Equity in Health and Health Care: The Case of China: Equity in Health and Health Care: The Case of China Gail Henderson, PhD
China the “Sick Man of Asia”: China the “Sick Man of Asia” “An eminent Chinese official stated that in Shensi province at the beginning of 1931, three million persons had died of hunger in the last few years, and the misery had been such that 400,000 women and children had changed hands by sale… There are districts in which the position of the rural population is that of a man standing permanently up to the neck in water, so that even a ripple is sufficient to drown him.”
-- RH Tawney, 1932 survey
China the “Sick Man of Asia”: China the “Sick Man of Asia” Life expectancy 35
9 of 10 leading causes of death were acute, infectious diseases
Dysentery, typhoid, cholera, schistosomiasis
TB accounted for 10-15% of all deaths
STDs 4th most common admitting diagnosis in urban hospitals
As many as 1/4 of children died before age one
Infant mortality rate (IMR) 200-250/1000 live births in first year
80% of these deaths were from tetanus
Health care facilities limited to urban areas
Slide5: Mao’s “Long March” to 1949 Liberation
Mao’s Revolution 1949-1976: Mao’s Revolution 1949-1976 Communist Party controls government and economy at every level
Transformation to socialist economy
focus on heavy industry
wage control, job assignments by the state
collectivized agriculture and urban workplaces
ban private economic activity
limit consumer goods and foreign imports
Household registration severely limits migration
Focus on community services, large standing army that can be mobilized for public works
Health Care is Declared a Right: First National Health Conference 1950: Health Care is Declared a Right: First National Health Conference 1950 Health care must be directed at the masses of laboring people
Unify traditional and western medicine
Emphasize prevention of disease
Utilize military-style mass campaigns to achieve these health care goals
Slide8: George Hatem
“The People’s Doctor”
with Mao Zedong
George Hatem, MD, 1910-1988: George Hatem, MD, 1910-1988 Born in Lebanon, 1932 UNC graduate
MD in Geneva, China for tropical medicine
Worked at Shanghai dermatology/ VD practice (100,000 prostitutes in 1930s/40s)
Met Mao in 1936 on Long March, military physician until Liberation in 1949
After Liberation, went to Beijing to work on STDs and leprosy – stayed 50 years
Mass Campaign to Eradicate STDs: Mass Campaign to Eradicate STDs Training of para-professionals and public health personnel
Mass screening and treatment
syphilis, gonorrhea, nongonococcal urethritis
Propaganda
mass media, mandatory education meetings, political messages in entertainment events
Complete elimination of prostitution
in context of 1950 Marriage Law which gave women legal and property rights
Interview at UNC School of Medicine by Dr. James Bryan, 1978: Interview at UNC School of Medicine by Dr. James Bryan, 1978
China’s Health Care System: China’s Health Care System “This system is characterized by widely distributed, relatively inexpensive, technologically simple health services and by a lack of orientation toward hospital care and more sophisticated alternatives for those who can or may be willing to pay for medical care.”
-- Robert Blendon, NEJM 1979
Slide13: Created 55,000 Commune Hospitals, >2000 County Hospitals
Slide14: “The Barefoot Doctors of China” Filmed in 1975
Health Achievements of the Maoist Era: Health Achievements of the Maoist Era Doubled life expectancy to ~ 65 years in 1975
Reduced IMR to ~ 50
Public health infrastructure
improved prenatal care, lowered birth rate
reduced childhood infectious diseases
85%+ had some form of medical insurance
Epidemiologic transition
leading causes of death shifted to non-communicable disease in all areas
Slide17: Urban-Rural Differentials Not Eliminated Life Expectancy in 1975:
Guizhou 59, Shanghai 72
Rural public health programs varied in resources and coverage
Continuing problems with infectious and parasitic diseases, malnutrition Recurrent Health Expenditures
Post-Mao Era, 1979-present: Post-Mao Era, 1979-present “Open door” policy
De-collectivization and decentralization undermined collective welfare system
Party control maintained
Remarkably rapid but uneven economic growth
9% growth per year
Increase in income inequality (Gini coefficient)
Enormous social change
Health in the Post-Mao Era: Health in the Post-Mao Era Underlying population growth dynamics
Declining birth and death rates
Changing age structure
Internal migration (120 million ‘floating’)
Changes in diet, tobacco use
Modernization & privatization of health care
Investment in urban, high tech medicine
Profits driving medicine and public health
1980-90, government funding to public health declined from 100% to 30-50%
Changes in burden of disease
Continuing rise in non-communicable diseases (cancer, stroke, cardiovascular disease)
Re-emergence of STDs and other infectious diseases
Population Growth: Population Growth When the People’s Republic of China was founded in 1949, it had a population of 540 million. Only three decades later its population was more than 800 million. This unprecedented population increase has created a strong population momentum that is now driving China’s population growth despite already low levels of fertility. Within the next three decades, China's population will increase by another 260 million (to 1,560,000,000)
Slide22: Population Growth, Crude Birth and
Death Rates, 1949 - 1996 GLF: 24 million excess deaths
Aging Population: Aging Population http://www.iiasa.ac.at/Research/LUC/ChinaFood/data/anim/pop_ani.htm
Slide24: Migration Between Provinces, 1985-1990 Dark green provinces have gained; dark brown provinces have lost.
Slide25: Food Calories Available for Human Consumption
in China by Commodity, 1961-1996 (kcal/person/day)
Slide26: Overweight Prevalence Among Adults 20-59y Participating in the 1991, 1993 & 1997 CHNS surveys Among non-overweight adults aged 20-59 in 1991.
Women pregnant or lactating were excluded. 8% 8% 9% 8% 14% 9% 17% 7% 9% 8% 13% 14% 24% 11% 11% 13% 17% 21% 14% 15% 16% 0% 5% 10% 15% 20% 25% Rural Urban <40 40-49 50-59 60-69 70+ % Overweight 1991 1993 1997 Source: Popkin AND increase in stunting in some rural areas, 1987-- 1992
Slide27: 300m Chinese Have No Access to Safe Water China Daily, March 23, 2005 The country is ready to launch a long-term project to deal with the lack of clean water, a headache threatening the health of some 360 million rural people, or about one third of the whole rural population.
"By the end of 2020, we are going to reach the goal of basically providing safe drinking water for all rural people," Zhai said.
Tobacco: Tobacco World’s largest smoking population
320 million, ¼ smokers in the world
60% of men and 4% of women smoke
40-50% of male physicians smoke
World’s largest passive smoking population
460 million (55% are non-smoking women)
1 million premature deaths in 2000
expect over 2 million per year by 2025
3% of health care budget Source: Hu Tehwei, UC Berkeley, 2005
Re-emergence of STDs and Illegal Drug Use : Re-emergence of STDs and Illegal Drug Use In 1979 China
opened its door
to the West
Economic reforms were introduced in the early 1980s STDs/HIV The economic and cultural environment changed
Sexuality and the behavior of young individuals changed
Prostitution re-emerged
Drug traffic from SE Asia
Annual Reported STDs in China 1985-2000: 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Year Cases Annual Reported STDs in China 1985-2000
Greater Freedom, Mobility and Inequalities Produce Three HIV Epidemics: Greater Freedom, Mobility and Inequalities Produce Three HIV Epidemics 1. IV drug users (IDUs) in border provinces and southern China: Drug traffic from the ‘golden triangle’ of SE Asia flourished in 1980s & 90s
2. Blood donors in 7 central provinces: Farmers with few resources sold blood, government failed to close down worst offenders and covered it up
3. Commercial sex workers and the influence of other STDS—both had been completely controlled under communist system, now fostering HIV epidemic
“Voices of HIV” Documentary, 2005: “Voices of HIV” Documentary, 2005 World AIDS Day 2004: President Hu Jintao shakes hand with AIDS patient in You’an Hospital in Beijing
Assessing Health Disparities: Assessing Health Disparities What is the question?
Comparing populations (urban-rural, gender?)
Comparing health status (what diseases?)
Comparing access to health care (what kind?)
Comparing provision of public health services?
Over time?
What kinds of data?
Individual, household, community level?
Quality of the data—measurement issues
Self-reports on morbidity vs. mortality data
What is omitted?
Measuring Health Care Equity: Answer depends on the measure selected: Access to Treatment
Geographic proximity
Cost as a barrier to care/ insurance
Services relevant to particular group (MCH)
Quality of Care
Health care providers
Technology, drugs, and services
Public Health Services
Financing issues
Surveillance and immunization Measuring Health Care Equity: Answer depends on the measure selected
For Example, Cost of Care: For Example, Cost of Care Medical costs up substantially since the reforms, but medical prices are lower in poorer rural areas than in wealthy rural or urban areas.
Despite this, a much higher non-use rate of medical care is reported in poor rural areas, and outpatient utilization in poor rural areas is more sensitive to income change than in non-poor areas. Why?
Affordability depends on price and income, and income growth has been much slower in rural areas.
Lack of insurance is related to lower use of care
Insurance Coverage in Urban and Rural Areas, 1993-2003: Insurance Coverage in Urban and Rural Areas, 1993-2003
Urban Rural
1993 73% 16%
1998 56% 13%
2003 55% 21%
2003: SARS Focused Attention on China’s “Failing Health Care System”: 2003: SARS Focused Attention on China’s “Failing Health Care System” The old rural cooperative health system gone…new one is under-funded. Only ~ 20% of farmers have medical insurance
YET, the medical and public health infrastructure (along with the army!) was mobilized to combat and defeat this threat to public health
“China: Increasing Health Gaps in a Transitional Economy” Liu et al.: “China: Increasing Health Gaps in a Transitional Economy” Liu et al. Does economic reform and growth improve health status for all?
Yes, in most cases
Have economic reforms lead to greater gender inequality in health?
Yes in IMR, less than expected female advantage in life expectancy (plus increased urban-rural gender differences)
Have economic reforms lead to greater inter-regional inequality in health?
Yes, clear socioeconomic gradient in life expectancy (64.5 vs. 74.5 years) [but in 1975, it was 59 vs. 72]