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

Increased government public funding was invested to expand the services (from 9 categories in 2009 to 14 categories in 2017) and availability of the basic public health package to almost everyone; an average of ¥15 was allotted per capita in 2009 and was increased to ¥55 in 2018. Supporting programmes to control the main public health problems. 51 52 Figure 2 illustrates the priorities and relationship among the three healthcare reform plans. mAIn reform InITIATIves And ACHIevemenTs of THe pAsT deCAde Health insurance system Reforming the health insurance system is essential and critical since it has served as the major source of financing for the healthcare delivery system. Basic health insurance in China, including the Urban Employee Basic Medical Insurance, the New Rural Cooperative Medical Scheme (NRCMS) and the Urban Resident Basic Medical Insurance (URBMI), laid the foundation for universal insurance coverage. Priority was given to expanding the scope and health service package of the basic insurance coverage, improving provider payment mechanisms, as well as increasing the financing level, fiscal subsidies and reimbursement rates. To improve equity in access to healthcare between rural and urban areas and efficiency in operation of the schemes, 53 the Chinese government consolidated the fragmented health insurance schemes by merging NRCMS and URBMI into the Urban and Rural Resident Medical Insurance in 2016, 54 and then established the National Healthcare Security Administration in 2018 to implement unified management for these insurance schemes. In addition, the government launched Medical Financial Assistance in 2003 and Catastrophic Medical Insurance in 2012 as supplementary medical insurance to provide funds for patients with poverty and catastrophic illness. 55 The moves, parts of 'Health Poverty Alleviation (HPA)' (a critical element of the national Poverty Alleviation Project), are significant steps towards 'Healthy China' and UHC, protecting people with low incomes from impoverishment due to exorbitant healthcare costs, and breaking the cycle of poverty and illness. 55 The payment reform is being implemented to modify the behaviour of providers and to control the unreasonable growth of medical expensesreplacing fee-for-service payment with comprehensive payment methods based on disease category. 56 drug supply and security system As the base of drug supply and security system, the national essential medicines system reform is comprehensive and includes but is not limited to the following: the selection, production and distribution of essential medicines; quality assurance; reasonable pricing; tendering and procurement; a zero mark-up policy on sales; rational use and reimbursement; and monitoring and evaluation. 57 The government issued a revision of the National Essential Medicines List (NEML) in 2009 including a list of 307 essential medicines, and constantly expands the list to fully meet the needs of basic healthcare. 58 These on-list medicines should be available at all primary care institutions. To improve access to medicines, China boosted the research and development of generic drugs, and required the evaluation of generics to prove they are equivalent to the originator products in terms of quality and efficacy. 59 A 'two invoice policy' tendering system was developed to avoid higher mark-up and reduce circulation during the process of distribution. 60 All medicines in the NEML are included in health insurance rei