Elsevier

The Lancet

Volume 379, Issue 9818, 3–9 March 2012, Pages 833-842
The Lancet

Review
Early appraisal of China's huge and complex health-care reforms

https://doi.org/10.1016/S0140-6736(11)61880-1Get rights and content

Summary

China's 3 year, CN¥850 billion (US$125 billion) reform plan, launched in 2009, marked the first phase towards achieving comprehensive universal health coverage by 2020. The government's undertaking of systemic reform and its affirmation of its role in financing health care together with priorities for prevention, primary care, and redistribution of finance and human resources to poor regions are positive developments. Accomplishing nearly universal insurance coverage in such a short time is commendable. However, transformation of money and insurance coverage into cost-effective services is difficult when delivery of health care is hindered by waste, inefficiencies, poor quality of services, and scarcity and maldistribution of the qualified workforce. China must reform its incentive structures for providers, improve governance of public hospitals, and institute a stronger regulatory system, but these changes have been slowed by opposition from stakeholders and lack of implementation capacity. The pace of reform should be moderated to allow service providers to develop absorptive capacity. Independent, outcome-based monitoring and evaluation by a third-party are essential for mid-course correction of the plans and to make officials and providers accountable.

Introduction

China unveiled its ambitious health-care reform plan in April, 2009, and committed to spending an additional CN¥850 billion (about US$125 billion) in the ensuing 3 years, with the goal of provision of affordable and equitable basic health care for all by 2020. The reform is anchored in five interdependent areas: expanding coverage to insure more than 90% of the population, establishing a national essential medicines system to meet everyone's primary needs of medicine, improving the primary care delivery system to provide basic health care and to manage referrals to specialist care and hospitals, making public health services available and equal for all, and piloting public hospital reforms.1, 2, 3

Is China on the path to achieving its stated goal? In this report, we assess strategies adopted in the 2009–12 phase of the reform and their progress, examine gaps in policy priorities, discuss challenges to the reforms, and provide recommendations for the way forward.

Section snippets

Goals, priorities, and strategies

Although the pursuit of universal health coverage is shared by countries worldwide, China's priorities and strategies are indicative of its prereform environment and the events that led to the reform. Before announcing health-care reform, the Chinese Government was faced with widespread public discontent stemming from unaffordable access to health care, major financial risks associated with out-of-pocket medical expenses, and growing inequalities in access to health care and health status

Progress in implementation

China monitors progress of its reform by setting targets for each level of government to meet. For the 2009–12 phase, most targets are input-based, including finances, enrolment, training sessions, and buildings. Few targets are based on outcomes of the reform, such as health improvement.

Between 2009 and the end of 2011, China will have spent more than ¥1·4 trillion on health (up from ¥3594 million in 2008), a third from central government and two-thirds from local governments, compared with

Achievements, gaps, and challenges

By examining the reform priorities against the problems and their causes in the prereform system, the reforms are mostly headed in the right direction. Accomplishing nearly universal insurance coverage in a short time is remarkable. Although initially shallow, insurance benefits are planned to gradually increase in scope and depth. These are major achievements and would have been impossible without the government's leadership. China now needs to address remaining gaps and challenges to bring

Policy recommendations

Health-care reform is complex and dynamic. China's reform goals and systemic strategies are exemplary for other nations that pursue universal health coverage. Despite its size and heterogenous environment, China has made big strides towards providing its population with affordable and equitable access to basic health care in the past few years. It has overtaken many developing nations and achieved nearly universal insurance coverage in less than a decade and has begun to establish some

Search strategy and selection criteria

We based our Review on reports (international and domestic), official documents, and published work. We searched PubMed, Google Scholar, EconLit, Medline, the Social Science Research Network, and China Knowledge Resource Integrated Database for articles and research published since 2000; we also included cross-references, landmark or highly regarded reports, and work suggested by peer reviewers. We restricted our search to works published in English or Chinese and used the search terms

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