Series on Contemporary China, v. 36. Hackensack, NJ: World Scientific, 2014. viii, 354 pp. (Figures, tables.) US$125.00, cloth. ISBN 978-981-4425-88-9.
China has undergone significant changes in health-care policy since the beginning of the twentieth century. In the late imperial period, Confucian governments were non-interventionist in people’s health. In the twentieth century, China’s government increasingly saw the management of the health of the population as an important responsibility, even if it was unable to care for the vast majority of the people. Policy changes in the People’s Republic in 1949, 1965, 1979, and 2009 have been dramatic. The first two provided near universal public health, and then basic primary health care, decreasing infant mortality from 200 to 34 per 1000 live births, and raising life expectancy from 35 to 65 years. Market-based reforms after 1979 saw state expenditures drop and health outcomes for the rural majority decline until a new round of reform attempts in the 2000s.
Health Policy Reform in China examines only the very recent round of reforms in China’s health policy from the perspective of comparative health economics. In part 1, Qian and Blomqvist introduce the results of moving away from a centrally planned health system toward a market-based one in the 1980s—central government subsidies for health care were reduced and patients faced higher charges as hospitals marked up drugs and added new fees. Insurance coverage from rural cooperative medical schemes and urban insurance were reduced. The economy of China boomed, but health care became a burden for a growing number of Chinese.
Qian and Blomqvist argue that a mixture of state and market mechanisms are the best model. Throughout the book, the authors offer comparisons to the UK and the Netherlands as positive models. They claim that all health-care economists agree on two basic requirements for health-care reform: equity and efficiency. Each system approaches these differently, with the NHS in Britain covering all residents equally, while adopting supply-side incentives where patients choose providers, while the Dutch system allows citizens to choose one of many competing social or private insurance plans. The US system is rejected for its inequity and inefficiency.
In part 2, Qian and Blomqvist examine the main components of the current health reform, including social insurance systems, primary care, hospital reform, and drug policy. Each component either works toward, or against, the two goals of equity and efficiency. Reformers face the question of whether social insurance should be covered by taxes or by fees, and whether there should be private insurance options. Three systems have developed: the Basic Health Insurance system for urban workers, the new Rural Cooperative Medical Scheme, and the Urban Resident Basic Medical Insurance. The government chose to take a more active role with the aim of universal coverage by 2012 (the year at which most data in the book ends). A recent report claims that 95 percent of Chinese people are now covered, indicating some measure of success for the new reforms in terms of equity, although it admits that the problem of expense and limited access despite insurance coverage has not yet been solved (Wen Xueguo and Fang Zhiwu, Zhongguo yiyao weisheng tizhi gaige baogao 2014–2015, Beijing: Social Sciences Academic Press, 349). Reforms to balance primary and hospital care and improve drug policy aim to address these.
Part 3 examines inequality in healthcare as part of the CCP’s slogan of “harmonious development,” and the authors argue that providing equal care to all Chinese is not currently realistic, and instead suggest that the government should guarantee access to “at least a basic menu of health services and drugs to everyone, including the poor” (239). Part 4 looks to the future of China’s health system and posits that a compromise solution between markets and government purchasing may be reached, as in a number of developed nations such as Canada or Japan. Finally, Qian and Blomqvist see the most likely outcome being that China will follow the Dutch model of a mixed private and public health insurance scheme.
This is a technical book for policy makers and economists and a weakness is its lack of historical perspective. Qian and Blomqvist admit that the Maoist-era government “could point to its health policy as a comparative success,” yet they nonetheless feel that the Reform Era of dismantling central planning has been “a vast improvement in comparison with what had gone before it” (3). Yet only one page later, the authors include UN data that demonstrates the opposite in one simple chart: life expectancy in China shot up dramatically between 1965 and 1975, the period of most intense revolutionary egalitarian health policies, only to return, in the Reform Era, to the standard rate of increase for developed economies.
The authors praise decentralization and privatization against the influence of officials (89–91). This small-government, decentralized approach fails to acknowledge that a private health bureaucracy creates at least as much inefficiency and waste as a centralized one. Ironically, the authors admit that “a large body of skilled managers” will be needed “if the system is to be managed in a decentralized fashion” (90). The shift to a market-based health-care system “has not led to higher productivity, [but] … only to substantially higher costs and more waste of resources” (12). Thirty years of market reforms have led to more untreated illness today than when the reforms began, as sick people wait to seek treatment until symptoms reach a crisis point, and providers push unnecessary and expensive treatments and medication to raise their income. The authors do not address the widespread phenomenon of desperate patients who physically assault health-care providers, euphemized as “the doctor-patient relationship” (yihuan guanxi). While one may hope that China will achieve greater health equity under the current reforms, one could well wonder if the hybrid market reforms suggested here are merely a case of treating the symptom rather than the disease.
David Luesink
University of Pittsburgh, Pittsburgh, USA
pp. 639-641