Universal health coverage in China part 2: addressing challenges and recommendations

As part of my commitment to Healthcare transformation for improved national, societal, communal and individual outcomes, I wanted to summarise a recent paper published by The Lancet Group as part of a two part series that evaluates the past, present and future state of healthcare coverage in China.

Strong political commitment and targeted financial investment have produced positive outcomes in reproductive, maternal, newborn, and child health (RMNCH) and infectious diseases. There still remains however, a fragmented and hospital-centric delivery system, rising health-care costs, relatively shallow benefit coverage of health insurance schemes, and little integration of health in all policies. These constraints have somewhat restricted China's ability to effectively prevent and control chronic disease and provide adequate financial risk protection, especially for lower-income households.

When China adopted a market approach to financing and organising its health care system in the 1980s, it resulted in unequal and unaffordable health care, the Chinese Government responded by providing equal access to essential RMNCH services through continuous government financing, effective international cooperation, and a hierarchical maternal and child health delivery network with strong communal roots.

The Chinese government also substantially increased its funding to expand public health insurance coverage and strengthen the health-care delivery system's infrastructure, leading to rapid increases in physical access and health-care utilisation. However, as a result, the Chinese government's health expenditure as a share of total health expenditure increased from 24·7% in 2008, to 30·4% in 2020, and the share of government health expenditure in total government expenditures increased from 4·4% to 7·8% during the same period.

Despite these increases, one cannot help but speculate why progress across these numerous initiatives has not been more widely publicised, in the same way that China's Gross Domestic Product (GDP), Artificial Intelligence (AI) and Property development efforts are shared internationally.

Publicity aside, there remain opportunities for primary health care (PHC) providers to better synergise with the hospitals. The hospitals have to survive financially by making profits from prescribing and dispensing drugs and providing high-technology tests, and physician compensation is tied to these profits. As a result, hospitals have few incentives to shift from treatment-based curative care to population-based health prevention and management. Physicians in hospitals are also often unwilling to coordinate care with primary health care (PHC) providers because referring patients to PHC providers is not in line with their financial interests.

As a result, Chinese patients often overuse tertiary care, even for simple conditions. In 2021, 53·4% of resources were concentrated at public tertiary hospitals and only 17·9% at primary care facilities.

Again perhaps as a product of China's size, sustained mechanisms for multi-sectoral collaboration has somewhat constrained progress in controlling health risk factors and, despite the collaborative vision of Healthy China 2030, fragmented governance and poor coordination between health, development, transportation, and education sectors reduces the consideration of health in all policies. For example, the tobacco industry in China has no incentive to engage in tobacco control due to its leverage as a major tax payer, which hinders China's progress.

Another example is the prevention and control of overweights and obesity in children and adolescents. Sugar taxes on food and drinks, promotion of physical activity in schools, health education, and increasing access to weight services are effective measures in obesity control, however, these measures are not implemented in a coordinated manner. Greenhalgh's study (how Coca-Cola shaped obesity science and policy in China) suggested that the soda industry had influenced obesity science and policy in China, leading to an insufficient emphasis on diet in anti-obesity policies.

Recommendations

Establish a population-based integrated delivery system

Transforming these hospital-led systems to ones that truly prioritise population health requires a systemic approach that strengthens Primary Health Care (PHC) centres so that people trust and willingly use them, and at the same time incentivises hospitals and holds them accountable for investing in population health instead of expanding high-tech diagnostic and treatment capacities.

1. Numerous randomised controlled trials (RCTs) from rural China have shown that primary care, led by village doctors or non-physician healthcare workers has been effective in the management of chronic diseases. International studies also show the potential role of non-physician PHC providers in improving health outcomes and patient satisfaction.
2. To attract and retain this primary care workforce, China can use both financial and non-financial incentives; for example, physician salaries can be supplemented with performance-based compensation tied to metrics, such as screening and management of NCDs, quality of basic health care, and patient satisfaction.
3. Financial incentives should be complemented by social recognition within the communities they serve and, importantly, among their professional peers.
4. PHC providers can leverage technological advancements, such as artificial-intelligence-enabled clinical decision support systems (CDSSs)

Leveraging digital tools to support healthier lifestyles

The government could make greater use of interactive digital health tools—such as mobile health and wearable technologies—to influence individuals to adopt healthy lifestyle behaviours. Wearable devices are unique in their ability to collect detailed information about individual health status and provide instantaneous feedback to affect behaviour change. Evidence from digital health programmes organised by Singapore's Health Promotion Board , such as the National Steps Challenge, supports the effectiveness of using wearable technologies and mobile health platforms to blend behavioural change principles with public health guidance. Mobile health technologies can also help create the social conditions necessary to sustain behavioural change such as healthy activities.

Mobilising modern information campaigns to address health risk factors

Evidence supports the effectiveness of traditional means of information dissemination, such as TV, radio, and public transportation advertisements, as well as educational initiatives at schools and within communities. In addition to these methods, the authors recommend that China uses its unique apps ecosystem to disseminate short video advertisements. For personalised nudges, studies have shown that tailored communication increases the perceived personal relevance of information, resulting in greater engagement in effecting the desired health behaviour change.

Improving financial protection for vulnerable populations

China should consider a re-design of its health insurance schemes and medical assistance programmes to protect low-income households. To protect these populations from financial risks, it is important to expand the central finance-funded medical assistance pools and establish assistance schemes providing tiered support for beneficiaries, setting an out-of-pocket maximum for individuals in different income brackets.

Promoting health in all policy making

Implementing health in all policies through multi-sectoral or multi-ministerial collaboration such as across national development, education, health and licensing is a proven approach to address health risk factors and improve population health. China should learn from this and establish a high-level coordinating body at the State Council with engagement from various sectors. The central government could incorporate key health-related indicators into performance evaluations for local officials, which are used for career promotion decisions

Building a monitoring and evaluation system for UHC

As mentioned in Part I, the existing WHO and World Bank global UHC monitoring frameworks are not fully compatible with China's health-care demand, a problem that high-income countries also encounter.

More quality-based indicators that measure service coverage of chronic diseases and conditions should be included to develop an informative UHC monitoring framework for China.

Conclusion

The Healthy China 2030 strategy and its corresponding action plans provide important platforms for advancing China's Universal Health Coverage (UHC). Given the rapidly rising incidence and burden of NCDs, these action plans prioritise the prevention and treatment of NCDs, including minimising smoking prevalence, promoting exercise, reducing air pollution, increasing hypertension and diabetes management, improving cancer detection and treatment, and promoting long-term care.

However, transforming these targets into reality requires a systemic approach guided by continuous monitoring, evaluation, and adjustment.