The Health Care System and Public Health in China

Jesse Huang ， MB ， MHPE ， MPH ， MBA

Assistant President and Dean for Continuing Education

Professor of Epidemiology

Chinese Academy of Medical Sciences

Peking Union Medical College

Email:pumcjesse@yahoo.com.cnTel: 6529-5986 13910822961

• China’s Health Care SystemChina’s Health Care System

• Public Health in ChinaPublic Health in China

I will discuss…

• Basic Statistics/Economic statusBasic Statistics/Economic status

• System overviewSystem overview

• Who pay for health services?Who pay for health services?

• Government’s health policies Government’s health policies

China and its Health Care SystemChina and its Health Care System

• Area: 9.6 million km2

• Total population: 1.27 billion (2000)

• Population in rural areas: 63.8％• Administrative Region: 31 provinces

• GDP: 8,940.4 billion RMB

• Number of health agencies: 330 thousand

• Number of health workers: 5.568 million

• Number of school of public health: 36

China:Basic Statistics

•Source : China statistical year book,2001

Economic Status by Province, 1999

Source : China statistical year book,2000

Health Care System

The organization structure of Chinese health Care system

State Department

Government of Provincial, Municipal,

Autonomous Region

Prov Dept of Health

Local Dept.of Health

Chinese Academy of Medical ScienceChinese Academy of Preventive Medicine Medical Colleges and UniversitiesDrug and Bioengineering Product Research Institute

The Ministry of Health

General and Specialized hospitalEpidemic Prevention StationMaternity and Children Health Care Hospital (Clinic)Drug Inspection Station

Regional Administrative Office

General and Specialized hospitalEpidemic Prevention StationMaternity and Children Health Care Hospital (Clinic)Drug Inspection Station

Government of Municipal, County, District

Township hospital (clinic), District hospitalOutpatient clinic

Municipal (District) hospital, County hospital, Epidemic Prevention Station, Endemic Disease Prevention StationMaternity and Children Health Care Hospital (Clinic), Secondary Health School

Township government, Subdistrict Office

Villagers’ committee, Neighborhood residents’ committee Village health station, Red Cross

health station

District department of Health

Three tiered prevention and

health care system

County Hospital Agencies: 2008Workers:487684

Township hospital(Clinic) Agencies: 47928

Workers:1163700

County Maternity and Child Health Hospital

Agencies: 1387Workers:49313

Township hospitalsAgencies:693518Workers:1282310

Health Network of Three Tiered in Rural Area

County Epidemic

Prevention StationAgencies: 1657Workers:87468

China Health Information System

Ministry of Health, P.R.China

China CDCCenter of Information of MOH

Institute of Medical Information, CAMS

Other

Health Project Research Institutionsof Medical Science

Medical Colleges

PreventionMedicineEducationResearch, and ExecutionFacilities

Facilities ofDiseasesControl and HealthSupervisionat all levels

Health Units Local Health Dept

Local Health Dept

Provincial Dept of Health

Univ.directly under MOH

Who pay for health services ?

• 1949-1977 free health services for the entire urban population, government pay system

• 1978-1996 government & hospital paid health services

• 1996-now government, collective & individual paid health services

The Medical Expenditure Per Capital Outpatient (Unit: RMB)

Average medical expenditure to per

person-time

ContainThe

range of

increase (%)

The cost of drug The cost of

Treatment and examination

Absolute number

proportion Absolute number

proportion

1990 10.9 7.4 67.9 2.1 19.3 12.4

1995 39.9 25.6 64.2 9.1 22.8 33.8

1997 61.6 37.8 61.4 9.7 15.7 17.4

1999 79.0 47.4 59.5 14.4 18.2 14.8

2000 85.8 50.3 58.6 16.8 19.6 8.6

Change Trend of the Medical Expenditure Per Capital Outpatient and Inpatient (Unit: RMB)

Treatment of Person-Time

Out-Patient

Expenditure of Patient

In- Patient

Treatment expenditure Cost of Drug Treatment

expenditureCost of Drug

1990 10.9 7.4 473.0 260.6

1998 68.8 42.7 2596.8 1278.8

1999 79.0 47.4 2891.1 1363.6

2000 85.8 50.3 3083.7 1421.9

Rate of increase (%)

Average rate 90-98 25.9 24.5 23.7 22.0

Average rate 1999 14.8 11.0 11.3 6.6

Average rate 2000 8.6 6.1 6.7 4.3

Total Health Expenditure 1995-2000 Unit:RMB

Index 1995 1996 1997 1998 1999 2000

1.Total health expenditure （ 100 000 000 ）卫生总费用

2257.8 2857.2 3384.9 3776.5 4178.6 4764.0

The budgetary health expenditure by Gov.(%)

政府预算支出 17.0 16.1 15.4 15.6 15.3 14.9

Health expenditure by society （ % ） 社会卫生支出

32.7 29.6 27.7 26.6 25.5 24.5

Health expenditure by individual （ % ） 个人卫生支出

50.3 54.3 56.9 57.8 59.2 60.6

2.The total health expenditure by per capita

人均卫生总费用110.1 143.3 179.7 205.2 245.6 318.1

3 。 The percentage to GDP by health expenditure(%)

卫生总费用占 GDP%

3.86 4.21 4.55 4.82 5.10 5.33

4 。 GDP(100 000 000)

国内生产总值 58478 67885 74463 78345 82068 89404

The absolute value of the national total health expenditure and total health expenditure per capita increased in successive years

This proportion of GDP showed increasing trend, but it is still lower than that of the countries of OECD.

The percentage of the individual expenditure showed increasing, Gov. and society expenditure showed decreasing trend

The proportion of the total health expenditure in China1990-1995

0

10

20

30

40

50

60

1990 1991 1992 1993 1994 1995 1998

Government

Society

Individual

The percentage to

GDP(%)

Urban

Rural

Population%

26 .4

73.6

Maldistribution of Health Resources

29.9

70.1

Population%

1991 1997Distribution of

Resource%

80.7

19.3 46.7

53.5

Distribution of Resource%

0

1

2

3

4

5

6

1995 1996 1997 1998 1999 2000

Total Health Expenditure As Percentage of GDP

The Percentage of Total Expenditure to GDP

0

2

4

6

8

10

12

14

16

60 65 70 75 80 82 83 85 86 87 89 90 91 93 95 97 98

Percentage( %

)

CanadaJ apanUSAChi na

14.2

6.9 7.6 7.2

3.85

0

2

4

6

8

10

12

14

16

USA English Spain Japan China

1995

Comparison the proportion of health expenditure to GDP in Five Countries in 1995

Health Policy in China(1950s)

• Meet health needs of the workers, peasants and soldiers

• Put the prevention first

• Combine the Western and Chinese Traditional Medicine

• Link the health care work with the mass movement

Health Policy in China(1980s)

• Put the prevention first

• Rely on the advanced scientific progress

• Mobilize the whole society to participate in

• Equal emphasis on the Western and Chinese Traditional Medicine

• Serve for people’s health

Health Policy in China(2000s) --The 1996 Health Meeting of China’s Central Gov.

• Emphasize on the health work in the rural areas

• Put the prevention first

• Equal emphasis on the Western and Chinese traditional medicine

• Rely on the science and education

• Mobilize the whole society to participate in

• History of Public Health

• Public Health Achievements

• Public Health Challenges

Public Health in ChinaPublic Health in China

Brief History of PH in China

• Before the Eighteenth Century

• The Eighteenth –Nineteenth Century

• The 20s-30s of the Twentieth Century

• The 50s-70s of the Twentieth Century

• The 80s-90s of the Twentieth Century

Brief History of PH in China --before of the eighteenth century

• The Yellow Emperor’ s Canon Medicine – the earliest and most comprehensive theory of traditional Chinese medicine The Ancientry philosophy of PH: The best medical doctor should know how to deal a disease before it developed

• Disease involves two aspects: pathogen and body resistance, both should be considered when dealing with disease prevention.

• Holistic health: regular life, a proper diet, an appropriate exercise, harmony in mental and emotional activities

• Book on epidemic febrile diseases

• Experience of diagnosing and treating

• Western(modern) medicine into China in 1830s,

by Christian missionaries

Brief History of PH in China -- the 18th –19th century

• The western medical hospital in China, represented by Peking Union Medical College Hospital

• The first Department of Public Health within PUMC in 1921, by Dr. John B. Grant, who was the Far-East representative of RF

• A model of health-care community in Ding County, Hebei province, as an educational field of department of PH in 1928

• An early example of primary health care system was established in Ding county during 1932-1937 by Prof. Chen Zhi-qian

Brief History of PH in China -- the 20s-30s of 20th century

• Coping the public health system of the former Soviet Union in 1950s

• Setting up an anti-epidemic system in 1950s• Separate public health school from clinical

medicine in 1950s• Forming Patriotic Health Campaign, established

PHC • Barefoot doctor system in rural areas in 1960s• Red cross clinic system in urban areas in 1960s

Brief History of PH in China -- the 50s-70s of 20th century

• The great sanitary awakening

• Preventing acute infectious diseases

• Health education

• Free basic immunization

• Established three-tiered PHC network

• A war against ‘four devils’: flies, mice, mosquitoes and sparrows

• In the 1960s-1970s

controlled many serious epidemics of communicable diseases, such as cholera, plague and malaria

Brief History of PH in China -- the 50s-70s of 20th century

• The rapid development of public health in China

reform and open policy development of science and technology and

education the primary health care in China international collaboration• Established and perfected health three-tiered

network • Strengthened maternal and child health • Expanded program immunization

Brief History of PH in China -- the 80s-90s of 20th century

The Development and improvement The Development and improvement Establishment Before 18th

century

18th –19th century

20s-30s 20th century

50s-70s 20th century

80s-90s 20th century

Timeli

ne of H

istory

of public

Hea

lth

Traditional medicine of China

Western medicine

The Beginning

Year BR(%) IMR(‰) DR(‰) LE(Year)

1950 37.0 195 18.0 40.8

1960 20.9 121 25.4 49.5

1970 33.4 61 7.6 63.2

1980 18.2 47 6.3 67.8

1990 21.1 38 6.7 70.9

1999 15.32 33 6.46 72.0 (1998)

Birth rate(BR). Infant mortality rate(IMR). Crude death rate(CDR). Life expectancy(LE)

Leading Causes of Death

Order Urban Rural

1 Cancer COPD

2 Stroke Cancer

3 Heart Dis. Stroke

4 COPD Heart Dis.

5 Injury Injury

0

5

10

15

20

25

30

35

40

year

Birth Rate (‰)

36 (‰)

16.6 (‰)

Birth Rate DecreasedBirth Rate Decreased

The Incident Rate of Communicable Disease in China(1965~1998)

0

2000

4000

6000

8000

1965 1970 1975 1980 1985 1990 1995 2000

7061/ 10万

195/ 10万

发病率（ 1/10万）

30 million/year 30 thou.

40‘s 90‘s

12 million 750 thou.

Parasitic Diseases:Under Control

Patient ‘s umber

of Malaria

Patient ‘s number of Schistose

0 20 40 60 80 100

50

60

70

80

90

95

Proportion of different infectious disease cases 1965-1995 (%)

Transmitted by sex or blood

Respiratory

Gastrointestinal

Vector-borne and natural

endemic

Year

Patriotic Sanitation Campaign

Clear

environment Kill mouse

污水处理

Sewage Sanitary privy

Strengthening Health legislation- issued 9 laws, 24 rule of laws and more than 400 regulations

0

50000

100000

150000

200000

250000

300000

1952 1957 1965 1975 1980 1985 1990 1995 19990

1000

2000

3000

4000

5000

6000

7000

Number of Heal th Workers

Number of Heal th Agenci es

Development of Epidemic Prevention Institutions

283000

5900

2500

500

World Health Report 2000 Selected Indicators

Attainment of Goals达标成就

Performance效能

Health level 健康水平DALY

Responsiveness反应性水平

Fairness in financial

contribution资金捐助公正性

On level of health

按健康水平评估

Overall health system

整体效能

USA 24 1 54-55 72 37

Sweden 4 10 12-15 21 23

Japan 1 6 8-11 9 10

China 82 88-89 188 61 144

Thailand 100 33 128-130 102 47

The Experts of the World Bank Evaluate Primary Health Care in China:

“Truly, Declare of Alma-Ata in

1978 about the realization ‘Health for all by the year 2000’ by primary health care was deeply influenced by Chinese model”

• Change of PopulationChange of Population

• Urbanization and industrialization Urbanization and industrialization

• Double burdens of diseasesDouble burdens of diseases

• Behavioral and Environmental Behavioral and Environmental

• Unreasonable of allocationUnreasonable of allocation

Challenges

Trend of Age Composition Change

1999 yearChina: 0.126 billion Asia: 0.314 billion World: 0.593 billion

2050 yearChina: 0.440 billionAsia:1.239 billionWorld: 1.969 billion

0

2

4

6

8

10

12

14

16

18

1953 1964 1982 1990 1995 2000 2015

1949 total 0.58 billionAging 8%

Trend of Population and Aging （ 0.1 Billion)

2050 Aging 25%

2000 total 0.126 B

Aging 10%

2050

2015 Aging 14%

0

10

20

30

40

50

60

70

1970 1980 1990 2000 2010 2020 2030

Year

Percentage / Ratio (%)

The percentage of populationaged 65+ years 65+人口比例

The dependency ratio of theyouth 青少年抚养比

The dependency ratio of theaged 老年抚养比

The percentage of medicalvulnerable population 医学敏感人口比例多项式 (The percentage ofpopulation aged 65+ years 65+人口比例)多项式 (The dependency ratioof the youth 青少年抚养比)

多项式 (The dependency ratioof the aged 老年抚养比)

多项式 (The percentage ofmedical vulnerable population医学敏感人口比例)

The change trends of the structure of population, The change trends of the structure of population, dependency ratio and medical vulnerable population dependency ratio and medical vulnerable population

in China from 1980 to 2025in China from 1980 to 2025

Urbanization and Industrialization

• Environmental pollutionEnvironmental pollution

• Life and work stressLife and work stress

• InjuryInjury

• Immigrant Immigrant

The Natural Ecological Environment

—— Pollution

050100150200250300350400450

1998 1999Year

The sewagedischarge amount

(×108t)

DomesticsewageIndustrialsewageTotal

The comparison of the sewage discharge between 1998 and 1999

Wastewater

↗4.6%↘1.6%

↗1.5

The amount of urban refuse in China

Beijing

In 1996 the amount of urban refuse cleared and transported

In 2000

Waste residue

↗8.98%

↗ 15%~20%

1.08×108 t

1.2×108 t ~1.4×108 t

• In 1999, the coal smoke type was still the main type of air pollution in China

Waste gas The major pollutants were total suspended particulates (TSP) and sulfur dioxide

A few megalopolises were the complex type of coal smoke and automobile exhaust pollution

Double Burdens of Disease

Threats of communicable disease and

parasitic disease still exists

Chronic and non-communicable

disease growth rapidly

Threats of communicable disease and

parasitic disease still exists

Chronic and non-communicable

disease growth rapidly

Threats of Infectious Disease and Parasitic Disease Still

Exists

Threats of Infectious Disease and Parasitic Disease Still

Exists

Threats from old infectious diseases such as

Tuberculosis and hepatitis still exists

New threats from new arising communicable

diseases such as AIDS

Threats from old infectious diseases such as

Tuberculosis and hepatitis still exists

New threats from new arising communicable

diseases such as AIDS

I nf ect i on2%

I nj ury6%

NCD91%

Other1%

Other14%

NCD58%

I nj ury3%

I nfecti on

25%

1957 Year 1999 Year

Changing Trend of Case of Death In urban

0

20

40

60

80

100

120

140

160

1954 1957 1963 1975 1980 1985 1990 1995 1998

100

thou

sand

RespiratoryHeart diseas

ecerebrovascular

cancer

Metabolized

disease

Digestive disease

The prevalence and mortality rate of chronic and non-communicable diseases rises continuously

( In urban areas, 1954-1998)

Behavioral Risk Factors

SmokingSmoking

DrinkingDrinking

DirtDirt

SmokingSmoking

At present China has turned into the biggest At present China has turned into the biggest country of tobacco consumption in the worldcountry of tobacco consumption in the world

Accounting for more than 30% of the total Accounting for more than 30% of the total tobacco consumption in the whole worldtobacco consumption in the whole world

Increasing at the speed of 5.3% annuallyIncreasing at the speed of 5.3% annually

0

500

1000

1500

2000

2500

3000

3500

4000

Production

Marketing

Production and Marketing of tobacco in China

Source:The Report of Tobacco in China

It is expected that it It is expected that it will reach 47.2624 will reach 47.2624 million tons in 2000million tons in 2000

1952~1978: 1952~1978:

The annual growth The annual growth rate was 5.3% rate was 5.3% DrinkingDrinking

The statistics of the annual sales volume of drink in ChinaThe statistics of the annual sales volume of drink in China

4726.24

0500100015002000250030003500400045005000

1940 1950 1960 1970 1980 1990 2000 2010

Year

Ann

ual s

ales

vol

ume

of d

rink

(100

00 t

on)

1982~1989: 1982~1989:

The annual growth The annual growth rate was 13.3% rate was 13.3%

1990~1995: 1990~1995:

The annual growth The annual growth rate was 13.1% rate was 13.1%

DietDietThe comparison of food consumption by residents The comparison of food consumption by residents between 1991 and 1997 in the city and country of between 1991 and 1997 in the city and country of

Chongqing Chongqing municipality municipality (kg/year·person(kg/year·person))

CityCity CountryCountry

GrainGrain

↓↓117.9→71.1117.9→71.1

↘↘

250.3→245.5250.3→245.5

The prevalence of overweightThe prevalence of overweight

18.28%18.28%

The prevalence of obesityThe prevalence of obesity

2.48%2.48%

In Chinese population aged 20+In Chinese population aged 20+

OverweightOverweight

240 million240 million

ObesityObesity

More than 30 millionMore than 30 million

Obesity: BMI ≥30kg/mObesity: BMI ≥30kg/m22Overweight: BMI≥25kg/mOverweight: BMI≥25kg/m22

Social population environmentSocial population environmentNatural ecological environmentNatural ecological environmentWorking environmentWorking environmentLiving environmentLiving environment

Environments Risk FactorsEnvironments Risk Factors

The new concept of environment and healthThe new concept of environment and health

Spirit

MindBody

FamilyPersonalBehavior

Psycho-Socio-Economic

Environment

HumanBiology

PhysicalEnvironment

PersonalTime

UrbanSystem

Work

Lifestyle

Culture

Biosphere

The model of the Human Ecosystem

——Hancock and Perkins, 1985