Xing Lin Feng1*, Jin Xu2 and Kristof Decoster3
1 Department of Health Policy and Administration, School of Public Health, Peking University.
2China Centre for Health Development Study, Peking University, currently Research Degree Student, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine
3 Department of Public Health, Institute of Tropical Medicine, Antwerp.
*Correspondence to firstname.lastname@example.org
Disease-specific programs could be harnessed diagonally to strengthen a country’s health system, World Bank President Jim Kim emphasized at the 66th World Health Assembly. “For decades, energy has been spent in disputes opposing disease-specific “vertical” service delivery models to integrated “horizontal” models. Delivery science is consolidating evidence on how some countries have solved this dilemma by creating a “diagonal” approach: deliberately crafting priority disease-specific programs to drive improvement in the wider health system. … Whether a country’s immediate priority is diabetes; malaria control; maternal health and child survival; or driving the “endgame” on HIV/AIDS, a universal coverage framework can harness disease-specific programs diagonally to strengthen the system.”
With this well received speech by the World Bank President, the 66th World Health Assembly witnessed a converging stance of the World Bank to the WHO’s on post-2015 health priorities and development. It appears that “Health for all” is back, but now reframed as Universal Health Coverage (UHC). The horizontal approach of a few decades ago is replaced by a diagonal one, after the experiment with vertical programs in the 1990s and early 2000s was less convincing than anticipated by some. Equal access to quality primary health care is thus back on the global agenda, 35 years after Alma Ata. As the largest developing country in the world, China not only inspired the horizontal approach in the 1970s, but also experienced a substantial shift to a “laissez-faire” paradigm in recent decades, in the belief that this would boost economic efficiency.
In this editorial, we reflect on China’s health development paradigm shift from a historical perspective and argue that there are other paths conceivable towards UHC, going beyond the diagonal approach now advocated by the World Bank. Strengthening a country’s health system with a view on making progress towards UHC can focus on some specific building blocks and functions, step by step, “crossing the river by feeling for the stones”, as Deng Xiao Ping would have called it.
Even if there are some dissenting voices, it is well documented that in Mao’s time, China managed to achieve a dramatic health improvement through a grassroots-based, deprofessionalized and low-tech health development paradigm. A three tiered village-township-county referral system with so called “barefoot doctors” serving at the village level, supported by a cooperative medical scheme (CMS) funded by the collective economy, was established to cover more than 80% of the rural population. By focusing on and adopting a feasible solution for the vast rural areas, China underwent its epidemiologic transition (in terms of control of infectious diseases and increase in life expectancy) at a very low economic development level, many years ahead of similar nations. China’s public health success in the 1970s was obvious, as can be inferred from the great reduction in infectious diseases. The barefoot doctor approach, aiming at delivering basic health care by people who had received little modern medical training, inspired the “horizontal approach” and became one of the role models for the Primary Health Care initiative in Alma Ata. However, no rigorous study has yet been conducted to identify the Chinese “magic bullet”. Although acknowledged by some international authors, the pivotal role of the Chinese national “Patriotic Health Campaigns”, which engaged the whole society to improve hygiene and sanitation, has been somewhat neglected so far. In Mao’s era, “People’s War” was actually considered as the solution to all public problems. What really mattered for the success, and is widely accepted as such by most Chinese national policy analysts, was not the roll-out of barefoot doctors that had no more than secondary education and no formal medical training in providing quality care, but rather the involvement of the whole Chinese society, through mass mobilization. Mass campaigns, embedded in a so called “mobilization culture”, helped improve hygiene and sanitation and were probably the decisive factor. The battles against smallpox, schistosomiasis and lepra were all typical examples of this approach and even the presence of barefoot doctors all over the country was one of its products.
The market-oriented economic transition since 1978 posed great challenges to China’s health system, as it was trying to catch up with a rapidly changing context. In the early 1980s, the CMS almost collapsed overnight along with the rural collective economy, transforming village doctors into profit-chasers who heavily began to rely on selling drugs. In 1992, Deng Xiaoping reaffirmed the need for fast and large scale adoption of market forces to boost economic development. Under Deng and his successors, China became, at least partially, a market economy, and the country leaders opted for a more “laissez-faire” paradigm than in Mao’s era. With the gradual withdrawal of the central planning system, the government was unable to financially support the oversized public sector (for example public hospitals and schools) any longer. Efficiency and modernization increasingly showed up in central considerations. “Autonomization” of public providers became the buzzword and health facilities were allowed to fund themselves through profit from more services, prescription of drugs and adoption of new technologies. Health development in China thus witnessed a major shift from a community-based approach to a facility-based one (especially hospitals), providing increasingly specialized care.
As China moved away from the horizontal approach, there were at least two major consequences. Firstly, boosted by increasingly common beliefs on science and technology as the primary productive forces in society, many health providers in China voluntarily and eagerly jumped on the modernization bandwagon. A quick glance at some of the large hospitals in China 30 years later, not only in developed metropolitan areas like Beijing and Shanghai, but also in second tier cities, shows a great convergence with the most advanced hospitals in the developed world, if not technological superiority. Secondly, the reforms towards more autonomization were accompanied by deregulation and monopolies, which fundamentally altered the behavior of the various health organizations considered as public providers. They, along with the lack of health insurance coverage, were responsible for the high incidence of medical impoverishment since the 1980s. As a result, in 2000, when the World Health Organization ranked the health systems of its 191 member states, China’s health system showed up in the lowest quartile with respect to providing fair financial protection.
After SARS (2003) and particularly after 2005, when the Development Research Center of the State Council, a key advisory body which recommends policies to the central government, concluded that China’s health reform had basically been a failure since 1978, policy makers gradually started to recognize the problem with China’s health system in shifting away from the primary health care focus. Central policy makers, international agencies and scholars discussed ways forward. Finally, after receiving nine proposals of reform suggestions from various think tanks and institutions, including the WHO and World Bank, a new health reform was kicked off. Aided by substantial financial investment, the new campaign-like movement achieved universal population coverage by introducing various types of social health insurance in a remarkably short time (2003-2009). However, there was no consensus on whether the rapid extension of coverage really made a difference in achieving its ultimate goal – reducing medical impoverishment -, partly due to the distorted incentives for health providers (see here and here, for example).
The government realized that the huge financial investments were compromised by the system’s fragmentation in terms of service delivery, since patients in China now prefer large hospitals over community health services for primary care. Moreover, due to the financial decentralization, a key aspect of China’s transformation since the 1990s, coordination between fiscal capacity and responsibility of different levels faced great challenges. Huge fragmentation could also be seen at the central level. At some point, no less than a dozen ministries were responsible for health issues, with all the bickering and jockeying for departmental interests that can be imagined. Now the biggest challenge for China is how to integrate and coordinate the financing and service delivery functions of its health system. Should the public hospitals go further on the path of the last decades, from increasingly autonomous entities towards fully privatized corporations, in which case the government could shift its focus to the provision of community health care? Or should public hospitals instead again become fully funded by public resources and function as real public providers? Since formal staff nominations in public hospitals are currently based on government tenure quotas, a deepening of political reforms should be on the agenda.
Two points warrant attention according to China’s experiences in recent decades. Firstly, contexts are always important. The horizontal approach was inspired by the barefoot doctor system, which was successful in Mao’s time. The approach needs to be adjusted to changing settings and environments; for example, it is unlikely mass mobilization like in Mao’s time still has a lot of appeal in an increasingly individualized society. Moreover, the Chinese example showed that the approach has its limits in terms of – sustainably – providing quality care. The primary health care approach needs the support of qualified staff to deliver the services, if it is to be successful and sustainable. Secondly, as China has demonstrated in recent decades, strengthening a national health system towards UHC may go beyond application of a diagonal approach, or “crafting priority disease-specific programs to drive improvement in the wider health system”, an approach which is no doubt valuable in many settings towards health systems strengthening and UHC reform. In China, however, reforms started in the 1980s by strengthening the service delivery function, along with the market-oriented transition. Unfortunately, with the increasing focus on efficiency, equity issues arose. Reforms then focused again on the financing function to correct the equity problem, after 2005. Again this was easier said than done, as substantial government financial efforts proved to be compromised by the new service delivery situation, whereby people had “learnt” to bypass community health centres and go straight to big hospitals. The road towards UHC can thus be complicated, and policy makers should be nimble in dealing with the many and sometimes surprising hurdles they encounter on the way. Without any doubt, though, national ownership and stewardship are indispensable to make progress. This, also, China has proved over the last decades.