Lessons from the East:
China's Rapidly Evolving Health Care System
At first glance, China might seem unlikely to
offer useful health care lessons to many other countries. Its health system
exists within a unique geopolitical context: a country of more than 1.3 billion
people, occupying a huge, diverse landmass, living under authoritarian
single-party rule, and making an extraordinarily rapid transition from a
Third-World to a First-World economy.
But first
impressions can be misleading. Since its birth in 1949, the People's Republic
of China has undertaken a series of remarkable health system experiments that
are instructive at many levels. One of the most interesting lessons from the
Chinese experience concerns the value of an institution that many countries
take for granted: medical professionalism.
Because the changes
in China's health care system have been so rapid and profound, it is helpful to
briefly review its recent history. What might be seen as the first of four
phases began when the Chinese Communist Party took power in 1949. The new
government created a health system similar to those of other communist states
such as the Soviet Union and its Eastern European allies. The government owned
and operated all health care facilities and employed the health care workforce.
No health insurance was necessary, because services were nearly free. A
distinctive accomplishment of this phase was the system's successful use of
community health workers, so-called barefoot doctors, to provide basic public
and personal health services at the village level. Between 1952 and 1982,
China's infant mortality rate fell from 200 to 34 per 1000 live births, and
age-old scourges such as schistosomiasis were largely eliminated.
In 1984, a second
phase began: China turned its health system on its head, almost as an
afterthought to dramatic free-market reforms in the rest of its economy. Led by
Communist Party leader Deng Xiaoping, China converted to a market economy and
reduced the role of government in all economic and social sectors, including
health care. Government funding of hospitals dropped dramatically, and many
health care professionals, including barefoot doctors, lost their public
subsidy. The government continued to own hospitals but exerted little control
over the behavior of health care organizations, which acted like for-profit
entities in a mostly unregulated market. Many health care workers became
private entrepreneurs. Physicians working for hospitals received hefty bonuses
for increasing hospital profits.
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