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发表于 2012-8-14 14:47:42
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本帖最后由 彭首一 于 2012-8-14 15:17 编辑
Health care in China: a rural-urban comparison after the socioeconomic reforms
Leiyu Shi1(Assistant Professor, Department of Health Administration,School of Public Health, University of South Carolina, Columbia,SC 29205, USA.)
This article provides an overview of the current Chinese health care system with particular emphasis on rural-urban differences. China's post-1978 economic reforms, although they improved general living standards, created some unintended consequences,as evidenced by the disintegration of the rural cooperative medical system and the sharp reduction in the number of "barefoot doctors" both of which were essential elements in the improvement of health status in rural China.农村合作医疗体系瓦解及赤脚医生数量的锐减就是证据，这两者都是中国农村地区健康状况提高的基本要素。 The increase in the elderly population and their lack of health insurance and pensions will also place enormous pressure on services for their care. These changes have disproportionately affected the rural health care system, leaving the urban system basically intact, and have contributed to the rural-urban disparity in health care.Based on recent data the article compares current rural-urban differences in health care policy, systems, resources, and outcomes, and proposes potential solutions to reduce them.
Introduction
With a population of 1130 million in 1990, China is the world's most populous country,accounting for 21% of the global population and for 28% of those living in developing countries.(J-2). China is also the largest agricultural country in the world with over 70% of its population living in rural areas.a Since 1949, when the People's Republic of China was established, improved social conditions and health services have given the Chinese people vastly improved health status. The near doubling of life expectancy from 1949 to the present time (from 35 years to 69 years) has put China on a par with developed countries (3). Overall mortality has fallen from 25 to 6.6 per 1000 population. Infant mortality has also declined markedly from 200 to 34.68 per 1000 live births, which compares favourably with the average
for developing countries of 92 per 1000 live births and the average global level of 81 per 1000 live births (4-6). Many features of China's health policy and system have been embodied in WHO's principles for community-oriented primary health care and its call for health for all by the year 2000 (7, 8).
Despite these significant achievements, China is facing new problems.From a social policy perspective,changes in the health care system not only reflect health reform measures but also the impact of the general economic reforms. China has now experienced three decades of Maoist-style Communism and one-and-a-half decades of economic and structural reform since 1978. This economic reform has dismantled many aspects of China's Maoist health and medical system, including the cooperative medical system in rural areas (9, 10). Demographically, aging of the population presents a major challenge; 90 million people are aged over 60 years (8.59% of the population) and this is expected to increase to 130 million (11% of the population) by the tum of the century (11-13). Population aging and the continued growth of the population put significant demands on health care resources. In addition, health care costs have increased dramatically. A recent survey of hospitals from 13 provinces found that medical costs have increased by 30-50% annually since the economic reforms (14). These escalating medical costs were ascribed to a number of factors, e.g., inflation and the fact that health care providers were disadvantaged by price reforms that increased their costs but continued to freeze the charges they were allowed to make to patients and insurers (15). The charges for outpatients, inpatients, and medical operations account, on average, for 29%, 63% and 40%,respectively, of the actual costs of these services (16).
These problems interact and exacerbate the disparity between rural and urban health. During the 1980s,the rural people's communes were dismantled,as was the cooperative medical system, which was organized and highly subsidized by the production brigades under the communes. Today, in most of China's rural areas, health care has shifted to a fee-for-service system, in which the former rudimentary arrangements for health and medical insurance have not been preserved (15). Reduced access to medical care has already been experienced in some rural areas (17), although urban residents are more or less covered by state insurance because of workrelated benefits.
Over 80% of the elderly in China live in rural areas (18). Unlike most of the urban elderly, who generally receive a pension of 70-80% of their final salary when they retire, the rural elderly are mostly agricultural farmers, primarily dependent on their children and savings for old-age support (19). As the size of families becomes much smaller owing to strict family planning policy, and family members migrate to urban areas, the future care of the rural elderly in China is of great concern (20-22). The aging of the rural population will also mean aging within the elderly group. Of today's rural population aged 65 years, 70% are aged <75 years; in the future,however, an increasing proportion of the elderly will be older and more frail (23-25). Today's systems of rural support for the elderly and rural medical care are inadequate to cope with these projections.
The present article provides an up-to-date overview of the current Chinese health care system,with a special focus on rural-urban differences. Much of the information in this article is based on data published over the last ten years or identified in Ministry of Public Health internal documents. Since China did not regularly publish information on its health care system until the 1980s, the data presented here may not be complete.
The "systems model" of health services is used to organize the article (26). The "inputs" component of the systems model represents the health care resources (e.g., health care professionals and institutions) needed to generate the "outputs" (i.e., to improve the health status of the population and access to care). The mechanism that converts the inputs to outputs is termed "the health care system",which is affected by the "external environment" representing health care policy. Thus, the article first reviews current Chinese health care policy and then describes the health care system; subsequently,health care resources and outcomes are dealt with.The article concludes by summarizing the current major problems that exacerbate the rural-urban disparity in health and by discussing potential solutions.
Health care policy
The First National Health Conference in 1950 promulgated the general health care guidelines as "serving workers, peasants, and soldiers; putting preven The First National Health Conference in 1950 promulgated the general health care guidelines as "serving workers, peasants, and soldiers; putting prevention first; and developing both Westem and traditional medicine" (27). In view of China's large agricultural population, it is not surprising that the first guideline emphasized the need to serve rural peasants along with urban workers. In 1965, Chairman Mao called upon the Ministry of Public Health to make concerted efforts to promote rural health care (28,29). As a result, urban doctors en masse were regularly sent to rural areas, and paramedics were trained and developed into "barefoot doctors". A cooperative medical system, i.e., a system under which the village collective ran and financed the clinics, paying the barefoot doctors to provide medical care to the villagers, became the dominant health care system at the grass-roots level (18). Medical expenditures at higher levels could also be reimbursed up to a certain percentage.
Since 1978, China has entered into a new era of post-Mao socialism. The basic tenets of health care policy developed over the previous three decades remained intact. The three most important principles for health development laid out for the 1980s reflect this policy continuation:
- to consolidate and improve further both urban and rural primary health care services;
- to put into effect the principle of "prevention first" and reinforce disease prevention and control;and
- to develop and promote traditional Chinese medicine and its integration with Western medicine.b
The remaining principles showed additional emphasis on the health care required by the country's demographic and economic environment and included the following:
- to develop maternal and child health and enhance family planning technical guidelines;
- to advance medical education and accelerate personnel training;
- to intensify and facilitate biomedical research;
- to improve health management by training management personnel and upgrading managerial skills.b
The emphasis on rural health was also reflected in the specific objectives of the Seventh National Five-year Health Plan (1986-1990), listed below(30).
1) To improve the quality of drinking-water, and make safe drinking-water available for 80% of the rural population in coastal and developed areas by 1990.
2) To stress the prevention and treatment of viral hepatitis, scarlet fever, rabies, malaria, and tuberculosis,and expand immunization coverage to 85% of all children at the provincial level by 1990.
3) To popularize contemporary methods of child delivery and strive to reduce further the death rates of infants.
4) To increase the number of hospital beds by 400 000.
5) To strengthen health services in the county hospitals and encourage multiform village clinics.
6) To increase the number of hospital beds by 80 000 for traditional Chinese medicine and develop ethnic medicine.
7) To ensure that 150 000 new medical graduates enter the medical service each year.
8) To reform institutional employment and management.
9) To tighten supervision and control over pharmaceutical products.
10) To expand international cooperation.
Although objectives 1, 3, and 5 specifically dealt with rural areas, health policy in the 1980s and 1990s was also affected by a change in socioeconomic policy that emphasized individual efforts. In particular, the production responsibility system in agriculture, which was introduced as a replacement for the commune work-point system, necessitated changes in the arrangements for paying village barefoot doctors (18, 31, 32). The responsibility system transferred responsibility for agricultural production from the collective to the ousehold level. Under the work-point system, the collective had to meet a state crop quota; profits from any excess production went to the collective, which provided for education, food relief, and subsidies to martyrs' and servicemen's families, in addition to health care (33). Under the responsibility system, each household must deliver a quota of crops to the state for a low, fixed price; any excess crops are then sold at the market price with the profits going to the individual household. As a result, there was little money left for the collective to pay for services and in many places the village doctors became fee-for-service practitionners. Govemment subsidies for preventive and health work contributed only 1-2% of doctors' incomes (32).结果，集体仅剩少量的资金来支付医疗服务。因此很多地方的乡村医生开始了按项目收费制来提供服务。政府补助乡村医生开展预防免疫及医疗服务的金额仅占其收入的1～2％。 As a result, most of the cooperative medical system disintegrated and many village clinics closed. A national survey showed that in 1986 only 9.5% of the rural population was covered by cooperative medicine,compared with 90% in 1978 (34). As a result of these changes, many peasants now pay an increasing proportion of their medical costs on a fee-for-service basis.
Another impact of the economic reforms was its emphasis on technology. Urban hospitals bought expensive medical equipment (e.g., computed
tomography scanners) without any regional coordination of their activities. In the rural areas, a uniform examination was established in the mid-1980s for all barefoot doctors (34, 35). All those who passed the examination were given the new title of "country doctor" and licensed to practice medicine; those who did not pass became farmers.
Comparison of health care policy in the pre- and post-1978 periods therefore shows that while the Chinese govemment basically espoused health care principles that built on the rhetoric of earlier policies,substantial changes have occurred in rural health policy since 1978. Specifically, the fee-forservice system has replaced the cooperative medical system and collectively employed barefoot doctors
became private practitioners. The change in rural health policy in tum has affected the health care delivery system, which is discussed below.
Health care system
Fig. 1 displays schematically the current Chinese health care system (30, 36-41). The State Council,the executive branch in China, has direct jurisdiction over the nation's 30 provinces, municipalities, and autonomous regions. Directly below the provincial level is the county govemment, which supervises the township govemment, formerly known as the people's communes. The lowest administrative level is the village, formerly known as the production brigade, which is under the supervision of the township.On average, each province has 71 counties,each county 25 townships, each township 14 villages,and each village a population of 1000.
Parallel to the administrative system is the health care system. Each county or higher level of govemment has its functional public health unit,which is under the dual control of the corresponding govemments and the public health units at a higher administrative level. Every level of govemment runs hospitals and other specialized health institutions that are directly supervised by the corresponding public health unit. In general, hospitals at the provincial level and above are viewed as urban hospitals and those at the county level and below as rural hospitals.The township health centres are general health institutions operated by the township govemment and supervised by the county department of public health. Village clinics represent the grass-roots level of the health care system, and are run by the village residents committees and supervised by the township health centre.
The principal levels of the rural health system are the village, township, and county. The village clinic is the primary source of care for most rural residents and accounts for half of the rural institutions (42). Such clinics are staffed by village or country doctors (formerly the barefoot doctors) who provide preventive services, matemal and child health services, and simple outpatient care to village residents, mostly on a fee-for-service basis. The township health centre is staffed by assistant doctors with two years of medical education beyond junior high school, and provides treatment for routine conditions as well as supervising the work and training of village doctors. The county hospital usually represents the top of the rural referral system, providing a full range of medical and surgical services, and is staffed by college graduate physicians. The county hospital also provides training for health workers at the lower levels. In 1990 there were 2256 county hospitals, 47 000 township health centres, and 638 580 village clinics in China (3). Every county has at least one hospital, 88% of the townships have a health centre, and 87% of the villages have a clinic.
The post-1978 economic reforms brought one major change to the rural health care system. Previously,the central govemment collected all revenues and allocated a portion to the local govemment, but now only finances institutions directly under its control such as national hospitals, research institutes and medical schools (36). Each province and lower levels of govemment are responsible for their own health care services, thus accentuating the already uneven distribution of health care services between rural and urban areas. With dwindling financial support and limited sources of funds, the health services in some poorer counties and townships have become less prevention-oriented, and prevention programmes are being withdrawn from the township health centres that traditionally provided both preventive and
patient services (43).
The urban areas are mainly served by provincial hospitals (tertiary care facilities) (44).Other urban health care facilities include city hospitals, army hospitals, work unit hospitals, street hospitals, and local clinics; these facilities primarily serve urban residents but well-to-do-rural people can receive treatment on a fee-for-service basis. Following the economic reform, and specifically the introduction of the responsibility system, urban hospitals have implemented a system of personal responsibility, in which the tasks of each type of health professional are clearly defined and specified and have issued quality-quantity standards. Health professionals are rewarded for exceeding the standards and fined for being unable to meet them; the reward bonus can represent 50-100% of their monthly salaries (15). A similar responsibility system is also being encouraged in rural hospitals because of the chronic underutilization of rural hospital beds (the occupancy rate in urban hospitals averages 85-90% but is <50% in rural hospitals). A recent survey of county hospitals and township health centres showed that, on average,they experienced an annual loss of 10 400 yuan (ca.US$ 2500), with an average occupancy rate of 43.8% (45). The responsibility system has raised the productivity in urban hospitals, but also widened the
economic gap among health professionals, particularly between the rural and urban sectors.
Private practices have appeared in both rural and urban areas.The village clinics, which were owned by the collectives, are being transformed into private practices. In 1989, fee-for-service private clinics accounted for 59.4% of all village clinics, of which 11.1% were group private practices and 48.3% individual private practices (37). In the cities, there were 164 000 private doctors in 1989 (3.4% of all urban doctors) (46), most of whom had retired or resigned from public hospitals and had been permitted to set up their own clinics.
Health care resources
Table I compares the resources and health service utilization in rural and urban areas. The health resources and service utilization in urban areas are much greater than those in rural areas. The per capita national health service fund (NHSF) allocated by the government to the urban areas is 4.34 times the amount in the rural areas. The number of beds and the number of health professionals per 1000 population in the urban areas are 4.33 and 5.53 times, respectively,greater than those in the rural areas; also,the health service utilization rate and the expenditure for services are much higher in the urban areas.
China's national budget includes several items related to health care: the NHSF is the principal source for funding health services at different levels;the construction fund covers the building and renovation of hospitals and other health care institutions;the free medical service fund is used for medical relief and to assist the childless elderly and the disabled; and the medical education fund subsidizes medical education in national medical colleges.Between 1978 and 1988, the NHSF increased from 2242 million yuan (ca. US $ 1121 million) to 7186 million yuan (ca. US$ 1700 million) at an average annual rate of 12.4%;C over this period the proportion that the NHSF represented of the national budget increased from 2.0% to 2.7% (46). Inclusion of other funds and of military health care expenditure increased the total national health care expenditure to 5-6% of the GNP.
There is a wide disparity of health care spending between rural and urban areas in China (47, 48).中国城乡之间存在巨大的健康开支差距。 On average, the NHSF spends 9.80 yuan (ca. US$ 4.90)per urban resident per year, 4.3 times more than the amount per rural resident (2.23 yuan (ca. US$ 1.12))(34, 49).Dndividual health spending is also higher in urban than rural areas. The average annual per capita health services expenses in urban areas are 52.13 yuan (ca. US$ 26.07), 2.8 times greater than in rural areas.
A similar disparity occurs in the distribution of health care institutions and professionals.同样的差距也存在于医疗机构及卫生人员的分布上。 In 1989,the average number of beds was 6.1 per 1000 people in urban areas, and 1.4 per 1000 in rural areas. The number of senior doctors was >3 per 1000 people in urban areas, but <0.5 per 1000 in rural areas (50, 51).
Since the 1978-reforms, the differences in resource allocation to rural and urban areas have increased. Table 1 shows rural-urban differences in hospitals, beds, and health professionals between 1985 and 1989. To gauge the size of hospitals, we used the ratio of beds per hospital; this is, however,an approximation since non-hospital beds were also included in the calculation. In general, urban hospitals were over three times larger than rural hospitals,with an average of 90 beds per hospital compared with 26 per rural hospital. The average size of rural hospitals remained constant over the period 1985-89, but there was a slight decrease in urban hospitals. While the number of urban hospitals increased steadily, the number of rural hospitals declined owing to closures caused by financial losses (45).当城里的医院数量稳步增长时，乡镇医院数量却在减少，主要的原因是缺乏财政支持而被迫关停。 The number of urban hospital beds increased from 4.6 per 1000 people in 1985 to 6.1 in 1989, but the number of rural hospital beds declined from 1.5 per 1000 people to 1.4 over the same period. A similar trend was observed in the number of health professionals,which increased at an annual rate of 4.5-6.6% in urban areas but declined in rural areas;in 1989, there were 12.6 health professionals per 1000 urban residents compared with 2.3 per 1000 rural residents.
Table 2 shows the developments that have taken place in the provision of rural health institutions,hospital beds, and health professionals in China since 1949. County hospitals continued to increase in size after the 1978-reform, regardless of whether this was measured by the hospital beds-hospital ratio,doctors-hospital ratio, or nurses-hospital ratio. The average size of township health centres appeared to increase when measured by the number of beds per health centre and the number of nurses per health centre, but decreased when measured by the number of doctors per health centre.
The number of county hospitals increased annually until 1980 and then declined. A similar trend was observed for township health centres, whose number started to decline after 1980, presumably because of a time lag after the implementation of rural economic reforms. The number of hospital beds increased at a much slower rate after the reforms.Between 1949 and 1978, the number of county hospital beds increased by over 2600% (880% per decade).In the decade after 1978, the number of county hospital beds increased only by 29%, while the number of beds in the township health centres started to decline after 1980.
The number of health professionals at the county level increased after the 1978-reforms but declined at the township and village levels. As discussed above,the decline in the number of rural doctors may be attributed to changes in the financing system and stricter practice standards. At the county level, the number of doctors, nurses, and administrators continued to increase after the reforms; however, at the township level, while the number of nurses increased, the number of doctors and administrators declined. Most of the reduction in village health professionals was due to the decrease in the number of barefoot doctors (estimated reduction rate, 18-33%) (9, 32, 52).乡村卫生人员的减少主要是因为赤脚医生人数的降低（估计减少的比例为18～33％）
Investment in rural health resources increased dramatically after the revolution in 1949, but the rate of increase slowed noticeably after the 1978-reforms; moreover, the number of hospitals and health centres decreased significantly. Township and village-level health resources were affected most by the impact of the reforms, since the number of health care institutions and professionals were markedly reduced; this reduction could ultimately affect the health status of the rural population.
Health outcome
Current health conditions in China are very different from those that prevailed 40 years ago; instead of the threat of communicable and infectious diseases,China is now mainly confronted by chronic illnesses.当前中国的健康状况和40年前有巨大的不同，在之前中国主要受传染性的疾病影响，而现在中国主要受到慢性病的威胁。Table 3 compares the mortality rates in 1988 for the leading causes of death in rural and urban areas;these causes accounted for >90% of all mortalities.While cancer and stroke were responsible for 42% of the urban deaths, respiratory diseases were the principal killer in rural areas, accounting for 25% of the deaths. The rural population was proportionally more likely to die from injuries and poisoning, tuberculosis,infectious diseases, and neonatal complications than their urban counterparts, who were more likely to die from heart diseases and cancer. In both rural and urban areas, males were more likely to die from cancer, injury and poisoning, digestive system diseases, neonatal complications, and infectious diseases than females, who were more likely to die from stroke, respiratory diseases, and heart diseases.
Table 4 shows selected measures of population characteristics, health status, and use of health resources in rural and urban areas of China. The average urban per capita income in 1989 was 1387.81 yuan (ca. US$ 328), 2.3 times higher than in rural areas. The urban population used more health resources: in 1986, compared with the rural population, they spent 2.8 times more per capita on health
service expenses, having both more outpatient visits (4 per year per person versus 3) and inpatient-days (1.34 days per person per year versus 0.49) There were also more doctors (3 per 1000 population versus 0.98) and beds (6 per 1000 population versus 1.4) in urban areas, while the government spent 4.3 times more on health care in urban areas.
Although it is premature to make the generalization that the rural-urban disparity in health resources leads to differential health outcomes, it is clear that the urban population enjoys better health status than those who live in rural areas. For example, the urban infant mortality rate is 24 per 1000 live births, 60% lower than in rural areas; urban females live, on average, 4.5 years longer than rural females, and the life expectancy of urban males is 3.7 years longer than that of rural males.
Limited data are available to examine the changes that have occurred in health status since the 1978-reforms. However, according to the "two-per-thousand-population" fertility survey that was carried out in China in 1988, the infant mortality rate declined sharply up to 1977, then stabilized for a full decade up to 1987 at approximately 40 deaths in the first year of life per 1000 live births (2, 54).d The weakening of primary health care at the village and township levels where rural people receive most of their care may have affected antenatal care and the maternal and child health network the most, which would help to explain the lack of further improvement in infant survival after 1978. The Ministry of Public Health has reaffirmed that there are continuing problems with infectious and endemic diseases and a weak infrastructure for preventive and primary care in rural areas (10). Also, a recent study on China's mortality trends noted that working-age males in rural townships have experienced significantly increased mortality owing to industrialization(54).
What is relatively clear is that access to health care has been adversely affected in rural areas. The reduction in the number of village health professionals and township health centres represents a major cutback of needed resources from which the rural population obtain their primary health care.尽管作为农村人口获得其初级医疗服务的途径，乡村卫生人员数及镇级医疗机构数都在减少，证明了必需的卫生资源被削减。 Since 1978 China's health system has shifted toward curative medical care and away from preventive activities (42, 43). The long-term health impact of such a shift is a cause for concern since China's success in controlling infectious diseases and increasing life expectancy has been attributed to its emphasis on preventive programmes rather than curative health services (32, 37, 38).
Access to care is not only limited by resources but is modulated by insurance status or income.There is a major difference between urban and rural areas with respect to health insurance coverage (21,26, 30, 32, 37). In the urban areas, the government insurance plan, which is financed exclusively from the national budget, provides free outpatient and inpatient services to government employees, college teachers, and college students. In general, only the primary participants are covered and dependents receive no benefit entitlements. Workers and staff employed in state enterprises with more than 100 employees are insured by the labour insurance plan,which is financed exclusively by the enterprise, with no individual prepayments. This plan entitles primary participants to free health care for life and Their dependents to 50% reimbursement of health care costs. Since most working people are employed either by the government or by state enterprise, most of the urban population has little financial constraints about seeking medical care. In recent years, some urban programmes have introduced cost-containment incentives to insurance programmes; for example, by introducing deductibles, co-payments, percentage of coverage, or monthly payments that recipients can use for medical care or keep if they are not ill. However,these innovations are based on the premise that recipients have access to essential medical care services.
In the rural areas of China health insurance has been organized through a cooperative medical plan with money being provided mainly from local collective welfare funds and supplemented by individual premium assessments.Beneficiaries are entitled to free or substantially reimbursable services and drugs at the village clinics and also at higher level referral centres. Since the implementation of the individual responsibility system, local collectives can no longer retain the surplus production output for public welfare services, such as financing cooperative medical care. Because the insurance provided through cooperative medical plans depends on the solvency of the local collective welfare fund, coverage has to be suspended or restricted when this fund is used up. Thus,the rural population, whose income, on average, is less than half that of the urban population, now has to pay to use medical services, increasing the financial
burden imposed by illness.
The people most affected by these changes are the rural elderly. Currently, 6% of the rural population is over 65 years of age, compared with 5% in urban areas (see Table 4). Of the 36 665 homes for the aged, 78% are in rural areas, where >80% of the nation's elderly live; 74% of the beds in these homes are in rural areas. The urban elderly are 25% more likely to stay in homes for the aged than their rural
counterparts.
In urban areas, the elderly are more likely to receive retirement pensions ranging from 60% to 100% of their last wage, depending on their length of service and prior participation in activities during the revolution (18, 55-58). Medical insurance is also included as part of the retirement benefits provided by employers. In rural areas, only the childless elderly and the disabled are taken care of by the collective through a programme, called "the five guarantees",which covers clothing, food, housing, medical care,and burial expenses (12, 59-62). Currently about 6% of the elderly enjoy these benefits. For the majority of the rural elderly who have neither medical insurance nor retirement pensions, the family is their predominant mode of support (63). Recent projections indicate that China will have a substantially older population in the middle of the 21st century (2, 11,12, 64). The increase in the number and proportion of old people and the decrease in average family size because of the strict family planning policy will exert severe strains on the support of the elderly, particularly in rural China (2, 21, 65-69).
Discussion
While economic reforms in China have improved the general standard of living, they have also had some unintended consequences. The originally highly centralized health care system has been experiencing transformations brought about by the changes in the country's administrative system and economic policy.Such transformations are characterized by the disintegration of the rural cooperative medical system and by a sharp reduction in the number of barefoot doctors, both of which are essential ingredients to the improvement of health status in rural China. The increase in the costs of medical services in recent years owing to inflation, and the lack of health insurance among the rural population, will impose an economic burden on low-income individuals and affect their health status. Also, the increase in the elderly population and their lack of health insurance and pensions will place enormous pressures on services for their care. Unfortunately, these changes have disproportionately affected the rural health care system, leaving the urban system basically intact,
and have contributed to the rural-urban disparity in health care that was reduced during the Maoist era (3, 8-10, 17, 18, 28, 32, 39, 70, 71). The Ministry of Public Health also recognizes this inequality in resource distribution and in access to services as one of the critical problems in the current health system (72, 73). The Seventh National Five-year Health Plan (1986-1990) includes as one of its ten objectives the strengthening of health services in the county hospitals and the encouragement of multi-form village clinics (30).
To reduce this rural-urban disparity, a number of policy concerns have to be addressed as discussed below.
First, in terms of health resources, what is the most appropriate type of professional to provide rural primary health care? Currently in China, the three commonest health providers are as follows: senior doctors trained either in Western or traditional Chinese medicine, who have graduated after a fiveor six-year course in medical school after completing high school; assistant doctors, who have had two years of medical education in a technical college beyond junior high school; and country doctorse (former barefoot doctors), who have been educated to primary-school level and have completed 6-12 months of training in public health and primary health care, typically at a county hospital. Thus, it takes 17-18 years of formal education to train a senior doctor, 11 years for an assistant doctor, and less than 7 years for a barefoot doctor. Before the barefoot doctors are replaced by better-trained doctors,the relative cost-effectiveness of the latter at providing preventive and primary care services to the rural population needs to be determined. Health manpower training in China is still limited by its cost. The three-tier referral system that existed before the reform was built on the principle of efficient utilization of available health professionals. In the first tier, Barefoot doctors provided educational, preventive,and primary care services. Patients with more serious diseases were referred to the second tier (formerly called the commune health centre), which was staffed primarily by assistant doctors. The most seriously ill patients were referred to the county hospital,where senior doctors were available. The advantages and disadvantages of such a referral system need to be studied and compared before changes to it are made. In addition, the recruitment and retainability of these professionals in rural areas need to be compared and taken into account. Regardless of what type of doctors are practising in rural areas, their income, which is mostly regulated by the government, should at least be comparable to that of the local population. Currently, rural doctors generally earn much less than capable, ambitious peasants, dampening their incentive to serve in rural areas.
Second, what is the most appropriate method of health care financing - fee-for-service, or insurance,cooperative medicine or a universal, compulsory system? The fee-for-service approach is likely to increase the access gap between rich and poor.With the escalating health care costs that are expected to accompany a more market-oriented approach to health services delivery, the financial burden to care will be too great for most rural people and the incentive to seek preventive care will also diminish. Medical insurance is currently being tried in several wellto- do rural areas (15, 74-76) but its feasibility. acceptability, and manageability remain to be seen.In areas that are still poor, its applicability is certainly limited because peasants do not have sufficient income to pay for the premiums. If cooperative medicine is to be continued, peasants will have to contribute to the local welfare fund from their own harvest income. The psychological difficulty for peasants of having to spend money today on possible future benefits may dampen their enthusiasm for cooperative medicine, especially when they could spend their money on immediately tangible and appealing goods. A universal, compulsory system of financing health care therefore seems to be more appropriate. Such a system is also more likely to reduce the rural-urban and rich-poor differences in access to care.
Third, there is an urgent need to develop a new support system for the elderly that takes into account the impact of family planning policy. The traditional family-based elderly support system is likely to be weakened since strict birth control will reduce both immediate and extended family relationships. To achieve the objectives of both family planning and elderly care, a non-family-based system that combines both medical care and pension assistance should be explored; otherwise, the future care of the rural elderly will be in jeopardy. Currently, collectively financed old-age support is being tried on an experimental basis in many rural areas at various levels, including the village, township, county, and region (77-86). Nine provinces are also currently experimenting with their own social security system that combines resources from the individual, work units, and the state (87); under this system, individuals contribute 2-3% of their income. The national government appears to be supporting a provincialbased, old-age support system. In addition to financial support, the demand for long-term care is expected to increase substantially as a result of population aging. The current homes for the aged, which are capable of accommodating 4-5% of the elderly,may be insufficient to meet the increasing demand caused by the increase in the elderly population and the decrease in family size.
These challenges have to be met before the rural-urban disparity in health care can be reduced and continued progress made in improving the health status of the population. In order to reach the targets of health for all by the year 2000, which the Chinese government has endorsed, China has to structure a new system compatible with both the economic policy that emphasizes individual efforts and the health policy that stresses public health.
References
1. Yu, C. [China announces results of last year's census].People's Daily, 20 April 1992 (in Chinese).
2. Banister, J. China's population changes and the economy. In: U.S. Congress, Joint Economic Committee, ed. China's economic dilemmas in the 1990s:the problems of reforms, modernization, and industrialization.Washington, DC, U.S. Government Printing Office, 1991, pp. 235-251.
3. Fu, X. [A review of China health services development and policies]. Zhongguo Nongcun Weisheng Siyie Guanli (China rural health services management),1: 9-14 (1990) (in Chinese).
4. China's infant mortality declines in past forty years.China population newsletter, 6(2), April 1989, pp.11, 18.
5. World health statistics annual, 1983. World Health Organization, Geneva, 1983.
6. Ministry of Public Health. [The outstanding achievements of health services development in the past forty years]. Jian Kang Bao (Health gazette),16 September 1989 (in Chinese).
7. Tollman, S. Community-oriented primary care: origins, evolution, applications. Social science and medicine, 32: 633-642 (1991).
8. Yang, P. et al. Health policy reform in the People's Republic of China. International journal of health services, 21: 481-491 (1991).
9. Liu, X. & Wang, J. An introduction to China's health care system. Journal of public health policy,104-116 (Spring 1991).
10. Cheng, J. [What are the mistakes in the ten-year health reform?] China health information, 354: 4 (1989) (in Chinese).
11. Banister, J. The aging of China's population. Problems of Communism, 37(6): 71-73 (1988).
12. Liang, J. et al. Population aging in the People's Republic of China. Social science and medicine, 23: 1353-1362 (1986).
13. [State Statistical Bureau announces population census results: statistics of the age structure of mainland population]. People's Daily, 20 June 1992 (in Chinese).
14. Yuan, Y. [An important step in the modernization of medical and health work]. Jian Kang Bao (Health gazette), 7 August 1990 (in Chinese).
15. Cretin, S. et al. Modeling the effect of insurance on health expenditures in the People's Republic of China. Health services research, 25: 667-685 (1 990).
16. Han, Y. & Dal, G. [Health economics, health policy, and health reform]. Zhongguo Nongcum Weisheng Siyie Guanli (China rural health services management),6: 1-4 (1990) (in Chinese).
17. Zhu, A. [Exploring the problems of rural health system]. Zhongguo Nongcum Weisheng Siyie Guanli (China rural health services management), No. 10: 25-27 (1990) (in Chinese).
18. Goldstein, A. & Goldstein, S. The challenge of an aging population in the People's Republic of China.Research on aging, 8: 179-199 (1986).
19. Martin, L. G. The aging of Asia. Journal of gerontology,43: S99-S 13 (1988).
20. Banister, J. China's changing population. Stanford,CA, Stanford University Press, 1987.
21. Croll, E. et al. China's one-child family policy. London,Macmillan, 1985.
22. Hardee-Cleaveland, K. & Banister, J. Fertility policy and implementation in China, 1986-88. Population and development review, 14: 245-246 (1989).
23. Banister, J. The aging of China's urban and rural population. Paper presented at: International Academic Conference on China's Population Aging, Beijing,December 1989.
24. Rise in population age results in problems. Beijing Xinhua, 9 May 1989. Joint publications research service, No. JPRS-CAR-89-065, 1989, p. 42.
25. Tian, X. China's elderly surveyed. Beijing review,14-20 November 1988, p. 23.
26. Rakich, J. S. et al. Managing health services organizations, 2nd ed. Philadelphia, PA, Saunders,1985.
27. Chen, H. [China health care]. Beijing, People's Medical Publishing House, 1985 (in Chinese).
28. Sidel, R. & Sidel, V.W. The health of China: current conflicts in medical and human services for one billion people. Boston, MA, Beacon, 1984.
29. Rifkin, S. B. Health care for rural areas. In: Quinn,J.R., ed. Medicine and public health in the People's Republic of China. Washington DC, John E. Fogarty International Center for Advanced Study in the Health Sciences, 1973.
30. Cui, Y. [Public health in the People's Republic of China]. Beijing, People's Medical Publishing House, 1987 (in Chinese).
31. Parish, W.L. Chinese rural development: the great transformation. Armonk, NY, Sharpe, 1985.
32. Hsiao, W.C. Transformation of health care in China New England journal of medicine, 310: 932-936 (1984).
33. Parish, W.L. & Whyte, M. Village and family in contemporary China. Chicago, IL, University of Chicago Press, 1978.
34. [National health service research in the rural areas].Beijing, Ministry of Public Health, 1986 (in Chinese).
35. Huang, S. Transforming China's collective health care system: a village study. Social science and medicine, 27: 879-888 (1988).
36. [Chinese health almanac] (in Chinese). Beijing,People's Health Press, 1988.
37. Hu, T. Health services in the People's Republic of China. In: Raffel, M.W., ed. Comparative health systems:descriptive analysis of fourteen national health systems. University Park, PA, Pennsylvania State University Press, 1984.
38. Jamison, D. T. China's health care system: Policies,organization, inputs and finance. In: Walsh, J.A. & Warren, K., ed. Good health at low cost. New York, Rockefeller Foundation, 1985, pp. 21-32.
39. Henderson, G.E. & Cohen, M.S. Health care in the People's Republic of China: a view from inside the system. American journal of public health, 72:1238-1 245 (1982).
40. Liu, Y.C. China: health care in transition. Nursing outlook, 31: 94-99 (1983).
41. New, P. K. & New, M.L. The links between health and political structure in new China. Human organization,34: 237-251 (1975).
42. Zhu, J. [Exploring rural health care system]. Zhongguo Nongcum Weisheng Siyie Guanli (China rural health services management), 10: 22-24 (1990) (in Chinese).
43. Ministry of Public Health. [The rural prevention organizations are being reorganized in our country].Jian Kang Bao (Health gazette), 13 May 1990 (in Chinese).
44. Cohen, M.S. & Henderson, G.E. Medical care in the People's Republic of China: access and cost.Annals of internal medicine, 99: 727-728 (1983).
45. Cai, K. [The future directions of the county and township health institutions]. Zhongguo Nongcun Weisheng Siyie Guanli (China rural health services management), 4: 10-13 (1990) (in Chinese).
46. Ministry of Public Health. [Chinese health statistical digesfJ. Beijing, Ministry of Public Health, 1989 (in Chinese).
47. Hu, T. Issues of health care financing in the People's Republic of China. Social science and medicine, 15C: 233-237 (1981).
48. Prescott, N. & Jamison, D.T. Health sector finance in China. World health statistics quarterly, 37: 387-402 (1984).
49. [National health service research in the urban areas]. Beijing, Ministry of Public Health, 1987 (in Chinese).
50. State Statistical Bureau. [China statistics yearbook]. Beijing, China Statistics Press, 1990 (in Chinese).
51. Ministry of Public Health, Health Statistics Information Centre. [Health services development statistics].Jian Kang Bao (Health gazette), 10 April 1990 (in Chinese).
52. Rogers, E.M. Barefoot doctors. In: Rural health in the People's Republic of China: report of a visit by the rural health system delegation. Washington, DC, (DHHS Publication No. (NIH) 81-2124, 1980, pp. 43-62).
53. Zhou, Y. [An analysis of infant mortality rates in China]. Zhongguo renkou kexue (Population science of China), No. 3, 35-46 (1989) (in Chinese).
54. Banister, J. China: recent mortality levels and trends. Washington, DC, Center for International Research, U.S. Bureau of the Census, 1992.
55. Whyte, M.K. & Parish, W.L. Urban life in contem-porary China. Chicago, University of Chicago Press,1984.
56. Liu, L. Mandatory retirement and other reforms pose new challenges for China's government. Aging and work, 5: 119-133 (1982).
57. Chow, N. The administration and financing of social security in China. Hong Kong, Centre of Asian Studies, University of Hong Kong Press, 1988.
58. Davis-Friedmann, D. Long lives: Chinese elderly and the Communist Revolution. Cambridge, MA,Harvard University Press, 1983.
59. Ministry of Civil Affairs. Exploring rural social security. Hunan, Hunan University Press, 1987.
60. Du, R. Old people in China: hopes and problems. Beijing review, 27: 31-34 (1984).
61. Davis-Friedmann, D. Retirement and social welfare programs for Chinese elderly: a minimal role for the State. In: Nusberg, C. & Masako, M.O., ed. The situation of the Asian/Pacific elderly. Washington, DC, International Federation on Aging, 1981.
62. Davis-Friedmann, D. & Schultz, J., ed. Aging China: family, economics, and government policies in transition. Washington, DC, Gerontological Society of America, 1987.
63. Yang, C.K. Chinese communist society: the family and the village. Cambridge, MIT Press, 1965.
64. Greenhalgh, S. Fertility trends in China: approaching the 1990's. (Working Papers, No. 8). New York Population Council, Research Division, 1989.
65. Kaufman, J. A billion and counting: family planning campaigns and policies in the People's Republic of China. San Francisco, San Francisco Press, 1983.
66. Shi, L. Determinants of fertility: results from a 1989 rural household survey. Social science journal, 29:457-477 (1992).
67. Ma, E. One child, one family. Journal of the American Medical Association, 261: 1735-1736 (1989).
68. Ikels, C. Aging and disability in China: cultural issues in measurement and interpretation. Social science and medicine, 32: 649-665 (1991).
69. Banister, J. China's momentous population changes. People, 16: 14-16 (1989).
70. Mechanic, D.K. Ambulatory medical care in the People's Republic of China: an exploratory study.American journal of public health, 70: 62-66 (1980).
71. Sidel, V.W. Medical care in China: equity versus modernization. American journal of public health,72: 1224-1226 (1982).
72. He, J. Address at: National Symposium on Public Health Policy and Managerial Process for National Health Development, Chanhsha, Hunan, October 1988.
73. Yu, Z. [Health care reform and the basic policy].Jian Kang Bao (Health gazette), 19 May 1991,p. 3 (in Chinese).
74. Peng, L. & Gao, L. Chinese health services management Changchuen, Jilin Science and Technology Press, 1988.
75. Cao, G. & Zhang, B. [The transformation of China's health care system in rural areas and development research]. Chinese primary health care, 43: 5-10 (1990) (in Chinese).
76. Su, G. & Sun, J. [Survey on the establishment of medical care and social security insurance in Changsou areas]. In: Exploring rural social security.Hunan, Hunan University Press, 1987, pp. 177-190(in Chinese).
77. Cheng, W. [Survey of elderly support in Mulin Xiang, Sunyi County of Beijing Suburbs]. In: Exploring rural social security. Hunan, Hunan University Press, 1987, pp. 130-141 (in Chinese).
78. Gao, Z. & Tang, J. [Social economy and social security in Meitou township of Wenzhou city]. In: Exploring rural social security. Hunan, Hunan University Press, 1987, pp. 21-33 (in Chinese).
79. Han, M. [Exploring old-age support system in rich rural areas: survey of villages and townships in Jin County, Gan Jin Zhi District of Dalian city]. In:Exploring rural social security. Hunan, Hunan University Press, 1987, pp. 79-85 (in Chinese).
80. Leng, Y. [Social security at Guanshan village of Wuhan]. In: Exploring rural social security. Hunan,Hunan University Press, 1987, pp. 171-176 (in Chinese).
81. Li, L. [The current status of elderly support and the desire for future development among the aged of Shanghai suburbs]. In: Exploring rural social security.Hunan, Hunan University Press, 1987, pp.150-162 (in Chinese).
82. Wang, J. [The current status and future outlook of elderly support in the suburban areas: survey of Hufang Xiang]. In: Exploring rural social security.Hunan, Hunan University Press, 1987, pp. 163-170 (in Chinese).
83. Zhang, Y. [Survey of rural elderly support in Wuqin county]. In: Exploring rural social security. Hunan, Hunan University Press, 1987, pp. 142-149 (in Chinese).
84. Cui, N. Reflections on a social security system with Chinese characteristics. International social security review, 2: 170-175 (1988).
85. Luo, K. & Yan, W. [The three-combination elderly care model]. People's Daily, 16 May 1992 (in Chinese).
86. Jia, A. New experiments with elderly care in China.Journal of cross-cultural gerontology, 3: 139-148(1988).
87. Zhu, X. [China expands provincial-based old-age support system that combines resources from the state, enterprise and the individual]. People's Daily, 22 April 1992 (in Chinese). |
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发表于 2012-7-29 20:29:47
