Social Inequalities & Health in
Urban China
Beatriz Carrillo Garcia
China Studies Centre, the University of Sydney
Beatriz.Carrillogarcia@sydney.edu.au
Health Reform Phases in the PRC
FIRST PHASE 1949 – 1978
• Ambitious public health campaign to provide
universal basic and affordable health services
• The principle of egalitarianism drives policy
Urban China:
• Social insurances (health, old age) and other
benefits (lifetime employment, housing,
schooling, etc.) provided through SOEs and
collective enterprises (State supported)
• Health insurance covered dependants
Rural China: RCMS, funded collectively, basic medical care
Economic Reform and Health
Life expectancy
1949 – 35 years
1979 – 67 years
1990 – 70 years
2000 – 72 years
2013 – 74.8 years
Urbanization
(% urban population)
1978 – 17%
1990 – 26.41%
2000 – 36.22%
2012 – 52.57%
SECOND PHASE OF HEALTH REFROMS 1980-1998
Policy discourse: Egalitarianism portrayed as negative (i.e.
equal but poor)/ Inequality: incentive to spur innovation
and economic growth
Demographic and epidemiological transition:
• Declining fertility (one child policy) and rapid population
ageing
• Rapid urbanization: mainly due to rural-to-urban migration
• Higher Incidence of NCDs (linked to both aging and rapid
urbanization)
Changes to government funding of public hospitals and
clinics
• Government spending as a % of THE decreases; market
mechanisms introduced into health sector
• Public hospitals increasingly depend on fee-for-services
(emphasis on expensive curative services and drugs
• 1995 – drug sales accounted for as much as 60% of hospital
revenue
• Rising health care cost and out-of-pocket expenses for users
Changing Government Funding
Year
THE as
% of
GDP
Govt. Ex. as
% THE
Private Ex.
as % THE
Government
Health Ex. as % of
total Govt. Ex.
Social Health
Insurance Funds
as % of total Govt.
Ex.
1980
3.15
78.8
21.2
36.2
1998
4.4
41.8
58.2
12.9
55.8
2006
4.6
40.7
59.3
9.9
57.3
2009
4.6
50.1
49.9
10.3
66.3
2011
5.2
56
44
Third Phase of Health Reforms
THIRD PHASE 1998-2008
Reinstate the role of the State in health provision – build a more equitable
harmonious society
Build social health insurances alongside social assistance
1998 Urban Employee Basic Medical Insurance (UEBMI)
1993 – just over 50% of urban residents had social health insurance (employees +
dependants
2003 – 42% of urban employees had social health insurance (UEBMI)
Rural migrant workers not covered
2003 New Rural Cooperative Medical Scheme reestablished
2005 Medical Financial Assistance (MFA) scheme (tied to social assistance - dibao)
2007 Urban Residents Basic Medical Insurance (URBMI) piloted (established
nationally in 2010)
2011 covered 74% of targeted population (children, students, elderly or otherwise not
employed)
Upfront payment and low reimbursement rates(average 45% - URBMI)
Fourth Phase of Health Reforms
FOURTH PHASE 2009-2015
• Substantial increase in government funding for social
health insurances and the MFA
• Raising reimbursement rates; curbing medicine prices
• Real safety net for catastrophic health expenses
(Western regions, rural population, urban poor)
• 2013 National Health & Family Planning Commission
(relaxation of one child policy)
Meet the challenges of:
• Population aging (60+ - 13% in 2010, 24% - 2030) and
NCDs
• Soon to peak working age population
Socio Economic Status and Health
Outcomes in Urban China
National Health Services Survey [NHSS]
China Health and Nutrition Survey [CHNS]
• The degree to which health is associated with income
(inequality) more than tripled between 1991 and 2006
(Baeten et al 2012)
• Region is a major determinant of health (where a city
is located)
• Differential income mobility by age, gender and region
accounted for 70-90% of evolution in income-related
health inequalities
• Higher incidence of chronic disease amongst urban
elderly across the socioeconomic gradient, worst
among women over 55
Socio Economic Status and Health
Outcomes in Urban China
The old working class:
Life course cumulative disadvantage: sent down to the
countryside (Cultural Revolution), laid-off during
reform period, loss of status, new urban poor
Health utilization (inpatient care) remains low despite
URBMI coverage; out-of-pocket expenses remain high
(for all income groups)
Those who experienced downward mobility more likely to
report worse health (especially mental health
problems)
Socio Economic Status and Health
Outcomes in Urban China
Rural migrant workers:
Healthier than the urban population (younger)
Their hukou status not as significant as their SES and
demographic characteristics
But hukou restricts their access to health resources (e.g.
insurances)
Low social status – stigma: limited social capital
Social isolation, poor adjustment to urban society –
higher rates of depression have been observed amongst
this population
Harmonious Society & Health Equity
• Return of the discourse of equality and social
justice
• Important role of the State in redistribution
(provision of public goods)
• Will income inequalities be halted?
• Or will social insurance and safety nets be
band-aids for the more vulnerable populations,
rather than equalising programs?