Special theme – Health financing
Universal coverage and health financing from China’s perspective
Shanlian Hu a
Universal coverage of health services everyone should have an equal right to of government spending in total health
is required to ensure social equity and health. expenditure is less than 1% of GDP,
justice, particularly for China, which is The government focus has shifted multi-health insurance schemes have
a developing country with an enor- from developing the economy to offer- not been integrated and the basic ben-
mous population. ing public services aimed at improving efit package varies widely in different
Since the 1980s, the Chinese the living standard of the population. schemes and provinces. Enrolment is
health system has not been perform- Health development must be people- still based on voluntary participation.
ing well. The income gap between the oriented and sustainable. For example, Government subsidies are not enough
rich and poor has widened and the recently the Chinese government to relieve the economic burden when
“marketization” of medical services has significantly increased its financial sup- people on very low incomes need medi-
led to a decline in equity and access.1 port to farmers and rural areas. Funds cal care. Prepaid and capitation pay-
The world health report in 2000 showed were transferred from the central gov- ment systems, as well as the gatekeeper
that equity of financial contributions in ernment to provincial governments in system, need re-engineering. Promoting
the Chinese health system was poor,2 the middle and western parts of China the equality of public health services
and demonstrated that government for the development of the rural and is necessary. Now that China has put
spending was less than 20% and that urban medical insurance system. health financing on the political agenda,
user fees from consumers were nearly A resolution on sustainable health health reform policies will begin to
60% of total health expenditure.3 In financing, universal coverage and social move towards universal coverage. ■
addition, only 15% of the population health insurance was endorsed in the
in the formal sector is covered by social 58th World Health Assembly in May References
health insurance. The majority of rural 2005.6,7 In 2005, WHO’s Regional 1. Yanfeng Ge et al. Evaluation and
and urban residents, children and im- Offices for South-East Asia and the recommendations for Chinese health system
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(supp.1). Shanghai: Development Research
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is common in China. Although more on the United Nations’ Millennium improving performance. Geneva: WHO; 2000.
than 95% of health facilities are public Development Goals and the 2005 3. China National Health Accounts Report. Beijing:
hospitals, 90% of operational funds are WHO resolution. Since 1978, the China National Health Economics Institute; 2007.
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dependent on fees-for-service. Even in number of people classed as “absolute
force of China’s development. Xinhua Daily
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6. Sustainable health financing, universal coverage
has been booming. Gross domestic was covered by three medical insurance and social health insurance [WHA58.33].
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development does not necessarily lead rural and urban China will be covered and social health insurance [WHA58.20].
to investments in health. China’s expe- by medical insurance. Geneva: WHO; 2005.
rience confirms that political commit- Health reform and development is 8. Health financing strategy (2006-2010). New
Delhi & Manila: WHO Regional Offices for South-
ment is extremely important: changing facing a critical time in China and uni-
East Asia and the Western Pacific; 2005.
the government perception is the versal coverage has a long way to go.11 9. Wen J. [Keynote speech]. In: United Nations’
key. The Constitution of the People’s The vision is that a basic health system Millennium Development Goals Summit, New
Republic of China, amended in 2004, will be established to provide health York, 25 September, 2008.
mandated that the government respect services for all by the year 2020 and so 10. Hu SL, Tang SL, Liu YL, Zhao YX, Escobar ML, de
and protect human rights (Article 33) continuously improve the health status Ferranti D. Reform of how health care is paid for
and that it develop the required social of the Chinese population. in China: challenges and opportunities. Health
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insurance, social relief and medi- Compared with other transi- Available at: www.lancet.com
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enjoy this right (Article 45).5 Basic in the universal coverage of health at a crossroads. Health Aff 2008;27:460-8.
health rights are part of human rights; services and their financing. The share PMID:18332503 doi:10.1377/hlthaff.27.2.460
School of Public Health, Fudan University, Shanghai, China.
Correspondence to Shanlian Hu (e-mail: firstname.lastname@example.org).
Bulletin of the World Health Organization | November 2008, 86 (11) 819