Equity in Health and Health Care: The Case of China Gail Henderson, PhD.
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Transcript of Equity in Health and Health Care: The Case of China Gail Henderson, PhD.
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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85977
398512
157108
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13972449234
23534
199733
300466
0
100000
200000
300000
400000
500000
600000
700000
800000
900000
1000000
1985
1986
1987 19
8819
8919
9019
9119
9219
9319
9419
9519
9619
9719
9819
9920
00Year
Cases
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]