Towards universal health coverage: lessons from 10 years of healthcare reform in China

Tao, Wenjuan; Zeng, Zhi; Dang, Haixia; Lu, Bingqing; Chuong, Linh; Yue, Dahai; Wen, Jin; Zhao, Rui; Li, Weimin; Kominski, Gerald F

stage 1: 30 years after the founding of people's republic of China (1949 China ( -1979 At the founding of PRC, with a weak foundation, the state developed a centrally planned socialist system, emphasising public ownership and welfare, mass-based collectivism and egalitarianism. 20 In the health sector, the government managed a centrally directed health delivery system, and defined four principles to guide health and medical work: (1) serve the workers, peasants and soldiers; (2) put prevention first, in particular through the Patriotic Health Campaigns; (3) integrate traditional Chinese medicine with Western medicine; and (4) combine health work with mass movements. 21 22 These principles of healthcare delivery reform contributed to rapid improvement in the health of the population, 23 creating some reform models (eg, 'Barefoot Doctors', 24 'Cooperative Medical System' 25 and 'threetier health service delivery system') that were highly valued by the WHO. 26 During this period, despite a shortage of healthcare resources, China's healthcare BMJ Global Health system achieved almost universal access to healthcare and preventive services, producing impressive health gainsfor example, dramatically increased life expectancy and decreased infant mortality. 27 stage 2: 30 years after the 'reform and opening up' policy Beginning in 1978, China began its 'reform and opening-up' policy, ushering in a socialist market economy that encouraged a free market and focused on economic growth. This led to a fundamental transformation of the Chinese healthcare system and had a profound impact. 28 29 With privatisation and marketisation, the changes in the healthcare system included: a shift from public financing to private sources; a reorganisation of public hospitals and clinics into commercial enterprises; decentralising healthcare governance to local governments; and a pricing policy that enabled facilities to gain profits. 30 31 These changes helped expand healthcare resources and improve medical technology and equipment, but also posed many problems (eg, reduced government expenditure on healthcare, less emphasis on rural areas and public health, and overutilisation of unnecessary or expensive care), 32-34 resulting in a series of adverse effects, such as increased disparities between rural and urban residents, a decline in public health, rising healthcare costs and sharp decreases in insurance coverage. 23 31 35 In 2003, the severe acute respiratory syndrome epidemic revealed weaknesses in China's health system and focused a domestic and international spotlight on those weaknesses. 36 This wake-up call opened a window of opportunity for a new round of healthcare reform. 37 It is an unprecedented health system transformation towards UHC, aiming to provide universal coverage of basic healthcare by the end of 2020. 38 39 Following extensive interagency consultation and public debates, this launch emphasised a return to government-led, people-centred healthcare and healthcare as a public good. The latest round of healthcare reform adopted the 'best fit' with the existing institutional and policy frameworks towards achieving UHC by an incremental approach (step by step), which was recommended by the WHO team. 40 The 'Opinions on Deepening the Health Care System Reform' that were promulgated by the Central Committee of the Communist Party of China (CPC) and the State Council marked the start of China's new healthcare reform. 41 The comprehensive reform plan