School faculty were now engaged in a 20-year study of rural health and of possible basic health-insurance measures that could improve conditions among the rural population, and a 30-year study of environmental health and safety among textile workers (a useful pilot for a country with very high rates of industrial accidents, mortality, and morbidity). In recent years, HSPH faculty members have also provided executive training for personnel in the national and provincial health ministries, and had begun training high-level hospital managers.
After the success of the revolution, in 1949, Bloom said, the Chinese government put a high priority on healthcare, despite the country’s desperate poverty. But with the introduction of market reforms in the late 1970s, that focus had lapsed in almost all realms: preventive services, like vaccination and access to clean water, had slipped; access to care had declined in the rural areas where hundreds of millions of people still live; and equal access to care had declined sharply as payment for services was privatized. In 1978, he said, out-of-pocket payments accounted for 20 percent of spending on health services; by early in this decade, that proportion had risen to 60 percent—an unaffordable, untenable state of affairs for most of the population. Eighty percent of health services were concentrated in urban areas, where incomes were higher; rural services had declined. Given skewed price controls and regulations, drugs accounted for 45 percent of health expenditures (versus 10 percent in the United States), a strong indication of overuse of unregulated services as doctors and other providers sought to maximize their income.
On April 6, 2009, China unveiled an action plan for radical, extensive healthcare reform—the most ambitious such plan in the world, Bloom said. By 2011, it aims to provide basic health insurance coverage to 90 percent of the population, with universal access by 2020. At the same time, primary care is to be strengthened through investments in clinics and hospitals, control of infectious diseases, the institution of electronic health records, and focused management of chronic diseases. These and other measures are budgeted at 850 billion RMB (about $125 billion).
That such plans have advanced, Bloom said, represented part of a broader shift under President Hu Jintao, under the banner of development of a “harmonious society.” The major questions now were whether such health reforms signaled any broader move toward a more open society, whether they could be implemented successfully, and whether they would have wider effects on public values and processes of governance.
Yuanli Liu, who directs HSPH’s China initiative, said the country faces significant challenges in improving both its healthcare systems and the actual health status of the population. The former are complicated by the huge gaps in provision of care and by rising popular demands for care.
Moreover, despite economic development and recent investments in healthcare and education, the burden of disease is rising in China: he cited 130 million people with hepatitis B (half the world’s infected population), and 4.5 million afflicted with tuberculosis (one-third of the world’s infected population). China has a large incidence of sexually transmitted diseases, and remains vulnerable to new threats, such as H1N1 flu. Noncommunicable diseases account for a rising share of deaths, and there is an increasing burden of deaths and injuries from rising automobile traffic and from suicides. Even as access to insurance has risen, the portion of the population doing without care because of the inability to pay increased between 2003 and 2008, despite vigorous economic growth.
Looking ahead, he said, “China is getting old before it gets rich,” as the share of the population above 65 years old increases from 8 percent now (about 100 million) to 14 percent in 2025 (approaching 200 million)—posing large challenges of nutrition, care, and income support in a society with little in the way of pensions (and a huge migration of children from their birthplaces to jobs in coastal cities). Nationwide, environmental pollution is severe. And unhealthy behavior—particularly cigarette smoking (which rose from 1.7 billion to 2.2 billion units in the five years to 2008)—has worsened. Given the government’s dependence on cigarette taxes for revenue, it has resisted strong HSPH suggestions to use taxes to reduce consumption.
In this context, he said, the long-term strategic plan for health being developed since 2008 (Yuanli Liu has been the only external adviser) is likely to call for major action in three broad areas: targeted population groups (mothers and children, industrial workers, and the rural poor); certain disease actions (vaccination, treatment of chronic conditions such as diabetes and hypertension); and priority risk areas (clean drinking water, food safety, smoking, and so on). The resulting goals will be to raise life expectancy by four years (to 77) by 2020, to reduce the mortality rate from infectious diseases by half, and to achieve strong gains in reducing maternal and child mortality and deaths from cardiovascular disease and strokes.
Attaining such ambitious gains is not a foregone conclusion, he said. Other ministries will have to support the health ministry. Local governments will have to become heavily involved. And profit-minded medical providers, hospitals, and other players will have to change their behavior.
Anthropologist and psychiatrist Arthur Kleinman addressed just those behavioral factors in examining health and moral change in today’s China. His own research, begun in Taiwan in 1968 and on the mainland since 1978, has focused on depression, suicide, SARS and other epidemic infections, and individuals’ moral life and perceptions.
Before the revolution in 1949, Kleinman said, China had essentially no healthcare system, with huge gaps between rich and poor and between urban and rural populations. Famine, epidemics, natural catastrophes, the wartime displacement of 200 million people, and practices such as infanticide contributed to disastrous health outcomes.
During the first 30 years of communist rule, China built a public healthcare system, which yielded large gains in infant mortality and longevity, and significant improvements in the fight against epidemic diseases. But the economic reforms launched in 1978 dismantled the socialized healthcare system in favor of privatization, resulting in a collapse of much rural care and sharply wider disparities in the burdens of disease, as the other speakers had already noted. The healthcare system became riddled with conflicts of interest, corruption, widespread regulatory failures, ignoring of ethical protocols, and increased public distrust of health professionals.
During the Maoist era, in effect, Kleinman said, the individual owed his life to the state and the party. Now, in the era of economic reform, market forces played a large role, but the government and the party at least owed the individual a chance to live a good life. But the present, more individualistic, era came with troubling moral outcomes for much of the population: family and filial ties, a pillar of Chinese life, declined; the society as a whole became more materialistic and cynical; amid the widening of urban-rural gaps, in what had been an egalitarian system, public distrust rose.
On the other hand, Kleinman said, certain pro-social moral developments were under way. Discontent with the status quo was leading to the development of public ethical discourse. The younger generation was developing more global interests and connections through the Internet. The status of women had improved significantly. Voluntarism and altruism were spreading, as in the public outpouring of charitable aid for the victims of the Sichuan earthquake in 2008, entirely apart from state actions. And awareness of and advocacy for environmental quality and public health were awakening.
In this context, he saw China’s health challenges as having a moral dimension inseparable from political and medical developments. Only this way would China really come to terms with the social consequences of the disparities that had arisen in the market era, with rising problems of mental health, and with inadequacies in policy development and regulation. Rethinking of the one-child policy, the rising prominence of elder-care and welfare issues (in 2004, for the first time, China had more people over age 60 than under age 5), and re-examination of underdeveloped professional ethics all played into the new environment, most visible among the young, who exhibited a “enormously encouraging” interest in examining their reasons for being and the kinds of concerns they ought to pursue.