Brandon Fisher Nov 10 2019

A Brief History of Healthcare in China

medical-system-in-chinaGiven the physical size and population of China, the development of a modern healthcare system has been a long process. Understandably, that process has involved both progress and setbacks as new phases of development have been implemented.

After 1949, implementation of the Cooperative Medical System (CMS) across China was overseen largely by the central government and had little private involvement. The CMS consisted of three tiers, the first of which was ‘barefoot doctors’ whose focus was on basic hygiene and traditional Chinese medicine. Outpatient clinics at the township level, staffed by government-subsidized medical professionals, made up the second tier who together with barefoot doctors assumed responsibilities for most common illnesses. For seriously ill patients, the third tier county hospitals provided care.

Combined with public health campaigns, the CMS made astonishing strides over the next 30 years across China. Life expectancy almost doubled from 35 to 69 years and infant mortality was slashed from 25% in 1949 to 4% in 1980.

The system-wide shakeup caused by the agricultural reforms of the 1980s saw healthcare become unaffordable for many rural poor. However, in 2003 the New Rural Cooperative Medical System was implemented, which reformed the formerly fully government-funded CMS to a system funded by a mix of private and public sources. While the effectiveness of the system varies across China on a county level, and patients must cover up to 70% of the costs if treatment requires a visit to a large modern city hospital, the central government has announced a new Healthy China 2020 program which aims to provide universal healthcare access and treatment to all of China by 2020.  The hallmarks of the plan echo those implemented in many western countries by focusing on policies in nutrition, agriculture, food, and social marketing.

These programs, as in numerous western societies, focus on the urban population most significantly affected by changes brought by rapid modernization and the effects it has on dietary choices, inactivity and obesity, although with a Chinese twist that focuses on change through local communities. 

In addition to these reforms, China is also undergoing a complete reform to its medical insurance programs, dominated in the past by two primary systems that served state employees (GIS) and individuals (LIS) on a self-insurance basis. The old system left approximately 700 million rural Chinese without medical insurance or the means to pay for rising medical care costs.  Under the new system, those in lower and middle income brackets will receive healthcare subsidies where in the past there were no subsidies at all. While the effectiveness of the new system has yet to be fully evaluated, China, like the rest of the developed world, has recognized that healthcare costs are at the front and center of future budgetary concerns and prevention remains the key to long terms success. Recent implementation of country-wide smoking bans in public places are evidence of government efforts aimed at reducing one of the primary causes of death in a country with one third of the world’s smokers.

China’s central government faces a similar bubble in its healthcare pipeline that the US faces in terms of its baby boomers that will come of age in the next 10-15 years. In China however, it was not a post-WWII surge in births and the subsequent generational decline in birthrates that caused the bubble. The One Child Policy implemented by Deng Xiao Ping in 1979 is said to have prevented 400 million births roughly within the same 20 year period in which the US saw the baby boomers have far fewer children than their parents. Analysts point to economic development as a major contributing factor to the decline of birthrates in China, along with the One Child Policy. At the same time, different economic circumstances in the US, namely stagnant wage growth and the move to double income households, caused a decline in the number of children born.

Though different in their evolution, these bubbles in both the Chinese and American populations mean that at a point in the not-so-distant future, both systems will face significant challenges in the provision of adequate healthcare for their rapidly aging populations.

For expat readers of this article, its relevance to the issue of relocating to China may seem tenuous, given the access to world class healthcare they will enjoy while on assignment in the Middle Kingdom. It is valuable, however, in all aspects of your new life overseas, that you understand the context of the society that you will be living in and the privileged place you will occupy while enjoying those services. One of the keys to a successful relocation to a country like China is to develop at least a cursory understanding of the lives of those around you. Whether it’s your ayi, driver, handyman or the average person you pass on the street, that understanding – however superficial – is a handy tool when the seemingly insurmountable frustrations of daily life make you want to pack up and go home. Just look to your left and then your right and the empathy you feel will make your own frustrations melt away.