Health inequalities in China, Hong Kong and Macau
Introduction
Despite China’s reputation as the leader of industrial development and international economy in
the East Asia, the implementation of public health policies and welfares has been insufficient to
support its vast population and wide region. According to the WHO’s statistics of population
health in 2000, China was ranked as 101 out of 191 countries for the health inequalities varied in
urban and rural areas. (Pengqian, 2010) Sustainable environment, national economy, urban and
rural difference which are very common social determinants of China’s solving poverty rate,
health access, health promotion in order to sustain public health for the great population. In the
research of “Is wealthier always healthier” (Brian Biggs, 2010), the co-effects of the growth of
GDP, poverty and inequalities have sustained a huge impact on population health positively, it
will be more resource for improving public health if a country is becoming wealthier. However,
China is still remaining as a developing country whereas China has been developing as the
greatest economy as well as developing public health promotion for its greatest population.
On the order hand, the two special administrative regions of Hong Kong and Macau under “One
country two system” which share different politic and economic structures from China.
Moreover, the GDP and income level of Hong Kong and Macau distributed more equal health
access and insurance to the population. Despite Hong Kong and Macau were highly ranked for
its population life expectancy, the disparity between the rich and the poor in society, the high
Gini coefficient, and the aging population still remain health inequalities. By contrast, the overall
life expectancy in Hong Kong was 85.0 and Macau shared 83.8 whereas the global life
expectancy only shared 73.4 in 2019. (WHO, 2019)
Health insurance
China has the greatest population in the world, it requires a large and equal amount of health care
and insurance. In China, there is 31 provinces which share difference in environment, population
density, urbanization, etc. Thus, there would be regional health inequality for different
development and governmental support in regions. So far, there is approximately 95% of
Chinese population benefiting from health insurance in public. (Radwan, 2020) Since 1949, the
Chinese government has nationalized the public health system by leading primary care to rural
area and modernizing urban health system. However, the disparity of health standard between
rural and urban areas or even coastal and inland provinces has been significantly changed since
the Chinese “Reform and Opening-up" in 1978. As a result, the medical health field has been
privatized that the majority of urban citizens has to pay the medical expenses all by themselves
whereas the rural residents cannot afford the medical expenses in urban hospital at all. Therefore,
the population would have relied on the health insurance along with the household registration
system. For now, China has provided basic health insurance for approximately 95% of the
population; however, the public health insurance usually covers about a half of the medical
expenses. Nevertheless, China's "Healthy China 2020" policy aims to reduce healthcare expenses
by mandating insurance companies to cover 70% of expenditures by the end of 2018. And the
government is making efforts to support all residents with affordable basic health services by
2020. (Yuanli Liu, 2011)
In Hong Kong, the health insurance for the population mainly focuses on public medical service
with government’s supplies. The 30% of outpatient service are provided by public hospitals
whereas the 90% of inpatient services are provided by government public hospitals. More than
95% of the income comes from government subsidies, so the individual’s out-of-pocket burden
is extremely low, and for all Hong Kong residents are treated equally. (Department of Health
HK, 2018) Although Hong Kong's medical system is famous across the world, it is riddled with
inconsistencies. The major issue is that the public system waiting times are too high and the
service efficiency is quite low. In recent years, Hong Kong has launched three health care reform
to adjust the unbalanced allocation of public and private resources including voluntary health
insurance, elderly health care voucher schemes, and public-private collaboration.
In Macau’s situation, Macau citizens can be benefited from medical insurance provided by the
government from the government, non-profit making and private medical institutions. The public
health insurance provided by the government can be divided into primary health care and
hospital medical service. In 2010, the number of people served by the health center was
approximately 530,000, and more than 80% of the residents registered at the health center,
reflecting that most residents can get basic medical insurance in Macao. (Macau Health Bureau,
2011) In terms of specialized medical services in hospitals, all Macao residents can enjoy a 30%
reduction in medical expenses. In addition, specific people such as the elderly over 65 years old,
children, elementary and middle school students, pregnant women, patients with mental illness,
infectious diseases and cancer, can enjoy free of charge of hospital medical services. Moreover,
Macau also initiated the “medical subsidy program” along with “medical voucher” in order to
support citizen’s health service in private doctors. From 2009 to 2010, the utilization rate of
medical vouchers reached 90%.
Life Expectancy
The average life expectancy of a population refers to the average number of years that people
born in the same period can expect to survive under a certain age-specific mortality rate. The
average life expectancy of the population is a basic indicator that comprehensively reflects the
level of health. As shown in table 1, the overall life expectancy among China, Hong Kong and
Macau are continuously raising by years through the co-development in economy, social welfare
and public health. However, the rising life expectancy may also lead to aging population issue as
government need to raise extra expenditure to elderly health care. It may create a health
inequality to aging population with different level of pension and post-health care.
Region
China
Hong
Kong
Macau
Gender
Male
Female
Male
Female
Male
Female
2015
73.7
78.2
81.2
87.3
79.9
86.3
2016
74.0
78.5
81.3
87.3
80.2
86.4
2017
74.3
78.8
81.7
87.7
80.3
86.4
2018
74.5
79.0
82.2
87.6
80.6
86.6
2019
74.7
79.6
82.3
88.1
80.8
86.7
Table 1. Life expectancy (*years) at birth in China, Hong Kong and Macau, 2015-2019
Morality rate
Mortality is one of the important indicators to measure the health of the population, and it is a
comprehensive reflection of the cultural and health standards of a region. In table 2, the
consistency of morality rate among three regions reflected that public health has been effectively
promoted to sustain population health. Even though there was a substantial decline of mortality
rates across lower and higher socioeconomic strata, there was a widening of inequality between
the two which means the health of whole population had improved in the context of rapid
economic growth whereas the benefits were spread unequally. This was true for all-cause
mortality and all but one of the particular reasons investigated, such as ischemic heart disease,
other cardiovascular disease, cancers, respiratory illness, other medical and external causes.
Region
2015
2016
2017
2018
2019
China
7.07
7.04
7.06
7.08
7.07
Hong Kong
6.4
6.4
6.2
6.4
6.5
Macau
3.1
3.4
3.3
3.1
3.4
Table 2. Morality rate in population in China, Hong Kong and Macau, 2015-2019
Poverty
Poverty is a major source of health inequalities at all stages of life, with widespread poor health
consequences that compound over time. There appears to be a multifaceted relation between
health and poverty - i.e., poverty is a cause of poor health and being in poor health can also cause
poverty. China’s poverty mainly focused on rural area that the poverty line was per capita annual
net income is less than 2,300 Chinese Yuan which shared 3.1% of population was under poverty.
(China Bureau of Statistics, 2017) Hong Kong’s poverty line focused on the per household
income per resident and shared with 7.3% of poverty rate in total population. (HK Census and
Statistics Department, 2021) Even though Macau has not shared any poverty measurement, there
is an existing extremely welfare gap between the rich and poor. Living in poverty means having
insufficient income to access a range of services and resources essential to health including
decent housing, sufficient nutritious food, health care and participation in social and community
life that has led to health inequalities in environment and resource.
Conclusion and policy implementation
The health inequalities existed among China, Hong Kong and Macau which mainly reflected in
health insurance for public health and poverty in population. The public health in three regions
was not only associated with socioeconomic background, but also health promotion and health
service. The increasing economy also raised up the life expectancy; however, there would be a
regional and social class difference without sufficient investment in health resources and primary
health care. The policy maker should focus on how to sustain equal distribution of health with
more complete health indicators, public health systems of uprising economy and life expectancy
and distribution of primary health and hospital services within regional and resource difference.
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