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
Recurrent Health Expenditures
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
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/Chin
aFood/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 Consumption
in China by Commodity, 1961-1996 (kcal/person/day)
Overweight Prevalence Among Adults 20-59y
Participating in the 1991, 1993 & 1997 CHNS surveys
25%
24%
21%
20%
1991
1993
1997
17%
% Overweight
17%
16%
15%
14%
15%
14%
13%
11%
10%
9%
8%
14%
11%
9% 9%
8%
13%
8% 8%
7%
5%
0%
Rural
Urban
<40
Among non-overweight adults aged 20-59 in 1991.
Women pregnant or lactating were excluded.
40-49
50-59
60-69
70+
Source: Popkin
AND increase in stunting in some rural areas, 1987-- 1992
300m Chinese Have No Access to Safe Water
China 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 China
opened its door
to the West
Economic reforms
were introduced in
the early 1980s
The economic and cultural
environment changed
Sexuality and the behavior of
young individuals changed
Prostitution re-emerged
Drug traffic from SE Asia
STDs/HIV
Annual Reported STDs in China
1985-2000
1000000
900000
859040
Cases
836655
800000
700000
632307
600000
500000
400000
362654
300000
100000
0
398512
300466
175528240848
200000
49234
432626
139724
85977 157108
23534
199733
Year
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?
Measuring Health Care Equity:
Answer depends on the measure selected
• 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
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
1993
1998
2003
Urban
73%
56%
55%
Rural
16%
13%
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 interregional inequality in health?
– Yes, clear socioeconomic gradient in life expectancy
(64.5 vs. 74.5 years) [but in 1975, it was 59 vs. 72]