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Original Research

Expanding public health in China: an empirical analysis of healthcare inputs and outputs

F. Deng a,c, J.H. Lv b, H.L. Wang c, J.M. Gao d,*, Z.L. Zhou d

a Xi'an Jiao Tong University Health Science Center, Xi'an, China b Central Hospital of Baoji City, Baoji, Shaanxi Province, China c Baoji Centre for Disease Control and Prevention, Baoji, China d Xi'an Jiao Tong University, School of Public Policy and Administration, Xi'an, China

a r t i c l e i n f o

Article history:

Received 11 March 2016

Received in revised form

18 August 2016

Accepted 12 October 2016

Available online 22 November 2016

Keywords:

Public health

China's health reform

Input and output

Empirical analysis

* Corresponding author. Xi'an Jiao Tong Univ E-mail address: [email protected]

http://dx.doi.org/10.1016/j.puhe.2016.10.007 0033-3506/© 2016 The Royal Society for Publ

a b s t r a c t

Objectives: The Chinese Government claims that China's health policy is primarily focused

on prevention. However, this does not appear to be the case. Researchers with an interest

in China's health policy may be aware that the Chinese Government launched a health

reform in 2009 to improve the health status of the entire population by 2020.1 This health

reform has been in place for 7 years, and only 4 years now remain to achieve the overall

objectives by 2020. This study analyzed the main inputs and outputs of China's health

reform in order to identify the main problems and highlight the major challenges. It is

hoped that this study will provide some reference for health reform in China and other

developing countries.

Study design: This study focused on health, with human resources and healthcare costs as

the main input indicators, and 2-week prevalence of illness and prevalence of non-

communicable diseases as the main output indicators. By longitudinal comparison of

real data from 2009 to 2014, the effects of China's health reform were analyzed to identify

the main challenges, enabling suggestions to be made for future reference.

Methods: This was a retrospective analysis of empirical data. Data were collected between

2009 and 2014 as follows: (1) data on the distribution of healthcare professionals were

collected from the Statistical Bulletin of China's Health Development, issued by the Na-

tional Health and Family Planning Commission every year between 2009 and 2014; (2) data

on government health expenditure were obtained from the Annual National Public Fiscal

Expenditure Data, released by the Financial Ministry of the People's Republic of China from

2009 to 2014; (3) data on the prevalence of chronic diseases, 2-week prevalence of illness,

residents' medical service demands, and utilization of health services were obtained from

the Fourth and Fifth National Health Care Surveys in 2008 and 2013; and (4) data on total

healthcare expenditure, medical expenditure and out-of-pocket payments were obtained

from the 2015 China Statistical Yearbook.

Results: From 2009 to 2014, China's healthcare human resources were distributed primarily

in hospitals that focus on providing treatment. By 2014, 62.5% of the health professionals

ersity Health Science Center, No. 76 Yanta west, Xi'an 710061, China. Fax: þ86 02982656259. (J.M. Gao).

ic Health. Published by Elsevier Ltd. All rights reserved.

p u b l i c h e a l t h 1 4 2 ( 2 0 1 7 ) 7 3 e8 474

and technical personnel were distributed in hospitals. From 2009, the Chinese Government

spent more money on health care than previously, with approximately 67% spent on

disease treatment and 14.19% spent on disease prevention. However, the 2-week preva-

lence of illness increased by 5.2 percentage points, and the prevalence of chronic diseases

increased by 9 percentage points. Meanwhile, residents' out-of-pocket payments for health

care were as high as 50.61% of the total healthcare expenditure and were particularly high

in rural areas.

Conclusion: China should adjust the direction of its health reform as soon as possible to

focus on improving health status rather than treatment of disease. In the future, as China's

population ageing trend intensifies, China must take effective measures or the country's

non-communicable disease rates will continue to increase. To meet this challenge, China's

health reform should take effective measures to control the rising trend of the incidence of

non-communicable diseases. First, China should focus on the core goal of its health reform

policy, which is disease prevention. Second, China should focus on strengthening public

health systems to effectively prevent and control key epidemic diseases. Third, China

should increase the number of public health personnel, improve the level of education and

training of public health personnel and increase the input of funds into the field of public

health as soon as possible.

© 2016 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Introduction

The global population is ageing rapidly due to a decline in

fertility and an increase in life expectancy.2 Longevity is our

precious wealth.3 Older people are a wonderful resource for

their families and communities, and they contribute to the

formal and informal workforce. Our elder population is a re-

pository of knowledge and can help us to avoid making the

same mistakes made in the past. Indeed, if we can ensure that

older people live healthier as well as longer lives, if we can

make sure that we are stretching life in the middle and not

just at the end, these extra years can be as productive as any

others. The societies that adapt to this changing demographic

can reap a sizeable ‘longevity dividend’ and will have a

competitive advantage over those that do not. However, the

extent of these human and social resources, and the oppor-

tunities available to each of us as we age, will be heavily

dependent on one key characteristic: health. If people are

living these additional years in good health, their ability to do

the things they value will have few limits. However, if these

additional years are dominated by a decline in physical and

mental capacities, the implications for older people and so-

ciety may be much more negative.4 Unfortunately, there is

little evidence that older people are healthier than their par-

ents at the same age, although it is generally believed that life

extension is accompanied by a health extension.2 Many

health problems faced by the elderly are related to chronic

diseases, particularly non-communicable diseases (NCDs).

Most NCDs can be prevented or delayed by adopting healthy

behaviours.2 However, prevention and control of NCDs is not

just an issue for elderly people; healthy ageing begins at an

early stage of the health behaviour.5 In other words, preven-

tion and control of NCDs requires the whole population to act

together.

Major changes are associated with development of the

economy and society, including the spectrum of human dis-

eases, population age structure, life behaviours and environ-

mental factors. NCDs represent the first factor to threaten the

health of human beings and become a public health problem

of global concern.6 Data show that 20% of non-infectious

diseases occur in high-income countries, and 80% of the

deaths due to non-infectious diseases occur in low- and

middle-income countries. Deaths from chronic diseases in

low- and middle-income countries are more serious.7 As the

leading cause of death globally, NCDs were responsible for 38

million (68%) of the world's 56 million deaths in 2012. More than 40% (16 million) of them were premature death in people

aged less than 70 years. Almost three-quarters (28 million) of

all NCD deaths and the majority (82%) of premature deaths

occur in low- and middle-income countries.8

China, the country with the largest population in the world

(>1.3 billion), has made remarkable progress over the past 20 years, both economically and in terms of public health,

including increasing life expectancy by one-third, decreasing

childhood mortality rates by more than one-half, and a three-

fold increase in the number of hospital beds.9 However, China

still faces challenges in many aspects of its healthcare sys-

tem.10 Therefore, China launched a healthcare reform in 2009

that aimed to establish a basic universal healthcare system for

the population of China. By 2013 (the midpoint), China's health reform had led to several achievements. Over 90% of residents

across the nation were covered by basic health insurance.11

However, patient dissatisfaction was high, and conflicts be-

tween patients and doctors or hospitals had increased.12

Furthermore, the prevalence of chronic diseases was

increasing with the ageing population.13 In common with

other countries, China is facing the challenge of an ageing

population; the population aged �65 years accounted for 7% of the total population in 2000,14 and this increased to 10.1% in

p u b l i c h e a l t h 1 4 2 ( 2 0 1 7 ) 7 3 e8 4 75

2014.15 China's economic growth and development outcomes over the past 30 years are enviable. However, societal devel-

opment in China lags behind the world's most economically developed countries.16 The United Nations Development

Programme announced the results of the human develop-

ment index in 2010, and China ranked 89th among 169 coun-

tries.17 The health-adjusted life expectancy of Chinese

residents is 66 years, which is 10 years less than the life ex-

pectancy seen in a group of 20 major developed countries.18

It is the general aim of China's health reform to increase the health status of Chinese residents by 2020.19 With only 4

years remaining to achieve this goal, the effect of China's health reform is worth further research. It has been reported

that the health level of China's residents was at the forefront of developing countries in 201220 and was generally in the

range of middle- and high-income countries in 2015.21

Are these reports really true? We should analyze these

findings scientifically. First, health is not only the absence of

disease but also the sum of physical, mental and social

health.22 Second, after careful inspection of the original report,

the main bases for the above-mentioned indicators are

increased per-capita life expectancy, decreased maternal

mortality and decreased infant mortality.20,21 Can these in-

dicators reflect the true health status of the residents? Third,

life expectancy can reflect the survival time of the population,

but not the quality of life. China's per-capita life expectancy was only 35 years in 1949. At that time, the impact of infectious

diseases on per-capita life expectancy was up to 70%.23 Sub-

sequently, the Chinese Government implemented the national

patriotic health campaign and other major disease prevention

and control actions. Average life expectancy in China

increased to 67.9 years in 1981,20,23 and then entered a slow

growth period reaching 75.8 years in 2014.20,21 Fourth, over the

past 30 years, the study and application of population health

status evaluation, which is based on the comprehensive study

of population health, has been advancing rapidly in developed

countries and international organizations.24e29 It compre-

hensively considers death, disease and other non-fatal health

outcomes information for a population using a single mea-

surement of population health status on behalf of the overall

population.27 Summary measures of population health can be

divided into expected health and health disparity of two types

of index; the former is also known as ‘healthy life expectancy’.

Sanders29 proposed the concept of ‘effective life years’ in 1964,

and Sullivan30 proposed the concept of disability-free life ex-

pectancy. Katz et al.31 proposed the concept of active life ex-

pectancy (ALE) in 1983. ALE is an important indicator to assess

the health status of the elderly and is based on the self-care

ability of the elderly.31 Hyder et al.32 discussed the disease

burden of Ghana in 1998, and proposed ‘healthy life years’. In

2000, the World Health Organization (WHO) proposed the use

of ‘disability-adjusted life expectancy’ (DALE) for population

health indicators, and the use of the Sullivan method to

calculate DALE for all 191 countries.33 In 2001, WHO proposed

changing DALE to ‘health-adjusted life expectancy’.34 The

global average life expectancy of newborns was 71.4 years in

2015, which is 5 years higher compared with those born in

2000. However, the health-adjusted life expectancy of new-

borns was only 63.1 years in 2015.35 In Chinese cities, including

Beijing,36 Shanghai,37 Zhejiang38 and Chongqing,39 research

has found a large gap between healthy life expectancy and life

expectancy. Health is the foundation of life extension, but the

extension of life is not necessarily healthy. Fifth, China has

controlled the rates of infectious diseases, maternal mortality

and infant mortality at lower levels than ever. The People's Republic of China Infectious Disease Prevention law stipulates

that the 39 key infectious diseases are required to be reported.

These infectious diseases are divided into three categories (A,

B and C) and include 39 types of specific infectious diseases,

which are the basic common infectious diseases in China.40

According to statistics, the mortality rate from ‘legal’ infec-

tious diseases in China (per 100,000 statutory infectious dis-

eases) was 1.22, the maternal mortality ratio (per 100,000 live

births) was 21.7, and the infant mortality rate (per 1000 live

births) was 8.9 in 2014.41 In 2012, the number of deaths due to

non-infectious diseases accounted for 87% of all deaths in

China, whereas infectious, maternal, perinatal and nutritional

disorders accounted for only 5% of all deaths in China.42

Methods

Selection of evaluation index

In China, health reform inputs include government attention,

policy preferences, increasing expenditure for health and

increasing professional health personnel. However, the main

objective data that can be measured are health expenditure and

healthpersonnel.Accordingtothesourceofexpenditure,health

expenditure mainly includes government, social and personal

investment. According to the direction of flow of health expen-

diture, that expenditure mainly includes disease treatment, and

disease prevention and control. In other words, China's health expenditure is mainly spent on medical institutions (disease

treatment) and public health institutions (disease prevention).

The outputs of China's health reform include outpatient visits, hospitalization, amount of reimbursement for medical

expenses and number of public health services. Although

these indicators are well documented, they do not represent

the core index. The core goal of China's health reform is to improve the health of residents, rather than just to solve the

problem of disease treatment. Since health reform was

introduced in China, with more attention focused on quality

of life, NCDs have become the primary healthcare factor in

China. Considering data availability, the authors chose to use

the prevalence of NCDs and 2-week prevalence of illness as

key indicators to evaluate the health status of residents to

evaluate the core outputs of China's health reform. Fig. 1 shows the input and output model of China's health reform.

Data source

Data for this study were collected from the following public

resources:

(1) Data on the distribution of healthcare professionals

were obtained from the Statistical Bulletin of China's Health Development issued by the National Health and

Family Planning Commission every year between 2009

and 2014.

Input of China’s health reform

Input of expenditure

Input of personnel

Hospital Health insurance Community health Public health

Hospital Community health Public health

Output of China’s health reform

Prevention

Cure

Health

Fig. 1 e The input and output model of China's health reform.

p u b l i c h e a l t h 1 4 2 ( 2 0 1 7 ) 7 3 e8 476

(2) Data on government health expenditure were obtained

from the Annual National Public Fiscal Expenditure

Data released by the Financial Ministry of the People's Republic of China from 2009 to 2014.

(3) Data on the prevalence of chronic diseases, 2-week

prevalence of illness, residents' medical service de- mands and utilization of health services were obtained

from the Fourth and Fifth National Health Care Surveys

in 2008 and 2013.

(4) Data on total healthcare expenditure, medical expen-

diture and out-of-pocket payments were obtained from

the 2015 China Statistical Yearbook.

Definitions

In China, healthcare human resources include medical and

healthcare professionals (e.g. physicians, physician assis-

tants, dentists, obstetricians, registered nurses, pharmacists,

physiotherapists, optometrists) and healthcare-associated

professionals who support implementation of health care,

including public health administrators, medical educators,

medical research scientists and other support staff who work

in hospitals.

Healthcare human resources are allocated to hospitals,

primary care facilities and public health institutes (PHIs).

Hospitals in China are organized as a three-tier system (pri-

mary, secondary and tertiary institutions) according to the

hospital's ability to provide medical care and medical educa- tion, and to conduct medical research.9 Primary care facilities

include township healthcare clinics in rural districts, and

community healthcare clinics and service centres in urban

areas. PHIs are non-profit organizations that improve the

public's health by fostering innovation, leveraging resources and building partnerships across sectors, including govern-

ment agencies, communities, the healthcare delivery system,

media and academia.

Total healthcare expenditure includes government

expenditure, social expenditure and out-of-pocket payments

made by the population. Government expenditure is expen-

diture incurred by central and local government authorities,

including spending on health care and population and family

planning, subsidies to health insurance, and health adminis-

tration costs. Social expenditure is expenditure incurred by

social funds, including spending on social health insurance,

private health insurance, sociomedical assistance and dona-

tions, and administration costs. Out-of-pocket payments are

healthcare costs that are not reimbursed by any type of in-

surance scheme, including deductibles, coinsurance and

copayments for covered services, plus all costs for services

that are not covered. Out-of-pocket healthcare payments per

capita were calculated as the sum of total healthcare expen-

diture of the population divided by the number of people. The

social health insurance scheme in the Chinese healthcare

system includes a new rural cooperative medical scheme

(NCMS), urban resident basic medical insurance (URBMI), and

urban employee basic medical insurance (UEBMI).

Indicators

(1) Two-week prevalence of illness refers to the number of

diagnosed patients among subjects during a 2-week

survey, divided by the total number of subjects in the

survey.

(2) Chronic disease is defined as any NCD that typically

lasted for �1 year and required ongoing medical atten- tion and/or limited activities of daily living. The preva-

lence of chronic disease refers to the number of patients

suffering from chronic conditions within 6 months of

the survey in the total population of that year.

(3) Annual average number of visits was calculated as the

total number of visits for the year/population for that

year.

(4) Annual average in-hospital rate was calculated as the

total number of patients discharged from hospital in the

year/total population for the year � 100%. (5) Percentage of out-of-pocket healthcare payments per

capita out of total healthcare expenditure was calcu-

lated as out-of-pocket healthcare payments per capita/

out-of-pocket healthcare payments per capita þ social insurance expenditure (NCMS þ URBMI þ UEBMI) � 100%.

(6) Out-of-pocket healthcare payments per capita as a

percentage of average annual household living con-

sumption expenditure per capita was used as a proxy

indicator to estimate the financial burden of health care

placed on the population. Annual household living

consumption expenditure per capita was defined as

total consumption expenditure for daily life including

food, clothing, housing, education, health care, trans-

portation and so forth.

Results

Healthcare resource allocation during healthcare system reform from 2009 to 2014

Healthcare human resources In China, health workers are all staff members who work in

health institutions. Health institutions include hospitals, PHIs

p u b l i c h e a l t h 1 4 2 ( 2 0 1 7 ) 7 3 e8 4 77

and grassroots medical and health institutions (including

township hospitals, village clinics, urban community health

service centres and community health service stations).

Health workers are divided into health professional and

technical personnel, and administrative logistics manage-

ment service personnel. Health professional and technical

personnel are those who have professional health knowledge

and are engaged in healthcare services in health professional

technical posts. This group includes all types of physicians,

docimasters, pharmacists and nurses. As shown in Table 1,

more than half of these professionals work in hospitals, over

one-third work in primary care facilities and approximately

9% work in PHIs. Most importantly, the allocation of health

professional and technical personnel changed unidirection-

ally between 2009 and 2014. Approximately 5% of medical and

healthcare professionals and 4% of healthcare-associated

professionals migrated from primary healthcare facilities to

hospitals or PHIs. There were no significant changes in the

number of professionals in PHIs. Among them, the number of

medical and healthcare professionals was 1.4-fold higher than

the number of healthcare-associated professionals, and this

did not change significantly between 2009 and 2014 (1.4- vs

1.35-fold), as shown in Table 1.

Healthcare financial resources Change in total health expenditure and composition from 2009 to 2014. From 2009 to 2014, total healthcare expenditure in China increased approximately two-fold from 1.75 to 3.53

trillion RMB. All sources of expenditure, including government

expenditure, social expenditure and out-of-pocket healthcare

payments by the population, increased significantly (2.20-,

2.18- and 1.72-fold, respectively), as shown in Table 2. More-

over, the percentage of government expenditure out of total

expenditure increased from 27.5% to 30%, the percentage of

out-of-pocket payments decreased from 37.5% to 32%, and the

percentage of social expenditure increased from 35.1% to

38.1%. In 2009, the percentage of government expenditure was

slightly more than one-quarter of total expenditure.

Components of government healthcare expenditure from 2009 to 2014. As shown in Table 3, government healthcare

Table 1 e Healthcare resource allocation during healthcare sys

Year Medical and healthcare professionals

Total workers

Hospital Primary care facilities

Public health institutio

n % n % n %

2009 778.1 395.8 50.9 315.2 40.5 60.1 8.6

2010 820.8 422.7 51.5 328.2 40.0 62.5 8.5

2011 861.6 452.7 52.5 337.5 39.2 64.1 8.3

2012 911.6 493.7 54.1 343.7 37.7 67.0 8.2

2013 979.0 537.1 54.9 351.4 35.9 82.6 8.4

2014 1023.4 574.2 56.1 353.7 34.6 87.5 8.5

Data source: Statistical Bulletin of China's Health Development, issued by 2009 and 2014. Unit: 10,000. a Healthcare-associated professionals are health professionals and healt

pharmacists, nurses and so forth.

expenditure increased over two-fold from 399 to 926 billion

RMB. Fig. 2 depicts the four categories that accounted for the

majority of the expenditure (approximately 80e90% of the

total), including hospitals, primary care, public health care

and social basic medical insurance. The 6-year growth trends

of these four components of government healthcare expen-

diture are shown in Fig. 2. The same four components as

percentages are shown in Fig. 3. Social basic medical insur-

ance has always been the main component of government

healthcare expenditure, and this increased rapidly over two-

fold in terms of absolute spending, accounting for over half

of government healthcare expenditure. From 2009 to 2014,

although the Chinese Government's direct investment in hospitals decreased from 18.6% to 14.8%, China's basic medi- cal insurance funds mainly go to hospitals. In total, 65% of

health expenditure by the Chinese Government is on hospi-

tals, 15% is on public health care and 10% is on primary care

(Table 3).

Achievements of healthcare system reform from 2009 to 2014

Two-week prevalence of illness and prevalence of chronic diseases In China, the data on 2-week prevalence of illness and prev-

alence of NCDs came from an analysis report of a national

health service survey performed every 5 years. The data on 2-

week prevalence of illness came from the Chinese Fifth Na-

tional Health Service Survey, conducted in 2013. The popula-

tion reporting 2-week prevalence of illness was 24.1% in 2013,

which represented a 5.2 percentage point increase compared

with the Fourth National Health Service Survey in 2008.43 The

population aged �15 years reporting prevalence of NCDs was 33.1% in 2013, which was 9 percentage points higher than in

2008.43

Healthcare service utilization rate As shown in Table 4, the overall annual number of patient

visits increased from 54.9 billion visits per year in 2009 to 76.0

billion visits per year in 2014. Adjusted for population, the

average annual number of clinic visits per person also

tem reform from 2009 to 2014.

Healthcare-associated professionalsa

ns Total

workers Hospital Primary

care facilities Public health institutions

n % n % n %

553.5 320.0 57.8 183.3 33.1 46.6 8.4

587.6 343.8 58.5 191.4 32.6 48.7 8.3

620.3 370.6 59.7 196.3 31.6 49.8 8.0

667.6 405.8 60.8 205.2 30.7 53.2 8.0

721.1 442.5 61.4 213.8 29.6 60.9 8.4

759.0 474.2 62.5 217.7 28.7 63.2 8.3

National Health and Family Planning Commission every year between

h technical personnel, including all types of physicians, docimaster,

Table 2 e Contribution of China's healthcare financial resources from 2009 to 2014.

Year Expenditures

Total Government % Social % Out-of-pocket %

2009 1754.2 481.6 27.46 615.4 35.08 657.1 37.46

2010 1998.0 573.2 28.69 719.7 36.02 705.1 35.29

2011 2434.6 746.4 30.66 841.6 34.57 846.5 34.77

2012 2811.9 843.2 29.99 1003.1 35.67 965.6 34.34

2013 3166.9 954.6 30.14 1139.4 35.98 1072.9 33.88

2014 3531.2 1057.9 29.96 1343.8 38.05 1129.5 31.99

Data source: China statistical yearbook, 2015. Unit: billion RMB (¥).

Table 3 e Components of Chinese Government's healthcare expenditure from 2009 to 2014.

Year Government healthcare expenditure

Hospitals Primary care Public health care Social basic medical insurance

RMB RMB % RMB % RMB % RMB %

2009 399.4 74.2 18.6 39.5 9.9 29.3 7.3 189.2 47.4

2010 480.4 87.6 18.2 44.8 9.3 76.9 16.0 222.8 46.4

2011 643.0 94.0 14.6 61.4 9.6 111.7 17.4 325.1 50.6

2012 724.5 101.3 14.0 86.3 11.9 110.2 15.2 365.7 50.5

2013 828.0 115.7 14.0 91.8 11.1 120.6 14.6 429.4 51.9

2014 926.3 137.1 14.8 93.8 10.1 131.4 14.2 483.5 52.2

Data source: Annual National Public Fiscal Expenditure Data released by the Financial Ministry of the People's Republic of China from 2009 to 2014. %, percentage of government healthcare expenditure. Unit: billion RMB (¥).

0

100

200

300

400

500

600

700

800

900

2009 2010 2011 2012 2013 2014

Social Basic Medical Insurance

Public Healthcare

Primary Care

Hospitals

RB M

(b ill

io n)

Fig. 2 e Flow of government expenditure on health.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2009 2010 2011 2012 2013 2014

Social Basic Medical Insurance

Public Healthcare

Primary Care

Hospitals

% o

f t ot

al e

xp en

di tu

re

Fig. 3 e Proportion of the flow of government expenditure on health.

p u b l i c h e a l t h 1 4 2 ( 2 0 1 7 ) 7 3 e8 478

Table 4 e Healthcare service demands and utilization rate.

Year Annual patient visits (billions)

Annual clinic visits per person (times)

Annual hospital discharges (million people)

Hospital admission rates (%)

2009 54.90 4.20 132.50 9.90

2010 58.40 4.34 141.74 10.50

2011 62.70 4.63 152.98 11.30

2012 68.90 5.10 178.12 13.20

2013 73.10 5.40 192.15 14.10

2014 76.00 5.60 204.41 14.90

Data source: Statistical Bulletin of China's Health Development, issued by National Health and Family Planning Commission every year between 2009 and 2014.

p u b l i c h e a l t h 1 4 2 ( 2 0 1 7 ) 7 3 e8 4 79

increased (from 4.2 visits in 2009 to 5.6 visits in 2014). The

overall annual number of patients discharged from hospital

increased from 133 million in 2009 to 204 million in 2014. The

hospital admission rate increased significantly from 9.9% in

2009 to 14.9% in 2014. The total annual number of patients

discharged from hospital increased from 132 million in 2009 to

204 million in 2014, corresponding to the hospitalization rate

that increased from 9.9% to 14.9%.

Out-of-pocket healthcare payments per capita In China, healthcare expenditure can be divided into two main

categories: basic medical insurance from government funds

and out-of-pocket payments by individuals. Other resources

are available as supplements, including social medical aid and

commercial healthcare insurance, as shown in the data from

the Chinese Financial Ministry and the Chinese Insurance

Regulatory Commission.44,45

As shown in Table 5, China spent 1.8 trillion, or 5.15% of its

gross domestic product (GDP), on health care in 2009. This had

increased to 3.5 trillion by 2014, but the percentage of GDP had

increased only slightly to 5.56%. Out-of-pocket payments by

individuals increased from 0.7 trillion in 2009 to 1.2 trillion in

2014. Furthermore, as the largest part of the ‘healthcare

spending pie’, its share as a percentage of total healthcare

expenditure decreased from 64.9% in 2009 to 51.6% in 2014.

The majority of healthcare expenditure went on basic medical

insurance, and these funds increased significantly from 355

billion to 1102 billion. Other contributions came from social

insurance expenditure (NCMS þ URBMI þ UEBMI), which also

Table 5 e Contributions of healthcare expenditure.

Year Total healthcare expenditure

(trillion RMB [¥])

Healthcare expenditure in GDP (%)

Out-of-pocket payments (billions RMB [¥])

NCM (billio RMB

2009 1.75 5.08 657.1 92.3

2010 2.00 4.89 705.1 118.

2011 2.43 5.03 846.5 171.

2012 2.81 5.26 965.6 240.

2013 3.17 5.39 1072.9 290.

2014 3.53 5.55 1129.5 289.

Abbreviations: NCMS, new rural cooperative medical scheme; URBMI, ur

medical insurance.

Data source: China statistical yearbook, 2015.

increased: NCMS increased from 92 billion to 289 billion;

URBMI increased from 41 billion (in 2011) to 144 billion; and

UEBMI increased from 263 billion to 670 billion.

Financial burden of health spending by household Table 6 shows the average annual household living con-

sumption expenditure per capita, the out-of-pocket health-

care payments per capita, and the financial burden of health

care placed on the population from 2009 to 2013. The absolute

spending levels for living consumption expenditure and out-

of-pocket healthcare payments increased significantly for

both urban and rural residents. On average, healthcare ex-

penses accounted for approximately 7% of the household

budget for urban residents, and this remained virtually un-

changed over the 5 years from 2009 to 2013. However, for

residents living in rural areas, healthcare expenses accounted

for approximately 8% of the household budget in 2009, and

this increased significantly in 2013 by approximately 2 per-

centage points. The reader should note that the corresponding

data for 2014 did not have the same statistical calibre; thus,

Table 6 does not show corresponding data for 2014.

Discussion

An objective fact: China's public health team is very weak

In China, hospitals are mainly responsible for the treatment of

disease. Primary care facilities not only undertake general

S ns [¥])

URBMI (billions RMB [¥])

UEBMI (billions RMB [¥])

Basic medical insurance (billions RMB [¥])

Percentage of out-of-pocket healthcare

payments per capita out of

total healthcare expenditure (%)

e 263.0 355.3 64.91

8 e 327.2 445.9 61.26

0 41.3 401.8 614.2 57.95

8 67.5 486.9 795.2 54.84

9 97.1 583.0 971.0 52.49

0 143.7 669.7 1102.4 50.61

ban resident basic medical insurance; UEBMI, urban employee basic

Table 6 e Average annual out-of-pocket healthcare payments per capita from 2009 to 2013.

Year Urban residents Rural residents

Living consumption (RMB ¥) per capita

Out-of-pocket health care (RMB ¥)

per capita

% Living consumption (RMB ¥) per capita

Out-of-pocket health care (RMB ¥)

per capita

%

2009 12,264.5 856.4 6.98 3504.8 287.5 8.20

2010 13,471.5 871.8 6.47 3859.3 326.0 8.45

2011 15,160.9 969.0 6.39 4733.4 436.8 9.23

2012 16,674.3 1063.7 6.38 5414.5 513.8 9.49

2013 18,022.6 1118.3 6.20 6112.9 613.9 10.04

Data source: China statistical yearbook, 2014.

p u b l i c h e a l t h 1 4 2 ( 2 0 1 7 ) 7 3 e8 480

disease diagnosis and treatment but also undertake basic

public health services. PHIs are primarily responsible for dis-

ease prevention and control and health promotion, including

health education, maternal and child health care, and mental

health institutions and other institutions.

Scientific health personnel allocation should be stronger in

primary care facilities to solve primary health care and basic

medical problems of residents. PHIs are better suited to solve

the problems of prevention and control of major diseases,

reducing the incidence of disease from the source, and

improving the health level of residents. Hospitals are the

professional institutions for the diagnosis and treatment of

rare and serious diseases.

As shown in Table 1, the number of medical and healthcare

professionals in China has increased year by year since

China's health reform; more than half work in hospitals, approximately one-third work in primary care facilities, and

fewer than 10% work in PHIs. The allocation of healthcare-

associated professionals in hospitals increased significantly

from 2009 to 2014, reaching 62.5% in 2014. The allocation of

healthcare-associated professionals in primary care facilities

has decreased year by year, down to 28.7% in 2014. The allo-

cation of healthcare-associated professionals in PHIs

remained at approximately 8%. According to statistics, there

are 2.12 practising (assistant) physicians, 2.2 registered nurses

and 0.1 disease control institutions of professional and tech-

nical personnel per 1000 resident population in China.40 The

majority of disease prevention and control personnel are

engaged in the prevention and control of infectious diseases,

whereas fewer people engage in the prevention and control of

NCDs. According to statistics from the Chinese Centre for

Disease Control, the disease control agencies in China have

8264 NCD prevention and control personnel and 3656 full-time

NCD prevention and control personnel, accounting for 4.4%

and 1.9%, respectively, of the total number of Chinese disease

prevention and control personnel in 2011.46

A clear contrast: the high cost of disease treatment and the slow decline in personal cash health expenditure

As shown in Tables 2, 3 and 5, China's total health expenditure doubled from 2009 to 2014. Government health expenditure in

2014 was 2.3 times higher than that in 2009. China's basic medical insurance expenditure (including NCMS, URBMI and

UEBMI) in 2014 was 3.1 times that in 2009. In 2014, the total

medical expenditure in China was 2.2 times that in 2009.

Personal cash health expenditure as a proportion of total

medical expenditure declined 14.29 percentage points from

2009 to 2014, with an average annual decline of 2.38 percent-

age points. China's high input model of treatment of disease did not significantly reduce the burden of individual residents' medical treatment; Chinese residents' personal cash health expenditure as a proportion of total medical expenditure was

still more than 50% in 2014. In many countries, although the

residents have health insurance, they still face the risk of

catastrophic health expenditure.47,48 As shown in Table 3,

although 50% of government health expenditure is spent on

construction of the basic medical security system, the medical

burden on Chinese residents is still heavy. As shown in Table

6, based on actual payment capacity of urban and rural resi-

dents, the medical burden of rural residents increased each

year from 2009 to 2013.

A historic choice: urgent need to build a new healthcare model

At present, China is facing a historic choice between placing

health or disease treatment at the core of health care.

Objective analysis of China's current situation requires careful attention, as follows.

If China does not control the incidence of disease, health resources will never meet the needs of residents in the future Although prevention of disease can save more lives than

treatment of disease and is more cost-effective, most re-

sources are still being used for treatment.49e53 As shown in

Table 4, the number of medical visits increased to 21.1 billion

and the number of hospital visits increased to 71.91 million

from 2009 to 2014. Although the actual use of medical services

has increased rapidly in China, the proportion of patients who

had not received treatment for 2 weeks was 15.5%, and the

proportion of residents who were hospitalized was 17.1% in

2013.43 The main reason is the growing population. In 2013,

the prevalence of chronic diseases was 33.1%, representing an

increase of 9 percentage points compared with 2008.43 The 2-

week prevalence of illness in the survey population was 24.1%,

which was 5.2 percentage points higher compared with

2008.43 Many studies have shown that the incidence of chronic

disease has increased in China.54e59 Previous studies on the

rapid increase in the prevalence of chronic diseases have

p u b l i c h e a l t h 1 4 2 ( 2 0 1 7 ) 7 3 e8 4 81

suggested that elimination or control of the risk factors are

critical steps in the prevention and intervention of chronic

disease, rather than the treatment.48,60 Studies have sug-

gested that the challenges of chronic diseases, such as dia-

betes, continue to rise, and it is more important to strengthen

the NCD risk factors than focus on disease treatment in-

terventions.60,62 China's total population was 13.6 billion in 2013, and an increase in prevalence of one percentage point

means an additional 13.6 million patients. Although China's GDP ranks second in the world,63 the per-capita GDP level is

low.64 As a developing country, China's healthcare resources are still relatively limited. Therefore, it is very important to

strengthen the prevention and control of disease.

The high incidence of chronic diseases should be controlled as soon as possible Various factors have led to the high incidence of chronic dis-

eases in China. According to the Chinese health service sur-

vey, the prevalence of chronic diseases was significantly

higher in people aged �35 years, and prevalence in the older age group was significantly higher than that in the low age

group.65 The results show that the ageing population is one of

the factors leading to the high incidence of chronic diseases.

With the improvement of living conditions for Chinese resi-

dents, the problem of an unhealthy diet is more serious, and

problems of obesity and overweight have been highlighted.66

At the same time, smoking, alcohol use, reduced levels of

physical activity and environmental pollution also lead to

increased prevalence of chronic diseases.66 Of course, given

the focus on the health of residents, the number of people

participating in annual health examinations will increase,

which will increase the number of patients with chronic dis-

eases. However, this is not the main factor leading to the

increased prevalence of chronic diseases in China. First, ac-

cording to China's health reform policy, only residents aged �65 years have a free physical examination once per year.67 Second, according to China's relevant policies, primary healthcare institutions are responsible for free physical ex-

aminations of the elderly, and cancer and other chronic dis-

eases cannot be diagnosed at these facilities due to limited

technology. Third, due to limited economic conditions and the

fact that health literacy is not high,68 Chinese residents are

unlikely to undergo physical examinations at their own

expense. Experiences in many developed countries, such as

Finland, Britain, Canada, France and Germany, have shown

that many chronic disease prevention measures recom-

mended in WHO's Framework Convention on Tobacco Control and multiple drug therapy interventions used for cardiovas-

cular disease in high-risk populations are very economical

and effective.69e71 Moreover, control often appears much

sooner than expected. Some Chinese chronic disease in-

terventions have proved to be cost-effective and have long-

term effects for health improvement.72,73 Experience from

developed countries shows that reducing or eliminating risk

factors will improve the residents' health in China, and this will be noticed in a matter of years rather than decades.74,75 In

view of the high incidence of chronic diseases, the Chinese

Government should take effective comprehensive

intervention measures as soon as possible to cope with the

severe challenges of chronic diseases.

It is critical to build a new healthcare model with health promotion at the centre Improving the health of the entire population is the sacred

duty of the government.76 Facing the challenge of the ageing

population, the high incidence of chronic diseases, and

other health problems, the Chinese Government should

establish a system to protect the population's health, strengthen the Government's responsibility, strengthen cooperation between departments, mobilize the enthusiasm

of society as a whole and build a good environment for the

promotion of public health. At present, the most pressing

problem is strengthening the construction of the public

health system, and strengthening the prevention and con-

trol of major diseases. Specific recommendations are as

follows:

� Establish the core position of health goals. China's government-related policies, plans and input should be

guided by the goal of health.

� Establish the dynamic security mechanism of public health. The Chinese Government should focus on changes

in the health of residents to establish the dynamic security

mechanisms of professional PHIs and primary healthcare

institutions to ensure that PHI personnel and funds can

meet the basic needs of the work.

� Build a collaborative public health management mecha- nism. Many studies show that collaborative public health

management can effectively improve the overall perfor-

mance of local government management.77e82 In the 21st

century, interdependence and information have developed

into such an environment; boundaries between organiza-

tions and departments are more concepts than actual dif-

ferences.83 In theory, responsibilities of government

departments are clear, and responsibilities of different

departments are different. However, the Government often

requires departments to work closely with the Government

on major issues. For example, in dealing with public

emergencies, the Government sometimes has to cross

regional boundaries to gain cooperation. This is even truer

for public health.84 In the prevention and control of major

infectious diseases, collaborative public management in-

volves linking the power, function and advantages of

different departments into a common resource. The pri-

mary intention is to make public management more effi-

cient, and to improve the overall performance of the

operation of public management.85 The Chinese Govern-

ment should set health as the core goal; urge government

departments to cooperate actively; perform vertical and

horizontal cooperation; tap the potential of primary

healthcare institutions, professional PHIs and hospitals;

build strong health promotion patterns; and promote a

steady increase in the health of residents.

‘Healthy China’ has been incorporated into the overall

development plan of China's Government from 2016 to 2020.86

p u b l i c h e a l t h 1 4 2 ( 2 0 1 7 ) 7 3 e8 482

The Healthy China vision is worth looking forward to, but the

public health prong of the plan should be strengthened as

soon as possible.

Author statements

Ethical approval

Not required.

Funding

The Chinese Medical Board (G09-986, G09-946), the People's Republic of China Ministry of Science and support key projects

(2008BAI65B19), the People's Republic of China Ministry of Education, Philosophy and Social Science key projects

(08JZD0022), the People's Republic of China Ministry of Edu- cation, Humanities and Social Science Planning Fund

(08JA790099), and the Social Science Foundation of China (04

BJY 020) provided funding for this study.

Competing interests

None declared.

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