Equity in Health and Health Care: The Case of China

Gail Henderson, PhD

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”

• 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

Mao’s “Long March” to 1949 Liberation

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 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

George Hatem“The People’s Doctor”with Mao Zedong

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

• 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

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

Created 55,000 Commune Hospitals, >2000 County Hospitals

“The Barefoot Doctors of China” Filmed in 1975

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

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

• “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

• 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

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)

Population Growth, Crude Birth and Death Rates, 1949 - 1996

GLF: 24 million excess deaths

Aging Population

• http://www.iiasa.ac.at/Research/LUC/ChinaFood/data/anim/pop_ani.htm

Migration Between Provinces, 1985-1990

Dark green provinces have gained; dark brown provinces have lost.

Food Calories Available for Human Consumptionin China by Commodity, 1961-1996 (kcal/person/day)

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+

% O

verw

eigh

t

1991 1993 1997

Source: Popkin

AND increase in stunting in some rural areas, 1987-- 1992

300m Chinese Have No Access to Safe WaterChina 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

• 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

In 1979 In 1979 China China opened its door opened its door

to the Westto the West

Economic reforms Economic reforms were introduced in were introduced in

the early 1980sthe early 1980s

STDs/HIVSTDs/HIV

The economic and cultural environment changed

Sexuality and the behavior of young individuals changed

Prostitution re-emergedDrug traffic from SE Asia

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Annual Reported STDs in China 1985-2000

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

World AIDS Day 2004: President Hu Jintao shakes hand with AIDS patient in You’an Hospital in Beijing

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?

• 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

• 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

Urban Rural

1993 73% 16%

1998 56% 13%

2003 55% 21%

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.

• 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]