1. Government and Health Care in China Ling Li China Center For Economic Research at Peking University

2. Chinese health care system When health care was lead by government, during the period between 1950 to 1978, China had many achievements in health field to be proud of rapid and large reductions in mortality rate, despite China’s low income per capita at the time create a low cost, wide coverage primary health care model When health care is based on market mechanism After 20 years of economic reform, China’s healthcare system has not improved as well as the economy has. Instead, it has deteriorated in many aspects Patients, providers and government are all unsatisfied Medical costs are escalating rapidly

3. The existing problems Rapid increase in health care expenditure Increase share of personal income spent on health care Decrease in government health input Decrease in health insurance coverage Limited access to health care service High medical expenses Poor service qualities Health Inequality Regional Economic

4. Rapid increase in health care expenditure （ 1978-2004 ） Source: Health Statistic Yearbook

5. The Growth of NHE and GDP （ 1978-2004 ） Source: Health Statistic Yearbook, 2003; Statistic Yearbook, 2003

6. Decreased share of govt. exp. and increased share of out-of-pocket （ 1990-2004 ） Source: Health Statistic Yearbook, 2003

7. Increased of Gov. Exp. on Health but decreased share of total Gov. Exp. Source: Health Statistic Yearbook, 2005

8. China ’ s out-of-pocket share is high by regional standards Source: World Health Organization. The World Health Report 2002. Reducing risks. Promoting healthy lives. Geneva: The World Health Organization, 2002.

9. Out-of-pocket spending — an ever larger share of HH expenditure Source: China Statistic Yearbook

10. Big city Middle- size city Small city Rural 1Rural 2Rural 3Rural 4 inpatient 199334.0933.8753.4747.9563.1561.1467.72 199853.1258.4370.7763.8054.1270.2669.38 200364.435.674.877.674.975.573.6 Outpatient 19933.212.409.5815.1021.3619.5524.42 199836.6923.4842.9630.0931.6742.2938.72 200330.832.74729.233.941.249.1 Source ： The national health service survey, 1993 、 1998 、 2003 % of people who should see a doctor choose not to do so because of the cost

11. # of people who should see a doctor choose not to do so because of the poor service quality Source ： The national health service survey, 1998 、 2003

12. Regional disparity of health resource allocation: Rural Vs Urban Per capita NHE

13. Health finance in China Urban health insurance models are developed along the three stated goals by the central government: wide insurance coverage for basic services; establishment of individual savings account; social insurance (social pooling account). Low insurance coverage in rural areas Voluntary new cooperative medical scheme (NCMS) since 2003 Less generous than urban scheme (50 vs. 700 RMB), so large copayments and out-of-pocket payments for uncovered care

14. Health insurance coverage — stubbornly low Source ： The national health service survey, 1993 、 1998 、 2003

15. Insurance coverage lower among the poor Source: Akin JS, et al. Did the distribution of health insurance in China continue to grow less equitable in the nineties? Soc Sci Med 2004;58(2):293-304.

16. The poor get less — inpatient utilization in rural China Source: Gao J, Tang S, Tolhurst R, Rao K. Changing access to health services in urban China: implications for equity. Health Policy Plan 2001;16(3):302-12.

17. Health service delivery in China 1980s reforms restricted budget support to providers Providers paid fee-for-service (even typically by insurers), no incentive to contain cost Regulated prices are distorted Low (or negative) margins on basic care High margins on high-tech care & drugs Providers shift demand to high-tech care & drugs Asymmetric information makes hard to monitor appropriateness of care Result is over-supply of care 18-20% of all expenditures for appendicitis & pneumonia estimated to be unnecessary (33% in case of drugs) Rapid and seemingly unjustified increase in Cesarean section Drug exp. now 52% of total health spending (15-40% elsewhere) Sources: Liu, X. and A. Mills, "Evaluating payment mechanisms: how can we measure unnecessary care?" Health Policy Plan, 1999. 14(4): pp. 409-13. Cai, W., et al., "Increased cesarean section rates and emerging patterns of health insurance in Shanghai, China." American Jnl of Pub Hlth, 1998. 88(5): pp. 777-780. Lei Haichao, Hu Shanlian, Li Gang, 2002

18. Structure of Hospital revenue per patient （ general hospitals within health sector ） Source: Health Statistic Yearbook Revenue per outpatient （ yuan ） Revenue from medicine （ % ） Revenue from medical examinati on （ % ） Revenue per inpatient （ yuan ） Revenue from medicine （ % ） Revenue from medical examinati on （ % ） 199010.967.919.3473.355.125.7 199539.964.222.81667.852.830.4 199868.862.116.42596.849.228.1 19997959.918.22891.147.229.7 200085.858.619.63083.746.131.7 200193.657.720.13245.545.531.2 200299.655.4283597.744.436.7 2003108.254.728.53910.744.736.1 2004118.052.529.84284.843.736.6 2005126.952.029.84661.543.936.0

19. Public health in China Decentralization Most spending financed by county governments Poor counties have fewer resources for health & lower capacity, despite facing tougher health challenges & spillover effects associated with public health programs Lack of clarity on roles of different levels of government

20. The consequence of local financing: poorer provinces spend less on public health despite tougher challenges Source: Disease control expenditure data from Gong, X. (2003). Institutional Analysis of Chinese Public Health. Chinese Health Economics(11), 9-11. TB incidence data are for 2003 and are from China Health Statistics Yearbook 2004 (p.210). MOH defines TB incidence as reported active TB cases in a given year in a given region per 100000 population.

21. China’s unbalanced development— 1960-80 vs. 1980-2000 Source: Wang Shaoguang, 2003 图：中国人口平均预期寿命 femalemale Ave. 0 10 20 30 40 50 60 70 80 196019611962196319671970197219741982198719901992199719982001 去年去年去年去年 Chinese Life Expectancy

22. Life Expectancy （ year ） under-five mortality （ ‰ ） Increase of Life Expectancy Decrease of under- five mortality 1980199819801998 China 687042312-11 Australia 74791155-6 Hong Kong 74791135-8 Japan 7681845-4 Korea 67732696-17 Malaysia 67723085-22 New Zealand 73771354-8 Singapore 71771246-8 Sri Lanka 687334165-18 Source: Wang Shaoguang, 2003

23. China’s unbalanced development— 1960-80 vs. 1980-2000 Source: World Bank. World Development Indicators 2002. Washington DC: The World Bank, 2002., UNICEF. Progress since the World Summit for Children: A Statistical Review. New York: UNICEF, 2001.

24. Reasons of the problems above Government failure the absence of government role to insure people’s basic health care needs the weakness of the public health system the invalidation of the three-tiered health system the lack of government regulations. Market failure Asymmetric information Insurance market—selection problems Health care market—FFS encourages over-provision Externalities & public goods

25. China ’ s Health Care Reform China’s commitment to balanced development Health is the goal of economic and social development Government should take the responsibility to protect people’s basic health needs Government takes a leading role in health care sector, private market acts as a supplement