Medicine in China
中国医疗体系
An Introduction
Tom Xu, PhD, Family & Community Medicine, Lubbock
Yan Zhang, PhD, LAc, Family & Community Medicine, Lubbock
Weimin Gao, PhD, Environmental Toxicology, TTU/TTUHSC, Lubbock
April 13, 2011
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The population
The system
A tour at an urban hospital in Southwest China
Role of Traditional Chinese Medicine (TCM)
Medical education and research
Current and future collaborations
Overview
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China
USA
1,341 million
0.6%
1.06
307 million
1%
0.97
0-15 years
16-59 years
60+ years
Urban
21%
68%
11%
42%
21%
62%
17%
81%
High School Graduates
15%
87%
Total Population
Population Growth
Male:Female
Population
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China
USA
15+ yo Mortality (/1,000)
Infant Mortality (/1,000)
Life Expectancy at Birth
116
109
20
7
73
78
72 – M
75 – M
75 – F
80 – F
Leading Causes of Death
Cancers
Heart dz
Stroke
Cancers
Respiratory dz
Stroke
Heart dz
Respiratoary dz
Health
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< 5 yo Overweight
< 5 yo Underweight
Prevalence of Adult
(15+) Tobacco Use
Per Capita Adult
Alcohol Consumption
(in L, pure alcohol)
China
USA
9.2%
6.8%
7%
1.1%
31.8%
23.9%
5.2
8.6
Health
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DTP for 1 yo
HepB for 1 yo
w/ Sustainable Drinking
Water – Rural
w/ Sustainable Drinking
Water – Urban
w/ Sustainable
Sanitation – Rural
w/ Sustainable
Sanitation – Urban
China
USA
93%
91%
96%
92%
81%
94%
98%
100%
59%
99%
74%
100%
Public Health
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Hospital Beds (/10,000)
Physicians (/10,000)
Nurses and Midwives
(/10,000)
Ratio of Nurses and
Midwives to Physicians
Pharmaceutical
Personnel (/10,000)
China
USA
22
14
32
26
10
94
0.7
3.7
3
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Health Care Resources
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GNP Per Capita (PPP
int’l $)
Population Living on
<US$1/day
% of Health Cost in
GDP
Per Capita Health Cost
(PPP int’l $)
Per Capita Health Cost
at exchange rate (US$)
China
USA
7,740
44,260
9.9%
–
4.7%
15.2%
315
6,350
81
6,350
Health Care Cost
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% Paid for by Gov’nt
% Gov’nt Spending in
Health in All Gov’nt
Spending
Per Capita Gov’nt
Spending in Health
(PPP int’l $)
% Paid for by Private
% Out-of-Pocket in
Private $ (co-pay)
China
USA
38.8%
45.1%
1%
21.8%
122
2,862
61.2%
54.9%
85.3%
23.9%
Payers of Health Care
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The Three-Tier System
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• “Barefoot doctors”
• Paramedical, some primary care and prevention
• 2 doctors/1,000 population
Village Medical Centers
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Hospital-based
10-30 low acuity beds
Primary role: outpatient clinic
Population coverage: 10,000-30,000
Most qualified staff: assistant doctors
Village + Town Medical Centers = Rural Collective
Health System
• Care for ~ 60% of the entire Chinese population
Town Medical Centers
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• 50-300 beds
• Population coverage: 200,000-600,000
• Most qualified staff: senior doctors with a 5-year medical
school degree
• Major specialties
• Imaging: XR, CT, MRI
• Routine labs
• Inpatient + outpatient
The County Hospitals
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200-3,000 beds
In all major cities
All subspecialties
All routine imaging, scopes, dialysis, some with cutting-edge
varieties
Specialty labs
ICUs + designated ERs
Inpatient + outpatient
Most have branches throughout the city
Affiliation with academics
Only a few hospitals are privately owned
Urban Hospitals
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• All insurance plans have characteristics of managed care, such
as choice limit and tiered copays.
• Employees (and their family) of government, state-owned
enterprises and universities: coverage with deductibles and
copays
• Urban employees of non-state-owned enterprises: uninsured,
private insurance, or social welfare insurance if qualified
• Urban unemployed: uninsured or social welfare insurance if
qualified
• Lack of credit system  no money/insurance, no treatment,
even in the ERs.
Insurance In Urban China
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• After the collapse of the old state-funded system in 1980s
(including the barefoot doctor program), many struggle to
pay medical bills or simply forego care.
• 2005 New Rural Co-operative Medical Care System
(NRCMCS)
• Annual cost ¥50 (~$7): central government ¥20, provincial
government ¥20, and participant ¥10.
• >80% of rural population have signed up
• Tiered copay: town hospitals (20-30%), county hospitals
(40%), urban hospitals (70%)
Insurance in Rural China
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• Lack of general acceptance of primary care
• No gatekeeping physicians. Similar to Fee-For-Service
era in the US. No access barriers to specialists.
• Prevalent self-referral
• Rarely any discussion of medication compliance,
prevention, and health behavior during a visit due to
highly pressured workload (50 to 100+ patients per day)
Primary Care
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• “Reputable” pharmacies reside inside hospitals
• More expensive but less likely to have expired drugs or simply
packed flour powder
• Some prescription medications are only available at hospitals
• Street pharmacies are hit-or-miss
• Can be a physician’s additional source of income
• Commissioned by certain manufacturers
• Bonus indirectly tied to pharmacy revenue: different departments in
the same institution
• Medical Reform Plan (2009-2011): promotes the separation of
hospitals and pharmacies, and privatization of pharmaceutical
products
Pharmaceuticals
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An Urban Hospital
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City Population: 11 million
Provincial capital
# of beds: 2,300
# of specialties and subspecialties: 72
# of outpatient + ER visits: 3 million
# of hospital d/c: 68,000
# of operations: 54,000
An Urban Hospital
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Registration/Appt.
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To Clinics
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Waiting Room
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Ophthalmology Clinic
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Price Check / Cashier
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Labs
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Pharmacy
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Outpatient Prices
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Inpatient Prices
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Dialysis
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Emergency Room
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Emergency Room
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Trauma Bay
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“Cafeteria”
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A County Hospital
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A County Hospital
TRADITIONAL CHINESE
MEDICINE (TCM)
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• Traditional Chinese Medicine (TCM) is a comprehensive
system for the assessment and treatment of acute and
chronic disorders, as well as preventative health care and
maintenance.
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Acupuncture and Moxibustion
Herbal Medicine
Tuina (Medical Massage)
Qigong and Meditation
Diet and Lifestyle
What is TCM?
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• TCM is under the administration of State Administration of
TCM and Pharmacology.
• TCM is now available to 75% of the areas in China.
• In 2005, the output value of TCM amounted to RMB110.3
billion (about $13.8 billion), accounted for a quarter of the
overall output value in China's medical industry.
• The net yield and profits of TCM production is much higher
than the average for the country's medical industry.
• The total TCM market in China will rise to $23.5 billion in
2015.
TCM Practice and Market
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Integrative Medicine in
China
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• Combination of WM and TCM in diagnosis and
treatment
• applying disease identification in biomedicine and
syndrome differentiation in TCM, and
• applying treatment with biomedicine drugs and TCM herbal
formula
• Currently, across the nation:
• 300 IM hospitals,
• 30 IM departments in medical universities,
• more than 100 IM-specific institutes.
IM Clinical Practice Mode
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• Clinical practice in TCM hospitals usually includes IM
approaches.
• Diagnosis: patients obtain both WM diagnosis and TCM
syndrome differentiation.
• Treatment: patients mainly obtain herbal medicine.
However, they may also receive some WM treatment
depending on their condition.
IM in TCM Hospitals
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• IM approaches are included in clinical practice in many
WM hospitals.
• Clinical practice in the WM hospital usually follows a
biomedical model.
• There is a department of TCM in most WM hospitals in
China,
• TCM doctors are asked to participate in the treatment for
some patients (as requested by patients or by WM doctors).
IM in WM Hospitals
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Recognition of IM in China, 2004
100.00%
91.21%
93.52%
90.00%
80.00%
71.20%
70.00%
65.45%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
MP consider IM as best
dianogistic methods
MP consider IM as best
treatment methods
Pt favored IM hospitals
Pt favored IM therapies
Recognition of IM
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TCM and Health
Investment
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Harmony between humanity and nature
Harmony of physical and mental health
Balance of Yin and Yang
Prevention of disease
Promotion of health and longevity
Key Concepts
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Challenges
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MEDICAL EDUCATION
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Workforce
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Medical School Graduates
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Admission & Enrollment
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Gao T, et al. Medical education 1999; 33: 768-773
• High school graduates are admitted by the central
education system based on their scores of the national
entrance examination and ranking by students and
schools.
• About 550 secondary medical-pharmaceutical schools
• Over 120 medical-pharmaceutical universities
• About 30 colleges of traditional Chinese medicine
Admission & Enrollment
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Secondary (vocational) schools: 3 years
Universities: 5 to 8 years
No licensing examinations
No centralized accreditation body for medical schools
and universities.
Licensing & Accreditation
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Curriculum – 5 Years
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Schearz MR, et al. Medical teacher 2004: 26(3):215-222
Curriculum – 7 Years
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Schearz MR, et al. Medical teacher 2004: 26(3):215-222
• Year 1: general natural and social sciences: taught in the
university (e.g. Peking University)
• Years 2–3: medical sciences
• Years 4–6: clinical rotations
• Year 7: sub-internship in specialized fields
• Dissertation is required for graduation
Curriculum – 7 Years
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5 vs. 7 Years
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Schearz MR, et al. Medical teacher 2004: 26(3):215-222
• Leading to the degree of Doctor of Medicine (MD):
medical scientists and educators
• Been in Peking Union Medical College (PUMC) since
1917, founded by the Rockefeller Foundation.
• 4 parts:
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Premed: 2.5 years
Basic medical sciences: 1.5 years
Clinical medicine and rotations: 3 1/3 years
Research: 2/3 year
Curriculum – 8 Years
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RESEARCH COLLABORATIONS
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Most Respected TCM and WM
Research Institutes
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• Collaboration with Chinese Academy of Medical
Sciences & Peking Union Medical College
• Characterization of Chinese Herbal Medicine in Treating Diabetic
Patients (revision)
• Use of Compound Chinese Medicine in the Treatment of Lung
Cancer (Current Drug Discovery Technology, 2010, pp32-36)
• Curcumin modulates eukaryotic initiation factors in human lung
adenocarcinoma epithelial cells (Molecular Biology Reports,
2010, pp3105-3110)
Research Collaborations
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• Collaboration with Cancer Institute & Hospital /
Chinese Academy of Medical Sciences
• Cancer early detection and prognostic prediction using
biomarkers
Research Collaborations
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• Collaboration with Nanjing Medical University, School
of Public Health
• Environmental and human health
• Cancer molecular epidemiology
• Collaboration with Jinling Hospital, Nanjing, Jiangsu
Province
• Detection of RASSF1A promoter hypermethylation in
serum from gastric and colorectal adenocarcinoma patients
Research Collaborations
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