HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA

Item

Title
HEALTH POLICY
AND SYSTEMS RESEARCH
IN CHINA
extracted text
HEALTH POLICY
AND SYSTEMS RESEARCH
IN CHINA

O. Meng

G.Shi
H. Yang
M. Gonzalez-Block

E. Blas

In partnership:

China Health
Economics
Institute

World Health
Organization, China

UNICEF/UNDP/World

Alliance-HPSR

Bank/WHO

Special Programme for Research and
Training in Tropical Diseases (TDR)

Co intends
Terms and abbreviations

iv

Foreword

v

Executive summary

vi

i

Background

I

2

Policy context and challenges
2.1 The five balances
2.2 Health policy-research dialogue

........ . . 3
4

Research evidence for the nth Five-year Plan

5

3.1 Globalization and macroeconomic trends
....... 5
3.2 Population and health status trends ...
6
3.3 Economic reform and health care financing
7
Sources offunding.....................
....................................................................7
Allocative efficiency

..........

Equity

8
8

Organization and delivery of public health programmes
Ownership and governance
Cost containment and regulation
Provider performance management
National policies - local implementation strategies

9
II
II
12
13

Research needs and systems
4.1 Current research needs to close gaps in knowledge
4.2 Likely future research needs to close gaps in knowledge
4.3 Gaps in research capacity
4.4 Options for closing the gaps

IS
IS
16
I7
I8
18
18
19
19

Insurance

3.4
3.5
3.6

3.7
3.8
4

.... 1

...

............................

Improving the research-policy dialogue

Contracting-out and commissioning of existing institutions ....
Creation of new institutions ....
Capacity building for policy and systems researchers and policy-makers

5

Conclusion, strategy and way forward

20

Annex: Directoryof health policy research institutions

21

References

22

About the Authors ......................... ............................................................................

24

HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA - TDR/GEN/SEB/04 1

3

3
...

Terms and abbreviations
AIDS

Alliance-HPSR
CDC

Acquired immunodeficiency syndrome

Alliance for Health Policy and Systems Research
Center for Disease Control, a public health institution with responsibility for disease prevention

and control in China

CMS

Cooperative Medical System, a community financing scheme for health services in rural areas

of China

COPD
CT

Chronic obstructive pulmonary disease

Computerized tomography

DFID

Department for International Development, UK

DOTS

Directly Observed Treatment Strategy for Tuberculosis

EPI

EU

GDP
Gini coefficient

Expanded Programme of Immunization
European Union

Gross domestic product
A measure of income inequality, is a number between o and t, where o means perfect equality

(everyone has the same income) and i means perfect inequality (one person has all the income,

everyone else has nothing)
HIV

Human immunodeficiency virus

IDRC

International Development Research Centre. Ottawa,Canada

INCO

International Cooperation (EU)

MRI

Magnetic resonance imaging

NGOs

Nongovernmental organizations

PET

Positron emission tomography

R&D

Research and development

SARS

TB
TDR

Severe acute respiratory syndrome
Tuberculosis

UNICEF, UNDP, World Bank, WHO Special Programme for Training and Research in Tropical

Diseases
UK

UNICEF

UNDP

USA

United Kingdom

The United Nations Children's Fund

United Nations Development Programme
United States of America

WHO

World Health Organization

WTO

World Trade Organization

Foreword!
In 2003, the Chinese government proposed its strategy for achieving a Xiao Kang society, which is
people centered and based on a comprehensive, coordinated, and sustainable development concept.
A development plan based on five balances between urban and rural areas, regions, social and eco­

nomic sectors, humans and nature, and domestic and global markets, is the main strategy of the new
development concept. Health is an essential element of a Xiao Kang society - if the health of all peo­
ple is not improved, it will not be a Xiao Kang society. Thus more attention must be paid to health due

to its importance in social and economic development.

Over the past half century, China has, with very limited resources, made progress in improving the
health status of its people, and this has been recognized throughout the world. China now provides

widely accessible services to most of its 1.3 billion head of population. However, compared to the aims
of a Xiao Kang society, still more needs to be done to improve the health system.

Health sector reform and improvement of the health system requires research to provide scientific evi­
dence of the need to re-examine existing health policies and create more effective policies for the

future. Over the past two decades, great progress has been made in health policy and systems
research, and this has impacted positively on health reform and policies.

This document, prepared by the China Network for Health Economics, WHO, TDR, and the AllianceHPSR, is a product of the Health Policy Forum held in May 2004 in Beijing, with the participation of

high-level policy-makers from central and provincial levels as well as researchers. The document
describes the social and economic context of the country, carefully considers the opportunities and
challenges facing the government in public health, and systematically summarizes key research find­

ings relevant to policy-making. More importantly, it identifies knowledge gaps and proposes a number
of options for filling these gaps.
I believe that this document will be helpful for Chinese as well as international readers wishing to
understand Chinese health policy-making and systems research, and for identifying areas of coopera­

tion I hope the document will be given the attention it deserves.

Renhua Cai
Professor and Executive Director
China Network for Health Economics
October 75, 2004

Executive summary
In the past three decades, along with rapid economic

natural environment, and between the domestic and

development in China, the overall living standards of the

international markets. The five balance policy provides

population have generally improved. However, disparities

both opportunities and challenges for health sector poli­

in social and economic development between urban and

cy-makers and practitioners.

IN CHINA • TDR/GEN/SEB/04

1

rural areas, between the eastern and western regions,

and between the rich and the poor have increased The

The context of policy-making has significantly changed

health status of the population has improved, but the

over the past years with increasing awareness among

rate of improvement has reached a plateau. While non-

senior officials of the importance of evidence-based pol­

communicable diseases have become the major disease

icy-making. This is primarily a result of greater openness

burden, infectious diseases such as tuberculosis, hepati­

in the society to constructive dialogue and critique, i.e.

tis. and schistosomiasis are still the major health prob­

to learning from success and failure, including among

lems in poor rural areas HIV/AIDS and other emerging

the political leadership The outbreak of SARS played an

diseases such as SARS have become new threats to pub­

important role in opening eyes to the need for critical

lic health. Wide disparities in health status exist, eg.

review of the sector.

infant and maternal mortality are more than two times

higher in rural than in urban areas and in the western

The key research evidence relevant to the nlh Five-Year

compared to the eastern region

Plan can be grouped under eight headings.
• Globalization and macroeconomic trends. The devel

The social and economic transitions experienced since

opment of the labour market might have far reaching

the late 1970s have brought changes to the health sector

health consequences, the changes in lifestyle will

including its partial marketization and privatization.
Concerns have been raised by research related to

financing, efficiency, regulation, equity, quality, and cost

of health services. China faces a number of major chal­

lenges in the future, including: increased globalization,

population migration, and demographic and epidemiolog­

ical transition. How these challenges are addressed will be
critically important for the coming generations.

Over the past decades, significant changes in Chinese
society have affected the health sector in these ways:

• responsibilities have been rearranged between all five

result in increase of noncommunicable diseases
• Population and health status trends There is evidence

for higher prevalence of communicable diseases and

relatively worse child and maternal health in poor and
migrant populations; new health challenges are facing

China with its social and economic development

• Economic reform and health care financing. The intro­
duction of financing through user-fees has significant­
ly impacted equity in the society, and there is low effi­
ciency in the allocation of public resources for health.

levels of government (national, provincial, prefecture,

• Organization and delivery of public health pro­

county (district), township) in the economic and social

grammes. Several changes in policy have had adverse

sectors;

effects on the performance of public health pro­

• individual rather than collective arrangements now

play a greater role in providing social services,

grammes and possibly on disease patterns
• Ownership and governance. There is no conclusive sci­

• market mechanisms and forces have been applied to a

entific evidence that the new ownership models have

wide range of services and exchanges in the society;

had the intended impact; on the contrary, both the

• part of the public or collective sectors has been pro­

gressively privatized.

public and privately owned health services operate
along the same lines and lack willingness to engage in

e g. preventive services.

The n,h Five-Year Plan will address the main shortcom­

• Cost containment and regulation. There has been very

ings through the policy of five balances: between rural

limited success, if any, in containing costs in the health

and urban areas, between regions, between economic and

sector because providers find ways to compensate the

social sectors, between economic development and the

losses posed by the control attempts.

fied for the nth Five-Year Plan and beyond, e g. in relation

to:
• transformation of the health financing system in the

context of the economic transition, urbanization, and
globalization of China
• re-orientation and development of the public health

system in the next 10-20 years based on situation
analyses and projections of future health problems

• the opening and regulation of the health care market

• the pricing system reform, the tax waver policy to pri­
vate investors in the health sector, and the enforce­

ment of regulation in the health care market
• transformation of the health care delivery system in
accordance with regional health planning to promote

improved allocative efficiency in the sector.
• the massive population movement from rural to urban
areas.

However, there are shortcomings in current policy and
systems research in China. These include:
• lack of a health policy and systems research agenda

agreed by policy-makers and the research community

• lack of a bridging mechanism between policy-makers
• Provider performance management. Several cases
suggest that staff bonus systems have had detrimen­

tal effects on public health.
• National policies - local implementation strategies.

and researchers
• lack of incentives for researchers to participate in prac­
tical policy and systems studies

• weak capacity

Health policy-making in China is very complex and

• customary lack of critical independence

there is evidence of considerable discrepancy between

• unfeasibility of policy recommendations

the actual national policies and what happens on the

• lack of funding opportunities for health policy and sys­

ground, including non-compliance with official dis­

tems research projects.

ease control policies.

Possible options for closing the gaps in research capacity
In the past decade, health policy and systems research in

could include improving research-policy dialogue by the

China has made significant contributions to knowledge

contracting of existing institutions through rigorous

and understanding of the complex transition of the soci­

competitive processes rather than through the creation

ety, and there are concrete examples of research which

of new institutions.

has been translated into policy. However, many policies

are still formulated on the basis of weak or no evidence,

and health policy implementation is not systematically
evaluated. There is a long way to go before health policy

and systems research reaches its full potential. Improved
communication and dialogue between researchers and
policy-makers will be critical to achieving this. Several
health policy and systems research needs can be identi­

<sr_:

HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA - TDR/GEN/SEB/04 ’

1 Background
Over the past two decades, China has experienced dra­

[Ministry of Health, 2004a] While noncommunicable

matic changes in both its social and economic structures.

diseases have become the major disease burden, infec­

The market-oriented economic reform successfully sus­

tious diseases are still prevalent and are the major health

tained an average growth rate of 8.3% in gross domestic

problems in poor rural areas Tuberculosis, hepatitis, and

product (GDP) between 1980 and 2000 [Hu and Hu.

schistosomiasis are the common public health problems,

2003], and the per capita GDP reached US$ 1090 in 2003.

while HIV/AIDS and other emerging diseases such as

While the overall population growth rate has slowed due

SARS have become new threats to public health In addi­

to effective family planning policies since the mid 1970s,

tion, the ageing population and the changes in lifestyle,

the urban population has increased significantly due to

including smoking and dietary habits, are resulting in

migration Along with economic development, the over­

changes in health service needs

improved. Monthly disposable income of urban and rural

Wide disparities in health status exist, eg. infant and

residents increased from 478 and 191 Yuan in 1980 to

maternal mortality are more than two times higher in

1049 and 337 Yuan in 2002, respectively, after adjustment

rural than urban areas and in western compared to east­

for inflation [National Bureau of Statistics, 2003].

ern regions

Disparities in social and economic development between

China's health care system was developed in three tiers,

urban and rural areas, between the eastern and western

ie village doctors and clinics, township health centres,

regions, and between the rich and the poor have grown.

and general hospitals in rural areas; and community

There are, at present, 30 million people in rural areas liv­

health centres (stations), district hospitals, and tertiary

ing in poverty according to official reports, most of whom

hospitals in urban areas. In addition, there are specialized

live in the western regions [Gong, 2004]. Using the USS 1

hospitals, disease control centres, and maternal and child

per day standard, it is estimated that 12.5% of the rural

health institutions. Significant improvement has been

population, i.e. about 162 million people, live in absolute

achieved in health care quality, access to health

poverty [World Bank, 2003]. How to decrease the dispar­

resources, and number of qualified health workers.

ities has become one of the prime concerns for the gov­

However, the social and economic transition experienced

ernment

since the late 1970s also brought changes to the health

sector, including marketization and privatization of part
The health status of China's population has greatly

it, and concerns have been raised that the system is no

improved over the past five decades, especially between

longer as effective as it used to be The government

the early 1950s and the mid 1980s, starting from a low

might, therefore, need to rethink and adjust its strategies

baseline and with an emphasis on provision of primary

for health sector development The main concerns raised

health care. Life expectancy reached 71.8 years in 2001.

by research are:

From 1990 to 2000. infant mortality decreased from 65

• Financing. Collection and allocation of resources for

to 31 per thousand live births, and maternal mortality

health care services are inequitable In 2003, 79% of

decreased by nearly 50 per cent [Yuan, 2004] However,

the rural population and 45% of the urban population

the rate of improvement in some health status indicators

was not covered by any health insurance [Ministry of

has reached a plateau. For example, the under-five mor­

Health. 2004b]. The uninsured are charged the same

tality rate declined rapidly,from 202 to 51.1 per thousand

fees for a given health problem regardless of econom­

between 1960 and 19851 Since then, the rate of decrease

ic status. There is no price differential according to

has slowed and the mortality rate of under-fives

income in the premiums collected by rural health

decreased from 51.1 to 35 per thousand in 1985-2002

insurance schemes. Unemployed workers in urban

1 www.yaolan.com/shiqi/Toddler/app/toddler_article.asptarticle-1009.

HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA • TDR/GEN/SF.8/041

all living standards of the population have generally

areas face financial difficulties in paying for health

care even though almost all of them are covered by the
urban health insurance scheme. Very few people who

migrate from rural to urban areas are covered by

health insurance, as migrants are not included in the
current urban social health insurance policies.
• Efficiency. The majority of health resources are allocat­

ed to urban services and tertiary hospitals. Public

funding is not sufficient to ensure provision of basic
primary health care in rural areas. Drugs and high
technologies consume a large proportion of health

2

resources, while unnecessary provision of services and

HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA - TDR/GEN/5EB/O4.1

irrational prescription of drugs result in wastage of
resources

• Regulation. The health regulations lack coordination

between line sectors, e.g. the departments of health,
public security, drug administration, and finance

Enforcement is not well undertaken due to insuffi­
cient financial resources and shortage of capable reg­

ulators, especially in rural areas.
• Equity. Inequities in health status and access to health

care between geographical areas and social groups are
growing [Gao et al., 2002, Zhan et al, 2004] Disparities

of health status are evident between regions and pop­
ulation groups.

• Quality. The quality of health care has improved, espe­

ology of disease, lifestyle and health of the Chinese

people.
• Population migration. Population movement from
rural-agrarian to urban-industry/service environments
has increased rapidly and may even increase faster in
thecomingyears.constitutingan unprecedented pop­

cially in cities and large hospitals. However, in rural

ulation move. How to address health care provision

areas, quality lags behind, as measured in terms of

under such conditions will be a massive challenge.

qualification of health workers and services provided
• Cost. During the past two decades, medical costs have

• Demographic and epidemiological transition. The suc­
cess of the 'one child’ policy, combined with better

escalated by far in excess of income and inflation.

health and living conditions, will compress the demo­

Utilization of high technologies and expensive drugs,

graphic transition and lead to a population with a high

and the low occupancy rate of hospital beds are some

proportion of elderly people in China within one gen­

of the critical factors contributing to this cost escala­

eration, as compared to two or three generations in

tion.

Europe. While population ageing appeared in devel­

oped countries when per capita GDP reached US$ 10
China faces a number of major challenges. How these

000. in China, ageing of the population began when

challenges are addressed will be critical forfuture gener­

per capita GDP was less than US$ rooo [Gong, 2004J.

ations. They include:

This poses significant challenges as the health system

• Increased globalization. China is moving towards the

centre of the world with all that this entails in terms of
ideological and economic change, as well as of impact

of global production and trade processes on epidemi­

has to deal with the high prevalence of both commu­
nicable and noncommunicable diseases using limited

resources.

2, Policy context and challenges
2.1 l he five balances

in the Five Balances Policy statement, which will guide

the formulation and implementation of the nth Five-Year
The economic transition that began in the late 1970s has

led to profound changes in the social and production sec­

tors of the country. These changes have directly or indi­
rectly influenced health sector development, including
policy formulation and implementation. At the macro
level, these changes include:

• Reduced role of all five levels of government (national,

provincial, prefecture, county [district], township) in eco­
nomic and social sectors. In the health sector, this

Plan.

Balance t: Between rural and urban areas. While it is
recognized that the gaps cannot be filled in the short

term, more efforts are proposed, including adopting fis­
cal and taxing policies to increase transfer payments and

reduce tax burdens for the rural areas Other measures,
such as adjusting the rural labour structure and urbaniz­
ing the rural people, are also considered.

change implied reduced public financing of public hos­

Balance 2: Between regions. Strategies to reduce the

pitals and increased funding by user fees.

gap will include the National Strategy in Developing the

• Increased reliance on individual rather than collective

Western Areas, and China's Guideline to Reduce Poverty

arrangements for social services. In the health sector

in Rural Areas. The fiscal transfer payment system will be

this has affected preventive as well as curative health

further developed and investment encouraged to gradu­

care Further, disestablishment of the collective econo­

ally reduce the gap in social and economic development

my in rural areas led to a collapse of the rural

between the eastern and western parts of the country

Cooperative Medical System.

Balances: Between economic and social sectors.

• Application of market mechanisms andforces to a wide

Measures proposed include: expanding the social insur­

range of services and exchanges in the society This has

ance system to protect vulnerable groups, increasing the

led, in the health sector, to focusing on revenue gener­

inputs in the public health care system, and adjusting

ation by both institutions and professionals, at times

the income distribution system towards greater equi­

at the expense of public health interests.

tability.

• Privatization ofpart of the public or collective sectors. In
the health sector this has included converting village

level clinics from collective to private ownership, and.
in some areas, converting township/county and refer­
ral hospitals from government to private ownership.
This has led to fragmentation and relegation of public

Balance 4: Between economic development and
the natural environment. This balance includes two

points: saving natural resources for production, and pro­
tecting the environment Regulation enforcement
will be strengthened to control environmental pollu­

tion.

health services.

Balance 5: Between domestic and international markets.
China has made significant progress in improving the

Growth of the economy through development of the

general standard of living as a result of economic growth

domestic market will be given more attention.

over the past 25 years. However, economic growth is not

Implementation of the Five Balances Policy will substan­

a panacea to all problems in society. On the contrary, this

tially impact all aspects of the social and economic sec­

growth has created problems of its own, including.

tors. The new development paradigm, as expressed

increasing the gaps in development between regions,

through the Five Balances Policy, emphasizes improve­

resources and environmental problems, and increasing

ment in quality of life rather than mere economic

social conflict. All of this requires new thinking and new

growth. This is directly related to development of the

strategies. With this background, the government of

health sector Social services units, including the health

China has embarked on a new paradigm for develop­

sector, are facing new opportunities and challenges to

ment, putting the people first, and aiming for coordinat­

meet the requirements of the Five Balances development

ed and sustainable development. The goal is a balance

goal, especially in reducing the gaps between rural and

between economic and social development as reflected

urban areas and between regions.

2.2 Health policy-research dialogue
Adaptation of the health system to a market economy

llLLZUL

has involved a number of difficult policy decisions, while
the changing economic and health profile has made

many more policy options available. During the period of

jri

1

planned economy in China, policies and decisions were

usually made without sufficient empirical evidence. This

was mainly the result of three factors. First, policy-mak­

ing was dominated by political processes and policy­
critique of official policy was not welcome. Third, the

HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA - 1DR/GEN/5EB/O4.1

makers were reluctant to use research evidence. Second,

4

cy and action were lacking.

skills for conducting research and translating it into poli­

The context for policy-making has significantly changed
over the past years with increasing awareness among

senior officials of the importance of evidence-based pol­
icy-making. This is primarily a result of the greater open­

ness in the society, including among the political leader­

ship. to constructive dialogue and critique, including
learning from successes and failures. The outbreak of
SARS, further, has played an important role in opening

the eyes of policy-makers to critical reviews of the sector

The ongoing health sector reforms have also called for
more research evidence in proposal and project design

and implementation. For example, evidence has been
sought to improve the effectiveness of the regional

health planning project, the urban health insurance
reform, and the funding policy for public health services.
Under this increased receptiveness by policy-makers, the

challenge is how to organize research systems and
devise mechanisms for translating evidence into policy

improved the capacity of academic institutions to con­
duct research. A number of international organizations

including the United Nations Children's Fund (UNICEF),
the World Health Organization (WHO), TDR, the Alliance
for Health Policy and Systems Research (Alliance-HPSR),
the World Bank, the European Union (EU) under its

International Cooperation (INCO) programme, and bilat­

eral support programmes including the International
Development Research Centre (IDRC) and the UK

Department For International Development (DFID), have

provided support for health policy and systems research

through funding of research projects, policy seminars,
workshops, publications, and formal and informal discus­

and practice.

sions between policy-makers and researchers.

Interaction between research and policy has gradually
increased since the mid-1980s.

Departments of social

medicine and health management have been estab­
lished within medical universities, starting health policy
and systems-related training and research on a larger

scale. From the early 1990s, China’s Network of Health
Economics involving ten leading medical universities and

institutions was set up with support from the World
Bank and Ministry of Health. This programme has

expanded health policy and systems research and

3o Research evidence for
fthe 111th five-year plan
This section summarizes the major health policy and sys­

regions and between the poor and rich within the same

tems research findings in China from the past decade,

region also widened. This all indicates a rapid growth of

grouped into eight themes; Globalization and macroeco­

inequality in the society. Poverty related diseases such as

nomic trends, population and health status trends, eco­

TB are more prevalent in poor compared to rich areas

nomic reform and health care financing, organization

[World Bank, 2002).The widened income gaps constitute

and delivery of public health programmes, ownership

barriers for the poor in access to health care [Gao et al.,

and governance reform, cost-contamment, provider per­

2002]

implementation One aim is to provide a digest of evi­

Over the past two decades, China has experienced dra­

dence from research on the particular situation of

matic changes in both social and economic sectors

China's health care system which should be considered

During the economic transition, the public sector share

by policy-makers, in order to better appreciate the oppor­

of the total economy almost halved, i.e. decreased from

tunities and challenges of the new development para­

60% in 1980 to 33.9% in 2003 [Fulin 2004], and the pri­

digm. Another aim is to provide a basis for the identifica­

vate economy increased accordingly.

tion of key gaps in knowledge as well as health policy
research capacity in the country, and to propose strate­

China has increasingly found a central place in the world

gies to fill such gaps in the coming five-year period and

economy and production processes Labour intensive

beyond

manufacturing and service processes have increasingly

3.1 Globalization and
macroeconomic trends

or have developed as business areas in China in response

China has sustained a high GDP growth and improved

These global production processes include a wide range

living conditions for most people. Between 1980 and

of permutations of wholly owned Chinese companies

been either moved to China from elsewhere in the world
to world market demand

2000, GDP values doubled. According to the national

involved in primary production, joint ventures between

development goal for the next two decades, in 2020 GDP

domestic and foreign companies, contract production,

will be double that of 2000, household incomes will

support and infrastructure, etc.. Common to all is the

increase at the same rate as in the past two decades

need to establish market prices for both inputs and out­

[Gong, 2004]

puts, and to operate in a highly competitive environ­

The most serious concern in economic development is

of planned economy and has greatly influenced both the

ment. This is contrary to the situation during the period

the disparity between regions and population groups.

labour market and the way the society as a whole func­

The Gini coefficient2 of income was 0.22.0.39 and o 45 in

tions.

1980, 1995. and 2002, respectively [Yuan, 2004] The
income ratio of urban residents over rural residents

The tough world market competition requires Chinese

increased from 2.7 in 1995 to 3.1 in 2002 [National Bureau

producers to keep their costs as low as possible, which, in

of Statistics. 2003]. A study indicated that if non-cash

turn can lead to the compromising of environmental and

incomes were included, the income gap ratio between

occupational safety and health standards

urban and rural residents would be 6 [Gong. 2004].
Besides disparities of income between urban and rural

With an almost inexhaustible supply in China of cheap

areas, gaps in income between the western and eastern

labour, and with outdated labour and registration laws.

2 the Gini coefficient, a measure of income inequality, is a number between o and 1. where o means perfect equality
(everyone has the same income) and 1 means perfect inequality (one person has all the income, everyone else has nothing).

HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA - IDR/GEN/SEB/04.1

formance management, and national policies - local

globalization has also meant an influx of labourers from

graphic structure and rapid migration from rural to

rural to urban areas. These labourers accept very low

urban areas leads to changes in health care needs and

wages and no or limited job security and health care cov­

service utilization and. therefore, requires different

erage.

arrangements for health services financing and provi­

HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA - TDR/GEN/SEB/O4

1

sion

Globalization has impacted China not only in the eco­

The infant mortality rate in wealthier provinces such as

nomic sector, but in all aspects of the society, including

Beijing and Shanghai is now below 9 per 1000 live­

ideology, technology, and lifestyle. China today is more

births; in poorer provinces such as Qinghai, Guizhou, and

open, and global thoughts and values have been adapted

Gansu, the infant mortality rate ranges from 30-44 per

through international exchange The lifestyle, especially

rooo live-births [World Bank, 2002] A similar pattern can

smoking, diet and physical activity, is also being influ­

be found for maternal mortality, which is more than 5-

enced through increased advertisement, communica­

fold higher in poorer than wealthier provinces. There

tion, and development of trade and consumerism: these

were 4 7 million pulmonary TB cases in China in 2000

changes are likely to have an indirect impact on the

The prevalence rate was 254 per 100 000 population in

prevalence of noncommunicable diseases such as cancer,

wealthier provinces and almost twice as high, 1 e 451 per

diabetes and cardiovascular disease.

100 000 population, in poorer provinces [National TB

3.2 Population and health
status trends

tions combined with problems of access to health care

Survey, 2002]. Congested and generally poor living condi­

services are likely to lead to high TB prevalence also in
sub-groups, such as migrant workers and their families.

The population growth rate has been successfully con­

trolled in China. During the past five years, the net annu­

The demographic and lifestyle changes are likely to result

al increase in population was 9.2 million It is predicted

in a substantial increase in noncommunicable diseases

that the net annual increase of population will be 8 4

in the next ten to twenty years. An estimated 350 million

million during 2005 to 2010. and 8 million a year during

Chinese smoke, and it is predicted that about 1.2 million

2010 to 2020 [Wu and Sun, 2003]. This will significantly

will die from smoking related diseases every year*. The

change the population structure over the coming gener­

population with hypertension is now more than 100 mil­

ation Migration from rural to urban areas has increased

lion, and with diabetes and chronic obstructive pul­

over the past 25 years In 2000, there were 121 million

monary disease (COPD) is 20 million [Kong, 2002].

migrants, including 70 million moving from rural to

Cardiovascular and COPD were the first reasons for death

urban areas and 20 million moving between cities

in cities and rural areas respectively [Kong, 2002]. The

[Gong, 2004] In 2003, about 140 million people of rural

case rates of hypertension, diabetes and COPD were 26.2,

origin were working or temporarily residing in cities

5.6, and 7.5 per thousand, respectively, in the third survey

[Gong, 2004]. In 2010. it is expected that about 160 mil­

for health services In urban areas, changes in lifestyle,

lion population will move from rural to urban areasS

including in diet and in physical inactivity, have rapidly

In addition to poorer health, the migrants also have seri­

such as diabetes and hypertension. Unintentional

resulted in increasing prevalence of chronic diseases
ous problems with access to health services, leading to.

injuries have become the first reason of death among

for example, worse outcome of pregnancy in terms of

children in China. Traffic accidents and drowning are the

premature births and deaths compared to non-migrant

leading causes of death among children in cities and

women [Zhan, Sun and Blas, 2002). Changes in demo­

rural areas respectively [Jiang and Ding, 2000]. Health

3 the challenges for the implementation of child development protocol and woman development protocol in China, 2004

http://www.cinfo.org.cn/lgxg/zynr/o14 htm[
4 www.tobaccocontrol.com.cn/view.asp/id3i43

For public, collective and private village health clinics,
user charges, especially drug mark-ups, were the domi­

nant sources of financing. In township and county health
institutions, only a proportion of staff salaries could be

covered by the government budget so the remainder was
generated from user charges This form of financing has

moved attention away from preventive, promotive, and

other population based health interventions towards

individual clinical care, which can be charged to the
patient. The result has been a negative impact on the TB

and schistosomiasis control programmes [Zhan et al.,
2004; Bian et al., 2004].

from 2000 indicates that about 50% of the operating
costs of disease control institutions were covered by user

charges [The United Nations Task Force on Health, 2000].
A study which included detailed analyses of income at

ten schistosomiasis control stations in Hunan Province.
education towards changing the lifestyle, and cross-sec­

toral coordination between the departments of health

and transportation, need to be given more attention.

3.3 Economic reform and health
care financing

found that user-fees constituted, on average. 62% of
total income, ranging from about 30% to about 85%

[Bian et al., 2004].

Allocative efficiency
Health resources are often inappropriately spent on
high-technology equipment and drugs with low utiliza­

Sources of funding

tion and cost-effectiveness [Liu and Wei, 1996]. Public

The reduced role of the state has led to increased respon­

funding has not been appropriately allocated either to or

sibility of individual health institutions and of other sec­

within public health programmes One case in point is

tors. Public hospitals are financed through three sources;

the schistosomiasis control programme, where it was

government subsidies, user fees, and drug mark-ups

found that public funding had been diverted into dis­

Government subsides mainly come from local govern­

count prices for individual care of questionable cost­

ments. Provincial, county, and township governments are

effectiveness in order to generate revenue for the control

responsible for their own hospitals. The balance between

station [Bian et al., 2004].

the three sources of income has changed significantly

over the past 25 years. In 1980, government subsidies and
income from user fees and drug sales constituted.

respectively, 21 4%, 18.9% and 377% of total income. By
2000, government subsidies had fallen to 87%, while

The proportion of total health expenditure in rural areas

covered by government sources has also decreased. In
1993. government funding accounted for 34.9% of total

health expenditures; this had decreased to 24.9% in 1998
[Wang, Meng, and Bian, 2001].

income from user fee and drug sales had increased to
40.2% and 47.1% respectively [Ministry of Health, 1980

The allocation of public funds for rural health is not com­

and 2000]

mensurate with the health care needs and size of the

HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA ■ TOR/GEN/SEB/041

It is a concern that, from the mid 1980s, user fees were
also introduced in public health programmes. A report

rural population. In 1998, only 39% of the total govern­

bursement of the insured for only major medical costs

ment health budget was allocated to rural areas where

does not guarantee freedom from economic hardship for

70% of the total population resided [Zhao, Wan and Gao,

less costly events. This might affect the willingness to

.
2003]
Because of disestablishment of the collective

subscribe Second, local government in poor areas may

economy, rural health sector development relies much

not be able to provide matching funds, which would neg­

less on collective resources and, as a result, drug sales are

atively affect the scheme's sustainability. Third, qualified

the main source of income, accounting for 90% and 66%

personnel to manage the insurance fund are lacking in

in village clinics and township health centres respective­

many places Lastly, the catastrophic payments that are

ly [Wei, 1999].

being averted by the scheme are not easy to define as

they are often relative to the specific situation of a cov­

Finally, the distribution of resources between preventive

ered individual.

and curative care is not appropriate Health expenditures

HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA ■ TDR/GEN/SEB/04.1

8

on curative care accounted for 8r .8% of total government

Health insurance in urban areas has, in turn, two modal­

health expenditure, while expenditures for public health

ities. By the end of 2003. about 54% of urban residents

programmes accounted for only 10.9% of total expendi­

were covered by health insurance, including 27% by the

ture [Zhao. Wan and Gao, 2003]. The remaining 7.3% rep­
resents expenses for rehabilitative care, ancillary services

to health care, health administration, and capital invest­
ment. which account for 06%, 2.0%. 1.6%, and 3.2%
respectively [Ministry of Health. 2003]

Urban Social Health Insurance scheme [Ministry of
Health. 2004b; Ministry of Labor and Social Security,

2003]. The rest of the population, including economic
dependents of the insured, paid out of pocket for their
medical care. However, the expansion of insurance cover­

age and increased ability of insurers to reimburse were

Insurance
Insurance to protect against potentially catastrophic

found to increase health care utilization by the insured

when experiencing health problems [Liu et al., 2002]

payments for health care has been evolving in China fol­

The urban health insurance system faces a number of

lowing different schemes for rural and urban areas.

challenges. First, how supplementary insurance can be

Economic reform in rural areas from the late 1970s sub­

set up for pooling the catastrophic risks is still a concern.

stantially changed the financial context for the health

In most cities, only a small portion of the population is

sector owing to collapse of the Rural Cooperative Medical

covered by supplementary health insurance; the majori­

System (CMS), mainly due to the disestablishment of the

ty who are so covered are government employees [Chen

collective economy

Reorganization of the CMS is the main strategy to
improve the rural health care financing system and cov­

ered about io% of the total rural population by the end
of 2003 [Ministry of Health, 2004b]. For the poorer

provinces, a centra! government subsidy of io Yuan per

capita per year, matched by the provincial and county
governments, is allocated to support revitalization of the

CMS. Each individual covered should then contribute
about io Yuan per year as an individual premium. This

funding is only sufficient to cover major medical costs
that threaten economic well-being. However, in some
areas outpatient services are also covered. A pilot scheme
has covered more than 300 counties in China, but there
are some concerns for its design and implementation
even if there is no hard evidence at present First, reim­

et al, 2002]. Second, the expansion of urban health insur­
ance to all urban residents is challenging, especially so
for the poor who are not able to pay the insurance premi­

um [Cai, 2000; Meng. 2002] Lastly, the efficiency of oper­

ating existing insurance schemes should be improved.
particularly to reduce administrative costs. Even though
some success has been achieved, there is a need to fur­

ther investigate how to sustain the balance between
insurance income and expenditure through cost contain­

ment, among other measures

Equity
While health institutions have gained considerable inde­

pendence from political and bureaucratic control, costs
have risen and barriers in access to health care have been

created for vulnerable groups [Bloom, 1998; Bloom and

vent and control diseases through actions such as immu­

for the poor have not been effectively implemented,

nization, mass treatment, health education, regulation,

mainly due to the absence of a dedicated public subsidy

etc. In the case of TB and sexually transmitted diseases,

to compensate providers for loss of income resulting

public health programmes encourage individuals to

from providing the exemption [Meng, Sun and Hearst,

come forward for treatment in order to stop the spread

2002].

of disease

The current health financing mechanisms have deep­

ened the inequalities in society First, access to health

care is more constrained for the poor than for the rich

and for the uninsured than for the insured.The very large
percentage of patients who require hospitalization but

do not gain access to care due to financial constraints is

as high as 75% in rural areas and 56% in urban areas

[Ministry of Health, 1999] Public health programmes,

such as TB detection and observed treatment (DOTS),

have not been effectively delivered to the communities
in poor areas due to financial constraints [Meng et al,

2004a]

Coverage

by

Expanded

Programme

on

Immunization (EPI) activities was different between
poorer and richer areas by 10 to 25 per cent, especially for
hepatitis B immunization [Sun and Meng, 2004]. In cer­
tain urban areas, only 40% of migrant women received

pre-marital medical examination, 48% antenatal exami­
nation, and 13% postnatal examination, which was 20-

40% lower than for permanent residents [Han, Shi and
Liu, 2001] Such differences have been shown to lead to
worse outcome of pregnancy [Zhan.Sun and Blas, 2002].

Second, payment for health care is not equitable

[Ministry of Health, 1999]. It was found that poorer

households spent 8% of household income on health
care compared to 5% for higher income households [Han,
Shi and Liu. 2001]. Inequity has also been found in disease

control programmes such as schistosomiasis control,
where it was found that payment is extracted from

The 'three-tier' health care delivery system in both urban

and rural areas forms the basic structure of health care

organization in China. In rural areas, village clinics and

township health centres provide primary health care, and
county hospitals provide specialty medical services. In
urban areas, community health units and district hospi

tals provide primary health care services. Municipal and

provincial hospitals provide tertiary medical services to
both urban and rural people

Over the past five decades, the size of the health care

delivery system has continued to expand in terms of
number of health institutions and workforce. By the end

of 2003, there were close to 806 000 health institutions,
including 515 000 village clinics, 17 800 general hospitals,
44 300 township health centres, 3600 centres for disease

control (CDCs, which provide public health programmes
addressing infectious diseases, health education, food

security, environmental health, etc.), 3000 maternal and
child care institutions, and 1700 disease specific treat­
ment institutions. There were o 87 million village health

workers and 4.3 million health workers in township and
higher level health institutions [Ministry of Health,

2004a]. Expansion of the health care delivery system has
not been even in distribution; qualified health workers
and advanced equipment are concentrated in urban

areas and at tertiary hospitals [Liu and Wei, 1996].

patients to the limit of their ability to pay, something

which is likely to hurt the poor more than the rich [Bian

et al., 2004].

The private health sector has grown, as shown by the

fact that, at village level, about 50% of clinics now oper­
ate as private enterprises. In urban areas, the number of

private hospitals has increased rapidly especially in some

3.4 Organization and delivery of
public health programmes

southern provinces. One of the challenges in rural areas,
with the increased number of private clinics, is how pub­

lic health programmes can be effectively delivered. It was

Public health programmes are organized to address the

found that neither private nor public village clinics were

health of the whole population or of groups within the

willing to provide preventive care without reimburse­

population. They operate at the population level to pre­

ment. This was mainly because the operation of public

HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA - TDR/GFN/SfB/04.1

Tang, 2004] Well intended fee exemption programmes

ing basis for all health providers regardless of the cost­

turer's exit price was based on production costs plus a 5%

structure of the individual health institution [Meng et

profit margin, to which a 15% mark-up was added for the

al.. 2002].

wholesale price A further 15% margin constituted the

A high prevalence of unnecessary drug use has been

and retailers including hospitals were fixed, expensive

found to be one of the reasons for the escalation of phar­

drugs were preferred. In order to attract wholesalers and

maceutical expenditures in China. Unnecessary prescrip­

hospitals to their products, manufacturers would set

retail price Since profit margins for both wholesalers

HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA - TDR/GEN/5EB/O4.1

12

tion of drugs is caused by both the health provider and

higher-than-cost prices Under this system, drug prices

the user For the provider, drug prescription generates

were recognized by government to be unreasonably

revenue; for the user, drugs are the most visible treat­

high, which led. in 2000. to a change in the government’s

ment for their health problem and are therefore in

drug pricing strategy from controlling the entire cascade

demand [Xiang, 2002]. Revenue generated from the use

of prices for all pharmaceuticals to controlling the retail

of high technology was another important source of

price of selected products only However, drug expendi­

hospital financing. A study in 33 hospitals between 1994

tures for all patients still increased rapidly after imple

and 1997 showed that investment in high technologies

mentation of the new pricing strategy [Cheng, 2004].

such as magnetic resonance imaging (MRI) and comput­

After the price of drugs was reduced by the central and

erized tomography (CT) scanners has resulted in a mas­

provincial governments, the hospitals studied tended

sive waste of resources [Ci, 1997], For exam pie, the utiliza­

to prescribe more drugs for patients to maintain their

tion of positron emission tomography (PET) was shown

level of income. This meant that quantity more than

to be as low as 30% to 60% of the potential workload. To

price became the determinant for drug expenditure.

compensate for this underutilization, prices charged to

Improvement in rational use of drugs and correcting the

the user were set at exorbitant levels; targeted clients

present perverse incentive structure for hospitals will be

were mainly the insured and rich [Bian et al, 2002].

important challenges for containment of drug expendi­
tures [Cheng, 2004]. A study in Shanghai suggested that

Some studies assessing the urban health insurance

the use of a drug list and capping the annual growth rate

reform have shown there has been a positive impact on

of hospital incomes might be effective in controlling the

cost containment and access to health care.These stud­

rapid increases in drug expenditures [Hu et al., 2001]

ies found that replacing fees for services by contractual

However, there is no conclusive evidence for the effec­

relationships between the insurer and the health

tiveness of this strategy in other areas.

provider led to control of hospitals' use of resources
[Meng et al.. 2004b, Yip and Eggleston, 2001). However,

the studies did not provide evidence about the effect of

3.7 Provider performance
management

the new payment methods on quality and equity.
In order to stimulate health workers to increase their

Pharmaceutical expenditure in China was US$ 28 billion

productivity, a bonus system was introduced in the hos­

in 2001, and accounted for 44.4% of total health expen­

pital sector in the mid-1980s based on a flat rate Later,

ditures [Zhao, Wan & Gao, 2003]. This figure is 15% to

bonuses were introduced elsewhere in the health sector

30% higher than in most developed or middle-income

and increasingly performance based methods were

countries. The hospital sector is the main retail supplier

brought in, including elements such as revenue generat­

of drugs, and drugs have been the most profitable fee

ed and quality and volume of service. However, it has

item in hospitals since the early 1980s.

been found that income is the main element encourag­
ing health professionals to provide as much service as

Between 1980 and 2000, the government controlled the

possible, including drugs, and thus induces doctors to

entire cascade of drug prices, from the manufacturer’s

over-treat and over-prescribe [Xu et al, 2001]. Several

exit price, to the wholesale and retail price. The manufac­

studies have shown that, in public health programmes,

health providers under-provide less profitable services,

On the other hand, health is a sector that is closely relat­

over-prescnbe drugs, and over-provide more profitable

ed to many other departments, e g. the departments of

services. One study, for example, showed that TB health

planning and reform, finance, labour and social security,

care providers did not meet the minimum requirements

civil affairs, administration of food and drugs, and so

for visits to TB patients’ homes because such care did not

when a health policy is made at a particular level, all the

provide financial returns for the staff [Meng et al,

departments concerned should be involved.

2004a). Another study on TB care showed that, in addi­

prehensive analysis of needs and within the overall

health providers reduced preventive interventions in

development framework Central policies can then be

order to save costs and increased emphasis on profitable

implemented at the local level with consideration of the

clinical care activities [Bian et al., 2004].

specific situation. However, this approach also has poten­

tial problems, e.g. leakage of authority, risk of low compli­
An internal contracting system was introduced in the

ance in implementation.

hospital sector from the early 1990s, following recom­
mendations by the health authorities, in an attempt to

There are no incentives for local policy-makers to active­

improve both departmental and individual staff per­

ly develop polices that may be more suitable for their

formance including quality of care. This contract system

own situations. In addition, local financing limitations

is an internally administrated mechanism within each

might inhibit the implementation of centralized policies

hospital division and usually has four components: vol­

which require local government funding. Only a few

ume of work, quality of service, revenue generated, and

studies have addressed this area of policy research.

patient satisfaction. No systematic assessment has been

undertaken to date of the impact of this approach on

One study found that, for TB control programmes, overall

performance. However, in a study in Shandong and

performance was better in wealthier areas than that in

Henan provinces, it was found that clinical departments

poorer areas, partly because the poorer counties were

were concentrating on revenue generation because

not able to match the funding provided by the World

income had become the most important indicator in

Bank loan project [Meng et al., 2004a] Another study

assessments by hospital managers [Xu et al.. 2001].

showed significant delays in implementing policies man­

dated from higher levels. For example, in 1996 the central

3.8 National policies - local
implementation strategies
The health policy-making process in China is complex.

government asked for price adjustments to health care
services. However, up to 2001, this policy had not been
implemented for various reasons [Meng et al.. 2002].

Other studies found that the local governments did not

This is due partly to the five levels of government admin­

implement central government policies for disease con­

istration and to the transition towards more autonomy

trol. Guidelines issued by the Ministry of Health on TB

in health care financing and regulation for provinces and

prevention and control, including use of the DOTS strate­

counties. Decentralization has given local governments

gy and provision of free or subsidized services, were not

greater power in making decisions on the management

implemented; instead some inappropriate interventions

of local public affairs. This means that local government

were included in the local policy [Zhan et al., 2004].

can make policy for local affairs and adapt the policies

from higher level government in light of local circum­

stances. From this point of view, the governments at all
levels are both policy-makers and policy-implementers

13
1

make policies for the country as a whole based on a com­

.
2004]
In schistosomiasis control programmes, the

1DR/GEN/SLB/O4

implementation is that the central government can

tion to case detection and contact follow-up [Zhan et al.,



The advantage of this approach to policy-making and

HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA

tion. the providers extended treatment, provided unnec­

essary tests and drugs to patients, and paid less atten­

ing basis for all health providers regardless of the cost­

turer's exit price was based on production costs plus a 5%

structure of the individual health institution [Meng et

profit margin, to which a 15% mark up was added for the

al., 2002].

wholesale price. A further 15% margin constituted the

A high prevalence of unnecessary drug use has been

and retailers including hospitals were fixed, expensive

found to be one of the reasons for the escalation of phar­

drugs were preferred In order to attract wholesalers and

maceutical expenditures in China. Unnecessary prescrip­

hospitals to their products, manufacturers would set

retail price. Since profit margins for both wholesalers

HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA - TDR/GEN/SEB/04.1

12

tion of drugs is caused by both the health provider and

higher-than-cost prices. Under this system, drug prices

the user. For the provider, drug prescription generates

were recognized by government to be unreasonably

revenue; for the user, drugs are the most visible treat­

high, which led. in 2000, to a change in the government's

ment for their health problem and are therefore in

drug pricing strategy from controlling the entire cascade

demand [Xiang, 2002]. Revenue generated from the use

of prices for all pharmaceuticals to controlling the retail

of high technology was another important source of

price of selected products only. However, drug expendi­

hospital financing. A study in 33 hospitals between 1994

tures for all patients still increased rapidly after imple­

and 1997 showed that investment in high technologies

mentation of the new pricing strategy [Cheng, 2004].

such as magnetic resonance imaging (MRI) and comput­

After the price of drugs was reduced by the central and

erized tomography (CT) scanners has resulted in a mas­

provincial governments, the hospitals studied tended

sive waste of resources [Ci. 1997J. For example, the utiliza­

to prescribe more drugs for patients to maintain their

tion of positron emission tomography (PET) was shown

level of income. This meant that quantity more than

to be as low as 30% to 60% of the potential workload. To

price became the determinant for drug expenditure.

compensate for this underutilization, prices charged to

Improvement in rational use of drugs and correcting the

the user were set at exorbitant levels, targeted clients

present perverse incentive structure for hospitals will be

were mainly the insured and rich [Bian et al. 2002].

important challenges for containment of drug expendi­
tures [Cheng, 2004]. A study in Shanghai suggested that

Some studies assessing the urban health insurance

the use of a drug list and capping the annual growth rate

reform have shown there has been a positive impact on

of hospital incomes might be effective in controlling the

cost containment and access to health care. These stud­

rapid increases in drug expenditures [Hu et al., 2001)

ies found that replacing fees for services by contractual

However, there is no conclusive evidence for the effec­

relationships between the insurer and the health

tiveness of this strategy in other areas.

provider led to control of hospitals' use of resources
[Meng et al., 2004b; Yip and Eggleston, 2001]. However,

the studies did not provide evidence about the effect of
the new payment methods on quality and equity.

3.7 Provider performance
management
In order to stimulate health workers to increase their

Pharmaceutical expenditure in China was US$ 28 billion

productivity, a bonus system was introduced in the hos­

in 2001, and accounted for 44.4% of total health expen­

pital sector in the mid-1980s based on a flat rate. Later,

ditures [Zhao, Wan & Gao. 2003]. This figure is 15% to

bonuses were introduced elsewhere in the health sector

30% higher than in most developed or middle-income

and increasingly performance based methods were

countries. The hospital sector is the main retail supplier

brought in, including elements such as revenue generat­

of drugs, and drugs have been the most profitable fee

ed and quality and volume of service However, it has

item in hospitals since the early 1980s.

been found that income is the main element encourag­
ing health professionals to provide as much service as

Between 1980 and 2000, the government controlled the

possible, including drugs, and thus induces doctors to

entire cascade of drug prices, from the manufacturer's

over-treat and over-prescribe [Xu et al, 2001]. Several

exit price, to the wholesale and retail price.The manufac­

studies have shown that, in public health programmes,

health providers under-provide less profitable services,

On the other hand, health is a sector that is closely relat­

over-prescribe drugs, and over-provide more profitable

ed to many other departments, e.g. the departments of

services. One study, for example, showed that TB health

planning and reform, finance, labour and social security,

care providers did not meet the minimum requirements

civil affairs, administration of food and drugs, and so

for visits to TB patients'homes because such care did not

when a health policy is made at a particular level, all the

provide financial returns for the staff [Meng et al,

departments concerned should be involved.

implementation is that the central government can

tion to case detection and contact follow-up [Zhan et al.,

make policies for the country as a whole based on a com­

2004] In schistosomiasis control programmes, the

prehensive analysis of needs and within the overall

health providers reduced preventive interventions in

development framework. Central policies can then be

order to save costs and increased emphasis on profitable

implemented at the local level with consideration of the

clinical care activities [Bian et al., 2004].

specific situation. However, this approach also has poten­

tial problems, e.g leakage of authority, risk of low compli­
An internal contracting system was introduced in the

ance in implementation.

hospital sector from the early 1990s. following recom­
mendations by the health authorities, in an attempt to

There are no incentives for local policy-makers to active­

improve both departmental and individual staff per­

ly develop polices that may be more suitable for their

formance including quality of care. This contract system

own situations In addition, local financing limitations

is an internally administrated mechanism within each

might inhibit the implementation of centralized policies

hospital division and usually has four components: vol­

which require local government funding Only a few

ume of work, quality of service, revenue generated, and

studies have addressed this area of policy research.

patient satisfaction. No systematic assessment has been
undertaken to date of the impact of this approach on

One study found that, for TB control programmes, overall

performance. However, in a study in Shandong and

performance was better in wealthier areas than that in

Henan provinces, it was found that clinical departments

poorer areas, partly because the poorer counties were

were concentrating on revenue generation because

not able to match the funding provided by the World

income had become the most important indicator in

Bank loan project [Meng et al., 2004a]. Another study

assessments by hospital managers [Xu et al., 2001].

showed significant delays in implementing policies man­

dated from higher levels. For example, in 1996 the central

3.8 National policies - local
implementation strategies

government asked for price adjustments to health care
services. However, up to 2001, this policy had not been
implemented for various reasons [Meng et al., 2002].

The health policy-making process in China is complex.

Other studies found that the local governments did not

This is due partly to the five levels of government admin­

implement central government policies for disease con­

istration and to the transition towards more autonomy

trol. Guidelines issued by the Ministry of Health on TB

in health care financing and regulation for provinces and

prevention and control, including use of the DOTS strate­

counties. Decentralization has given local governments

gy and provision of free or subsidized services, were not

greater power in making decisions on the management

implemented; instead some inappropriate interventions

of local public affairs. This means that local government

were included in the local policy [Zhan et al., 2004].

can make policy for local affairs and adapt the policies

from higher level government in light of local circum­

stances. From this point of view, the governments at all
levels are both policy-makers and policy-implementers.

HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA - 1DR/GLN/SEB/O4

The advantage of this approach to policy-making and

essary tests and drugs to patients, and paid less atten­

1

2004a] Another study on TB care showed that, in addi­

tion, the providers extended treatment, provided unnec­

HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA ■ TDR/GEN/SEB/04.1

4= Research needs and systems
China has made significant leaps forward in health poli­

cy and systems research, and in knowledge generation

4.1 Current research needs
to close gaps in knowledge

and dissemination in the past two decades. Although

Balance 1: Between rural and urban areas. Addressing

research projects conducted over the past ten years, the

this balance includes transfer of payment between

number is probably in three digits. The projects were sup­

urban and rural areas, changes in the labour market

ported by the Chinese government (all levels) as well as

structure, and increased urbanization Addressing the

international agencies such as the WHO, World Bank, EU,

rural-urban divide, and the integration of health systems

TDR, and Alliance-HPSR. Some NGOs such as the Ford

between cities and industrializing peri-urban areas, are

Foundation, and bilateral development agencies such as

some of the major challenges for the coming years and

DFID, have also provided funds. As well, technical assis­

will affect very large parts of the population Research

tance for the projects was received from international

needs are.

academic

institutions

such

as

the

Institute

of

Development Studies at the University of Sussex (UK),

• The contributions made by health investment to eco­
nomic development and rural-urban disparities.

Harvard School of Public Health (USA), and other sources.

• Challenges and strategies in the regulation and man­

Some of the findings have already been translated into

agement of the health care market in both rural and

health policy by the central and provincial governments.

urban settings during the continuing transition from

Two examples are worth citing:
• Recommendations for promoting the health security

planned to market economy in China.

• The functioning of the health care system in a society

system, reallocation of health resources in urban and

which is in a large-scale and long-lasting transition.

rural areas, partnership between the public and pri­

• Strategy and policy on systems of medical assistance

vate sectors in health care service delivery, as well as

and social health insurance for floating populations.

re-regulation and deregulation of the health care serv­

• Access to health care services by the poor, including

ice market, were integrated into The Decision on

Health Reform and Development enacted by the

equity and outcome issues.
• Evaluation of Basic Medical Insurance for Urban

Central Committee of the Communist Party of China

Employees and the New Cooperative Medical System

and the State Council in 1997.

in rural areas, in terms of access to health care, quality

• The Cooperative Medical System was re-established in
2002, using earmarked funds transferred from the

of health care, responsiveness of hospitals, and cost

containment.

Ministry of Finance and Department of Finance of the
Provincial Government, as well as from the Prefecture

Balance 2: Between regions. Addressing the imbalance

Government.This policy is based on recommendations

between eastern, central and western areas will require

from research on the rural community health financ­

ing system conducted by the China Network [Wei,
19971-

encouragement and incentives for economic activities in
some areas. Addressing the regional effects will call for

multidisciplinary and timely case-study type of research
in order to capture the 'unexpected'. Health policy

However, many policies are still formulated on the basis

research could include:

of weak or no evidence and health policy implementa­

• The constraints and options for fiscal transfer for

tion is not systematically evaluated. There is a long way

health from Central Government and Eastern areas to

to go before health policy and systems research reaches

Central and Western areas of China.

its full potential. Improved communication and dialogue

• Strengthening of endemic diseases control in Central

between the researchers and the policy-makers will be

and Western China; formulation and application of

critical to achieving this.

specific policies; balance between preventive and cura­
tive services.

• Public and private partnership in health care delivery
in central and western areas of China.

15
HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA - TDR/GEN/SEB/04.1

there are no formal statistics about the total number of

disease (lung cancer, liver cancer, etc.) prevalence.

• Impact of the increased economic activity on the envi­
ronment and health status.

• Preventive policy and regulations on pollution transfer
from the developed world to China in the environment

• The labour market, health status and access issues

of globalization

Balance 3: Between economic and social sectors

• Quality-adjusted life years and economic losses effect­

Addressing this balance will involve both an increase in

and redistribution of resources between sectors and
within the health sector. Policy and systems research can

ed by ecological degradation in China.



Implementation and impact of health-related inter­

ventions to address environmental issues.

contribute to both policy formulation and evaluation of

policies. An increasing resource base for health provides

Balance 5: Between domestic and international mar­

an opportunity to do more, but also poses a challenge to

kets. Development of the domestic market is likely to

do the right thing in order not to waste the society's

accelerate globalization in terms of increased marketing

resources Research could include:

of manufactured consumer goods, some of which may



Empirical studies on the relationship between social

be harmful to public and individual health Market forces

development - including education, R&D, and poverty

will, by nature, drive activities to where the greatest prof­

alleviation programmes - and health status in China
• Theefficiencyofallocation of resources, cost-effective­

ness. and returns on investments in health.
• The impact of reforms to local tax systems on health
finance.



The interrelationship between health development

strategies and measures to reform local government
to make it more accountable to the community



Measures to enable people to become better

informed users of health services, and to improve the
capacity of local representative bodies to monitor and

influence health system performance
• National health accounts
• The disparities between health status and social fac­
tors such as gender, occupation, social group, and

income group.

its are found, hence will often be on a collision course

with public health and require strong evidence to sup­

port the public and political debates This can only come
from critical and independent research Specific studies

could be on• Survey of occupational injury and diseases, and the
impact of China's access to the World Trade Organi­
zation (WTO) on socioeconomic development.

• The challenges to and policy on tobacco control after

China deregulated the retail price, the wholesale

entrance policy, the manufacture and the import of
tobacco, according to its WTO commitments
• The alert and response system to infectious diseases

emerging across borders.
• Regulation of food safety.
• Regulation of the health care market, i.e the private,
semi-private and public markets.

Balance 4: Between economic development and
the natural environment. Continued rapid growth,

• The effect of different models of ownership and gover­
nance on the health sector.

including one that has social objectives and involves
attempts to geographically regulate the growth, will

potentially have an adverse impact on the environment
and will directly and indirectly impact the health of the
population. Addressing the relationship between eco­

4.2 Likely future research needs
to close gaps in knowledge
Experience from the past decade has shown that prob­

nomic development and nature, with its links to health, is

lem-oriented health policy and systems research has an

a challenge that requires critical independent policy and

important role to play in improving the process of health

systems research. Specific studies that could be under­

policy-making and implementation. Extensive dialogue

taken include;

and close collaboration among researchers, policy-mak­

• Development and application of policies for protect­
ing the environment and health.

• Empirical studies on environmental degradation and

ers and medical workers have played, and will continue

to play, a critical role in the development of the health
sector in China

Development of the socioeconomic environment, includ­

nate activity in this area. However, there is a need to

ing the health sector, which by all measures has been

improve shared priority-setting. The Ministry of Health

extremely rapid, will continue for a long time, probably

has not set up the health policy development agenda

for more than one generation. Health policy and systems

agreed by relevant departments in the central govern­

lenges of the nth Five-year Plan. In addition, health poli­

ment and the research community.
• The lack of a bridging mechanism between the policy
makers and health policy and systems researchers

cy and systems research is needed to prepare for the 12th

In spite of the China Network on Health Economics,

Five-year Plan and beyond. Long-term health policy and

policy-makers lack sufficient access to the results of

systems research is needed on:

policy and systems studies as well as to the skills need­

• Transformation of the health financing system to one

ed to assess and use these results for policy-making

which is equitable and sustainable

The policy researchers, on the other hand, are often

• The re-orientation and development of the public

unaware of the needs of health policy-makers, and lack

health system in the next 10-20 years based on situa­

the skills and channels to communicate their results

tion analyses and projections of future health prob­

lems
• The opening and regulation of the health care market:

effectively.

• The lack of incentives for researchers to participate in

practical policy and systems studies

pricing system reform, tax waver policy to private

At present, researchers are hesitant to conduct practi­

investors in the health sector, and enforcement of reg­

cal research because of the lack of financial support.

ulation in the health care market

including

from

local

health

authorities;

the

• Transformation of the health care delivery system in

researcher’s top priority is promotion in his/her aca­

accordance with regional health planning to promote

demic position rather than practical research findings.

efficient allocation of health resources.

Greater research commissioning is required to attract

• The massive population movement from rural to
urban areas.

the most talented researchers to the field.
• Weak capacity in policy and systems research

Researchers have insufficient training on policy and
The above are broad areas of research which need to be

systems related subjects, and most policy researchers

further developed and defined

have little experience on which to integrate theory
into practice. Most policy and systems research

4.3 Gaps in research capacity
There are important gaps in research capacity in China,

including in priority-setting and skills for translating
research findings into health policy and practice. It is nec­

requires

a

multidisciplinary

team,

but

many

researchers have little experience in managing and
participating in such teams.

• Customary lack of critical independence

For historical reasons, many researchers abstain from

essary for China's government to demand research to

making conclusions that critique existing policies.

meet their policy needs, and for the research community

Policy-makers, on the other hand, are slowly beginning

to push health policy and systems research forwards to

to realize the value of critical independent policy

meet the future challenges. The gaps between needed

health policy and systems research and current research
performance include

research.
• The unfeasibility of policy recommendations
Researchers tend to underestimate the obstacles to

•The lack of a health policy and systems research agenda

policy implementation in the real world, and often get

agreed by policy-makers and the research community

frustrated when their recommendations are not taken

China has made exemplary progress in developing a

up immediately and in the form that they are made.

well functioning network of health systems research

institutions and has national institutions that coordi­

17
HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA - IDR/GEN/SLB/04.1

research, therefore, will need to operate with a short­
term horizon, addressing the immediate needs and chal­

• The lack offunding opportunities for health policy and

able through close dialogue between researchers and

systems research projects

policy-makers at national and provincial level. Many

In China, only a small proportion of research funds are

strategies can be used to promote health policy and sys­

used for policy-oriented research, while funds from

tems research in China, including multidisciplinary

international donors directed to policy and systems

research collaboration, research capacity building

research are insufficient to meet the needs. Policy­

through training, research activities, and dialogue and

makers have no recurrent earmarked funds to support

communication between policy-makers and researchers.

research. Most funds for health policy and systems

There is also room for organizational development,

research come from foreign sources.

including establishing research and training networks
within provinces and internationally, and for technical

4.4 Options for closing the gaps

HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA - IDR/GEN/SEB/O4.1

18

China has made some progress in closing the gaps

assistance and funding support from the national and

provincial governments as well as from international
donors

between the requirements for conducting health policy

and systems research and the capacity of the research

Improving the research-policy dialogue

institutionsand researchers. For instance,China Network

Much research-policy dialogue has taken place on an ad

has sent 26 trainees to participate in the World Bank

hoc basis, depending on individual funding and project

Flagship Training Program on Health Sector Reform and

opportunities In order to bring researchers and policy­

Sustainable Financing since iggy.The China Network has

makers closer together, dialogue needs to be more for­

also held 24 training courses on health economics and

malized and could,for e g, include

health policy for trainers and researchers from the 10 key

medical universities in China, and has held another 28
training programmes for officials from the health
authorities at provincial/prefecture government level
Moreover, the China Network has coordinated eight

Senior Policy Seminars in which critical issues in health
policy were discussed and new research findings dissem­

inated to officials from relevant departments of central
and provincial government TDR has supported training
programmes on health economics and management,

• National and provincial health policy research fora.
which might e.g. bring policy-makers and researchers

together once a year to discuss new research findings
as well as policy challenges and research needs

• Publication and dissemination of regular policy briefs.

providing digests of research findings in a language

and form relevant to policy-making
• Establishment of a website for mapping research
needs and opportunities, including calls for proposals,
funding, etc.

and case-study research, among other things. DFID has

also provided funds to support dissemination of health
policy research findings, while the Alliance-HPSR has
supported training for Chinese researchers and policy­
makers in taking research into policy and practice and

has also funded a number of projects.
The concept of evidence-based development of health

systems has been accepted by officials, and a greater

Improved dialogue will help researchers and policy-mak­
ers develop a common understanding of the issues as
well as a common vocabulary, which eventually will facil­

itate communication and uptake of recommendations.

Contracting out and commissioning of
existing institutions

number of policy-makers are now aware of the impor­

More and more health policy-makers at national level

tance of concrete evidence in terms of the health prob­

emphasize research findings in the process of policy-

lems, health interventions, health outcomes, and per­

making. However, they frequently complain that they

formance of health financing schemes and health care

cannot find the reliable evidence they need, while offi­

delivery systems. So there is increased demand for scien­

cials from provincial level have difficulty in finding appli­

tific health policy and systems research, which is achiev­

cable research results relevant to their local situations. At

the same time, many researchers conduct their research

Creation of new institutions

according to personal interest and funding opportunities

At present, some policy-makers and researchers think it

rather than according to priorities for health policy

necessary to establish a national health policy research

Frequently, the quality of research undertaken is wanting

centre, and that a national institution should coordinate

due to a combination of lack of skills and the fact that

activities such as health policy and systems research pri

many policy and systems researchers work in isolation,

ority-setting, communication between senior policy­

i.e. are not exposed to the rigorous peer review process

makers and researchers, and management of resources

which characterizes science in many places

to support research However, others suggest that the

option to increase contracting and commissioning with

because:

whom are listed in the Annex. Suggestions for making

• There are already many national health policy and sys­

better use of, and further developing, existing capacity

tems research institutions, such as the China Health

and structures, include:

Economics Institute, the China Hospital Management

• Health authorities and relevant departments at

Institute and, in addition, every province has several

national and provincial levels should develop priorities

universities which could conduct health policy and

in health policy and systems research based on the

systems research What is needed is the challenge,

macro-socioeconomic environment and critical health

funding, and bridging of research to policy.

problems as well as on the evolution of health care

• Re-constructing and re-organizing the existing health

management. Government funds from national and

policy and systems research institutions in China could

provincial levels must be made available for health
policy and systems research

• Contracting out or commissioning of health policy and

lead to more benefits in a shorter period of time.
• The provincial governments will have more immediate

benefit from restructuring existing research capacity

systems research should be based on concrete princi­

because this will ensure local relevance and sustain­

ples and transparent process. Independent and techni­

ability, including providing training opportunities for a

cally competent review committees should be involved

in evaluating proposals and reviewing results.

new generation of local researchers.
• Large institutions with secure funding tend to lose

Competitive selection of researchers and projects is of

innovation and quality over time due to not being con­

paramount importance for the process

stantly challenged to improve performance

• There is a need to strengthen exchange and capacity

building programmes for conducting multidisciplinary
health policy research in order for Chinese academic

institutions to support the next generation of
researchers Participating in concrete and externally

Capacity building for policy and systems
researchers and policy-makers
Capacity building includes more than mere provision of

reviewed research projects is the best way to give

training courses. For it to be sustainable, a comprehen

young researchers a feel for, and the skills to conduct,

sive capacity building programme would include e g. the

high quality research.

following elements:

• Provision of opportunities for research dialogue, fund­
Use of existing capacities, provided that appropriate

structures for commissioning are in place, makes good

ing. peer review, and international exposure.

• Integration of health policy and systems research into

sense in terms of economy and sustainability. Further,

the curricula for researchers and policy-makers to be.

through a competitive model, researchers are challenged

• Specific skills training, including conduct of multidisci­

to continuously improve the quality of their research.

plinary case-study research.

19
TDR/GEN/Sl 8/04 I

existing institutions, as described above, is preferable,

rently involved in policy and systems research, some of

HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA

A large number of individuals and institutions are cur­

way forward
To maintain the social values in Chinese society, it will be

critical to develop a fair, efficient and sustainable health

care system during the coming two decades in accor­
dance with the new development paradigm. Health pol­

icy and system research can provide the evidence to
improve policy-making towards this goal.

Research undertaken in China in the past ten years,
mostly by Chinese researchers, has proved to be a valu­

able tool to identify problems in the health system and
to help resolve operational bottlenecks. Building on this

sound basis, research priorities can now be identified and

HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA - TDR/CEN/SEB/04.1

20

resources dedicated to research can be increased
To make new investments more productive, specific
strategies for improving health policy and systems

research and translation should be formulated These
should include capacity building for researchers and pol­
icy-makers. exercises for setting research agendas, coor­

dinating research at the national and provincial levels,
and disseminating research findings to policy-makers.
More funds and resources should be allocated to support

health policy and systems research programmes With

assistance from international agencies, the China
Ministry of Health should launch research projects tar­

geting priorities in the context of the new development

framework. Formal and informal dialogue between

researchers and policy-makers, funding for research, and

uptake of findings should be included in the formulation

of the nth and 12th Five Year plans for health develop­
ment.

It is our hope that the review presented this document
will contribute to the debate and facilitate the way

towards improved health, equity and health care delivery
in China and elsewhere in the coming years.

Annex: Directory of health policy
research institutions
Renhua Cai

Zhengzhong Mao

Jin Ma

Director

Professor

Professor

National Health Economics Institute

Health Executive Training Center,

Shanghai Second Medical University,

PO Box 218, Beijing Medical University,

Huaxi Medical University,

No. 227 Chongqinglu RD. 200025

Beijing, PRC 100083

Renmin Nanlu, Chengdu, Sichuan,

Wangpan@proxy.cnhei.edu.cn

PRC 610044

Hxh e@mail.sccninfo.net

Jiwei Zhang
Deputy Director
China Health Economics Magazine,

Ming Wu

41 Xiangshun Jie. Xiangfang District,

Professor

Shanlian Hu

Health Executive Training Center,

Professor

Harbin, Heilongjiang. PRC 150036

Beijing Medical University

Health Executive Training Center,

CHE@public hr.hl cn

Xueyuan Lu, Haidian District,

Shanghai Medical Univ.

Beijing, PRC 100083

138 Yixueyuan Lu, Shanghai, PRC 200032

Yuan Liping

Whong@public.bta.net.cn

Slhu@fudan ac.cn

Senior Project Officer POLICY

Guoxiang Liu

Junfeng Chen

Chma/USAID HIV/AlDs Program

Professor

Associate Professor

I yuan@policych 1 n a. com.c n

Health Executive Training Center,

Health Management Dept..
Hai Wen

Harbin Medical University

Dalian Medical Univ.,465 Zhongshan

199 Dongdazhi Jie, Nangang District,

Lu, Shahekou District, Dalian,

Professor

Harbin, Heilongjiang,

Liaoning Province, PRC 116027

Center for Health Policy &

PRC 150001

iohn5151@163.com

Management, Peking University

lgx@mail.hl.cn
Shuiyuan Xiao

Zhang Kaining

Qingyue Meng

Professor

Professor

Professor

Public Health School, Hunan Medical

Kunming Medical college

Center for Health Management and

Univ, 22 Beizhan Lu, Changsha, Hunan

Policy, Shandong University, 44 Wenhua

Province. PRC 410078

Xi Rd, Jinan, Shangdong 250012, PRC

Sphhmu@public cn.csh

Zuo Xuejin
Professor

Shanghai Academy of

Social Sciences

qmeng@sdu.edu.cn
Zhifeng Wang

Weifang Medical College.

Hu Angang

Yinchun Chen

Professor

Professor

Shengli Dajie, Kuiwen District, Weifang,

Professor

Health Executive Training Center,

Shandong Province, PRC 261042

Chinese Academy of Social Sciences

Tongji Medical University,

z hlifen gwang@163.com

Jing Jun

N0.13, Hangkonglu, Wuhan,

Professor

Hubei Province, PRC 430030

Qicheng Jiang

Chenyc2@sina.com.cn

Professor

Faculty of Sociology.

Health Management College,

Tsingua University

Jianmin Gao

Anhui Medical Univ. Anhui. PRC 230032

Professor

aydjqc@mail hfah.cn

Zhang Xiuran
Professor

Health Management Dept.

Xi'an Medical University, Zhuque Dajie,

Jianghong Rao

Institute of Social Security, Beijing

Xi’an, Shaanxi. PRC 710061

Professor

Normal University

Weig@irix.xamu.edu.cn

Social Science Dept., Jiangxi Medical
College, 161 Bayi Dadao, Nanchan,
Jiangxi Province, PRC 330006

Zhenhua Chu

Professor

Jiangsu Medical Information Institute.
No. 129, Hanzhong Lu. Nanjing. Jiangsu,
PRC 210029

HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA - TDR/GEN/SEB/04.1

Project/Futures Group International

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HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA - TDR/GEN/StB/04

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Chinese Traditional Medicine of Anhui, 2003, 6 529-530

HEALTH POLICY AND SYSTEMS RESEARCH IN CHINA ■ TDR/GEN/SEB/O41

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About the authors

Qingyue Meng, MD. MPH, MA(Econ), is Professor of Health

roles of government in the health sector Recently he was

Economics and Director of the Centre for Health Management &

involved in preparing major policy papers on key health issues in

He is a Member of the

China, which were presented to the Chinese government by the

Policy, Shandong University, China

Advisory Committee of Health Management and Policy to the

WHO Representative in China.

Ministry of Health. His research areas include cost-effectiveness

analysis of health programmes and health care financing, and

Miguel A. Gonzalez-Block graduated from Cambridge University

his research team has addressed the development of costing

and obtained a Doctorate in Social Sciences from El Colegio de

methodology for hospitals, cost-effectiveness and financial

Mexico His research interests cover health policy and systems,

analysis of public health programmes, and the impact of health

reproductive health, and primary health care. He was the

care financing reform on tuberculosis control programmes.

Founding Director for Health Policy Research at the National

Shi Guang is Deputy Director of the Department of Health Policy

the Mexican Health Foundation in the design and development

Research and Associate Professor at the China Health Economics

of health policy options Gonzalez-Block was Health Specialist for

Institute of Public Health of Mexico, and collaborated through

Institute. He holds a Master’s Degree in Social Science and

the Inter American Development Bank, in charge of health sector

Health Management from Harbin Medical University. He has

analysis and loan projects for Nicaragua. Panama and Belize. He

conducted health policy and systems research in the China

is currently Manager of the Alliance for Health Policy and

Health Economics Institute since 1997 and has published many

Systems Research.

papers on health care financing, health delivery system re-con­
struction, the governance mechanism in public health organiza­

Erik Blas is Programme Manager of the UNICEF/UNDP/World

tion, and performance assessment of public hospitals in China,

Bank/WHO Special Programme for Research and Training in

in journals on health policy and management at home and

Tropical Diseases (TDR).Witn a background in public health and

abroad.

corporate management, he has long experience of addressing

large-scale health programmes in developing countries from
Mr. Yang Hongwei, MPPM, a National Programme Officer in the

both a research and implementation perspective. He has held

WHO Representative's Office, China, is working in the field of

positions such as Programme Coordinator for the Expanded

health development and health policy. He has worked on health

Programme on Immunization in Tanzania; Chief of the Planning,

related issues for more than 15 years, accumulating much expe­

Management, and Training unit of the Global Programme on

rience and knowledge on health policies and their application.

AIDS; Chief Technical Advisor to the Central Board of Health in

After graduating from the University of Southern California, he

Zambia; and has authored several publications on health sector

focused on the issues of health and macroeconomics, and the

reform.

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