Transformation of Health Insurance Schemes in China: Lessons for Access

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1 Transformation of Health Insurance Schemes in China: Lessons for Access Madhurima Nundy Associate Fellow, Institute of Chinese Studies, Delhi Health insurance has been one of the major forms of health financing in China since the 1950s. Health insurance in China has seen dramatic shifts given the different economic and political contexts. From an almost universal coverage and access to health services in the pre-reforms period, China witnessed tremendous inequities in access with the breakdown of its collective financing structures and rising costs of health care in the 1980s and 1990s in both rural and urban areas with the onset of economic reforms. As a result policies in the late 1990s and 2000s shifted towards universalising access by introducing different insurance schemes for the urban and rural population. This article attempts to trace this transformation in insurance schemes through three distinct phases and draws lessons for access to health services. Keywords: China, health insurance, reforms, inequity INTRODUCTION Financing health services is one of the many sub-systems of health services system that includes infrastructure, human resources, technology, drugs and research. There are different approaches to health services financing. Financing could be through general taxation, fee-for-service, loans and grants or through insurance mechanisms. When financing and provisioning is mainly the state s responsibility then financing is tax based. In an insurance model of financing there could be several sources of funds. The concept is that of a prepayment mechanism in the form of contributions from individuals, employees, employers, government or communities to a pool of fund. These schemes could be public or private. A public insurance scheme could be voluntary or CHINA REPORT 50 : 1 (2014): Sage Publications Los Angeles/London/New Delhi/Singapore/Washington DC DOI: /

2 32 Madhurima Nundy mandatory and subsidised by the government while a private scheme is voluntary and managed by private players. Broadly, health insurance systems could be citizen based systems that provide universal coverage or could be targeted. Examples of targeted insurance include employee based schemes that cover the working population, private insurance schemes that are voluntary and can be purchased by any individual, public insurance schemes that provide coverage to vulnerable population and so on. Canada has a National Health Insurance which is universal and covers its citizens. It is state funded and regulated but provisioning is by the private sector. It is free at the point of delivery for the population and the state directly reimburses the providers. While this is an example of a single and universal health insurance system, a country could have different health insurance systems for different categories of the population for example, the employed, unemployed, rural residents each category is covered by different financing systems. Choice of financing health services tells us how fairly the burden of payment is distributed in a society and how accessible and equitable are the services to the population. It also reflects the socio-political environment of the state. This article traces the emergence and transformation of health insurance schemes that have been the dominant forms of financing from 1950s to the present across rural and urban China. These changes have to take into account the changing political and economic climate of the country. The urban and rural insurance systems have taken distinctly different paths and in terms of evolution the rural insurance system is of considerable interest. The transformation of the health insurance systems are seen through the lens of access and equity. There are three distinct phases in health insurance systems in China: the first phase is that of pre-reforms ; the second is the 1980s and the 1990s; and the third phase begins from early 2000s to the present. From 1949 to 1978, access to health services was based on the process of collectivisation that provided health security to all in rural areas. Health care financing for urban and rural areas developed on distinctly different lines and have been so since then. With the collapse of the collectives, the period of 1980s and 1990s witnessed a breakdown of a comprehensive health services system. Escalating costs of health care were part of the many dire consequences of this collapse of a holistic policy. The process of transition to bring the state back into the health sector in order to increase access was debated all through the 1990s. This resulted in newer systems and insurance mechanisms being introduced in 2000s. While the former role of the state, driven by collectives, was all encompassing as a provider, administrator and financer of health services, the scenario changed when the state withdrew in the 1980s and 1990s and then returned with new insurance models that were qualitatively different from the pre-reform period given the different political contexts.

3 Health Insurance Schemes in China 33 THE PRE-REFORM PERIOD ( ) Health financing in China needs to be viewed in a historical context to make sense of the present state of financing. The period of revolution in China was of immense turmoil and radical change preceded by a society that was marked with high inequalities and poverty. The peasants in rural China were to bring about change in the social structure through a process of reconstruction, collective production and investment. The process of collectivisation in the rural areas was seen as a way of attaining perfect social order and health of the population was a part of this overall development process. In the early 1950s the path to be taken towards ensuring better health systems was laid down by the Party. Medicine was meant to serve the working people, namely, workers, peasants and soldiers; preventive medicine was given priority over curative medicine; practitioners of Chinese traditional medicine were integrated with the practitioners of modern medicine and health work was integrated with mass movements (Sidel and Sidel 1982: 28). The first 16 years of health sector development from 1949 to 1965 was different for urban and rural areas. There was more focus on preventive services that took the form of patriotic health campaigns through mass mobilisations. 1 In spite of these developments and interventions the rural population lacked basic health services. The primary level of health care was provided by private practitioners in rural areas and was not free while the urban residents were covered by public service medical scheme or labour insurance and had right to free services. During the mid-1960s there were discussions within the Communist Party of China (CPC) regarding the urban bias in health services. In the days preceding the Cultural Revolution, in a Directive on Public Health in 1965, Mao said that the health services were skewed towards urban areas and that Ministry of Public Health should be renamed as Ministry of Urban Gentleman s Health. He emphasised that focus of medical and health work was the countryside (Schram 1974: 232). 2 The socio-political changes during the Cultural Revolution resulted in a greater focus on rural areas and were reflected in the development of health services as well. Most importantly, there was an effort to expand the Cooperative Medical System (CMS) that was established to provide health services to the peasants. Even as early as 1955, several cooperatives had experimented with medical schemes and served as models for the CMS that was universalised in the rural areas during the Cultural Revolution. 1 Destroying four pests mosquitoes, flies, rats and sparrows (later replaced by bedbugs) was one of the first campaigns advocated through mass community organisation. Campaigns were also organised against specific diseases like syphilis and schistosomiasis. 2 Mao called for reforms in medical education where he felt that there was no need to accept higher or lower middle school graduates into medical college but it was enough to give three years to graduates from higher primary school. They would then study and raise their standards through practice. During this period there was a move towards deprofessionalisation and decentralisation.

4 34 Madhurima Nundy Cooperative Medical System was a unique kind of pre-payment plan that was linked to the agricultural cooperatives. The system received premium contributions from peasants that amounted to 0.5 to 2 per cent of a peasant family s total income. The other contributors were the Village Collective Welfare Fund and subsidies from higher level government. The peasants obtained reimbursement for a fixed amount of health care expenses. The system involved community participation and cost-sharing. It enabled farmers to access basic health care (Liu et al. 1999: 1354; Xing-Yuan and Tang 1995). Methods of payment varied across communes where some who could not pay at all were exempted from service fees at brigade health stations while others were reimbursed of the costs they incurred; in some other cases, people who could afford made a nominal payment for out-patient services. There were informal methods of cross subsidisation adopted across communes. The CMS reached its peak by the mid- 1970s when more than 95 per cent of the brigades were covered by it. Provisioning was through the three-tier network of services at the brigade, commune and township level which was the backbone of rural health services. At the primary level, that is, at the brigade, the barefoot doctors became an important human resource in health and they were paid by the collectives based on the work points they earned (Acharya et al. 2001; Tang et al. 1994). This system was unique and was integrated within the overall health services system and none were excluded from accessing services. In urban China, all the workers of public industries and urban collective industries were covered through the Labour Insurance Scheme (LIS). Their dependents were partially covered. The state functionaries received free health services under the Government Health Insurance Scheme (GIS). Both the schemes started in the early 1950s. The remaining residents were covered by poverty aid programmes (Ma et al. 2008: 939). During this period of the socially planned command economy, the state attained universal health coverage through its provisioning and financing systems across rural and urban China. Access to health services was not dependent on the ability to pay. THE 1980s AND THE 1990s At the third plenary of the 11th National Party Congress of the CPC in 1978, the members explicitly spoke of socialist modernisation and since then China has undergone dramatic economic, political and social change with far-reaching implications for the health services system. Prior to economic reforms the rural health services received a substantial proportion of their income from the state and collective institutions. The onset of economic reforms led to decollectivisation that had significant implications for provisioning, financing and utilisation of health services. The CMS gradually collapsed and the three-tier network of rural health care weakened due to lack of funds from the state.

5 Health Insurance Schemes in China 35 By the late 1980s, less than 10 per cent of the rural population was covered by the CMS (Tang et al. 2008). Much of the financing was decentralised and left to the responsibility of the provincial and local governments. Local governments that had been once handling preventive and curative health services did not receive enough funds and regulatory systems weakened. Health facilities that were the backbone of the rural health services accumulated deficits. The macro changes made significant changes at the primary level, too. There was an increase in the number of private practitioners. Barefoot doctors during pre-reforms received a share of the output of the collective production. With introduction of market reforms, by the mid-1980s they had become licensed rural doctors and functioned as any private provider and were earning from various sources fees for service, sale of drugs, government grants for provision of preventive services, payments made from village welfare funds and also agricultural production. The state encouraged private practice at the primary level by issuing licences to these practitioners in the rich, middle and poor counties. User fees were implemented in a large scale in the absence of rural health insurance and there was a substantial increase in out-of-pocket expenses. The status of public sector institutions at the secondary and tertiary level was changed to state owned enterprises (SOEs) where they could behave commercially and generate revenue by selling drugs and technology. SOEs were initiated in the health sector in order to augment financial revenues by introducing mechanisms like user fees, charging for drugs and diagnostics, contracting in of services, attracting private capital and opening tertiary care to markets. These changes enabled the profit incentive to be embedded in the running of health institutions in the country. Institutions from this period became autonomous and there was an increase in purchase of technology like never before. This led to irrational medical practices and rise in costs. While there was an urgency to break away from the pre-reforms health service systems there was no clear roadmap for the health sector at the policy level. High costs were frequently cited as one of the reasons for failing to seek health care in the poor counties. There were financial barriers to access in-patient care and non-admission rates were higher in poor counties than in the rich ones. In 1993, out of all the rural people who needed treatment and refused to be hospitalised, 58.8 did not get hospitalised citing economic reasons (Liu et al. 1999: 1354). Accessibility and utilisation of services was dependent on region and socio-economic status. By 1990s income inequalities were rapidly accelerating. There were concerns being raised now on the inter-regional gaps in socio-economic status. The rural urban divide was visible as urban centres had more resources than their rural counterparts. The 14 th Party National Congress held in 1992 raised some concerns on the rising inequities. The report titled Accelerating the Reform, the Opening to the Outside World and the Drive for Modernization, so as to Achieve Greater Successes in Building Socialism with Chinese Characteristics proposed that along with accelerating the establishment of the market system, the system of distribution and social security had to be deepened. This included enhancing the establishment of a system of social security covering

6 36 Madhurima Nundy unemployment, the aged and health and the reform of the housing system in cities and towns (Beijing Review 2011). In response to the widening disparity, this period witnessed discussions around a Rural Cooperative Medical System (RCMS) to address the inequities in access to health services. By 1994, the RCMS design was implemented in 14 pilot counties. The insured population included farmers and enterprise workers. This followed an insurance system where contribution collection was carried out by village leaders on once-a-year basis. The sources of revenue were the contributions made by farmers, the village or county government and workers. The higher the income levels, the higher were the contributions. Coverage of benefits varied and there were different levels of reimbursement for various types of services, and for different levels of charge, from a low 20 per cent (mostly for in-patient services) to a high 70 per cent. The RCMS planned to keep separate accounts for farmers and workers. This design was limiting for risk-sharing as reimbursement levels were seen to be higher for workers and low for farmers (Carrin et al. 1999). This model was not scaled up in the 1990s and the population covered never exceeded more than 10 per cent of the rural population. The urban insurance system underwent reform process in 1998 and took a different path from what was happening at the rural front. In 1997, all medium-sized and large SOEs were enabled to release themselves from the financial difficulties to set up modern enterprise systems under the overall reform process. This was to happen in three years and hence all laid off workers had to be covered by social security systems. The health insurance managed to cover a very small percentage of the laid off or unemployed workers. By the late 1990s the costs of medical care drastically went up. The medical expenses of all employees were 28 times that of In 1998, the Urban Employee Basic Medical Insurance (UEBMI) was launched by the government. In contrast to the old labour protection medical care system, the new insurance system took premiums from the employee and employer and it was not mandatory for all enterprises to join (Zhang 2012). In a sense UEBMI saw the merging of the previous LIS and GIS schemes but did not cover dependents as the previous schemes did. It also did not cover the self-employed, employees in the informal sector and migrants. The breadth of coverage, therefore, reduced by 2003 and the proportion of poor covered also decreased (Korolev 2012). Almost 44 per cent of the urban population was without any health insurance and therefore proportion of population who had to pay out-of-pocket increased (Tang et al. 2008: 1497). Overall, this period witnessed rapid urbanisation with 668 cities in 1997 as compared to 193 in 1979 and increase in costs of health care for both rural and urban areas (Peng 2000). The state of medical care was exemplified by the commonly used phrase during this time kan bing nan, kan bing gui (seeking care is difficult and expensive) (Korolev 2012: 46). During the period of China s economic reform, the share of outof-pocket payment in total health expenditure increased sharply from 20.4 per cent in 1978 to 60 per cent in 2001 (Korolev 2012: 48). Although national expenditures had dramatically increased during these two decades, the out-of-pocket expenditure

7 Health Insurance Schemes in China 37 on out-patient services and treatment had increased several folds. Hospital bed use dropped from 80 per cent in 1990 to 60 per cent in 1999 and out-patient visits also decreased, thus indicating the inability of people to access health care due to financial constraints. Out-patient visits were noted to have declined between the early 1990s and early 2000s due to rising costs (Hu et al. 2008: 1847). It also showed that the rural population was spending higher on seeking health care than their urban counterparts. By 2003 population covered under health insurance in urban areas was 55 per cent while in rural areas it still remained about 10 per cent (Ma et al. 2008: 942). These consequences reflected the overall paradigm shift from a centralised command economy to one that was decentralised and based on market principles. The nation that was a model for the Alma-Ata declaration on Primary Health Care and epitomised universal, comprehensive and equitable health services in 1978 was ranked 144 out of 191 countries in terms of fairness in financial contributions to the health sector in 2007 (Mahtaney 2007). NEWER INSURANCE SCHEMES: 2003 TO PRESENT The new leadership that emerged with the 16th National Congress Party in 2002 articulated that balanced development was important. A framework of people-centred approach and sustainable development was opted. The outbreak of the severe acute respiratory syndrome in 2003 was in a sense a watershed that highlighted the poor state of the health services system that had failed to respond and was a global embarrassment for China. It was consensually acknowledged within the leadership that the increase in GDP did not reflect in balanced development. By this they meant to build a nation with less inequality in income and less regional disparity and more social justice by protecting the disadvantaged. At the policy level, the White paper on China s Social Security in 2004 and the 11th five-year plan ( ) stated the importance of a comprehensive social security system. The key emphasis of the 17th Party Congress in 2007 was on social security for everyone especially those in the rural areas and the poor who had been left out of the development process. This was restated to be an important policy that needed to be implemented. One of the outcomes of these deliberations at the Party level was the development of health insurance schemes to cover all urban and rural population. Presently, social insurance in China covers social welfare, veteran placement, social relief and housing service. In cities there are five pillars of social insurance pension, basic medical insurance targeting urban employees and urban residents, unemployment insurance, work injury insurance and maternity insurance. There were several health insurance schemes that were launched during this decade. The New Rural Cooperative Medical System (NRCMS) was made universal across rural provinces. A new health insurance was launched for urban residents who were unemployed. Attempts have been

8 38 Madhurima Nundy made in the past decade to universalise access and coverage through introduction of the three health insurance schemes. Table 1 gives a summary of the available health insurance schemes in China at present. The features of all the current insurance systems are given in the following. The NRCMS under the Ministry of Social Security was launched nationwide in 2003 as a voluntary insurance scheme for farmers and their dependents in rural areas. The premium is paid by three sources individuals and Chinese national and local authorities. By 2008, the NRCMS coverage extended to 2,679 counties and districts nationwide, leaving only 50 counties that were yet to be reached. The government contribution is about 80 per cent of the total amount. The coverage of services varies across counties. Some counties provide reimbursements for out-patient, in-patient and some catastrophic cases while some just provide for in-patients and so on. Name of the Insurance UEBMIS URBMIS NRCMS Medical assistance Medical allowance for civil servants Table 1 Summary of Features of Insurance Schemes in China Financing Mechanism Ministry Reimbursement* Coverage Employee, employer contribution (not mandatory for enterprises to join) Household contribution and subsidised by the government (not mandatory) Individuals, centre and local authorities (not mandatory) Government funding and voluntary funding by social sector Government funding Ministry of Health Ministry of Health Ministry of Social Security Ministry of Civil Affairs Ministry of Health 70 per cent is reimbursed 50 per cent reimbursed 40 per cent reimbursed Cash transfer 220 million people covered in 2009 (employees and retirees) million people covered at the end of million covered by 2009 (enrolment rate of 94 per cent) 47.4 million for all those covered under Wu Bao and Di Bao All government servants Benefit Package Varies from one enterprise to the other Varies from province to province It varies from one province to the other For some in-patient services For inpatient and out-patient services Source: Compiled from Korolev (2012) and Mao et al. (2011). Note: *These are the recent rates of reimbursement that was received through electronic mail correspondence with a scholar working with China National Health Development Research Centre (under the Ministry of Health) in the Health Security Department on 6 February 2013.

9 Health Insurance Schemes in China 39 The basic medical insurance for urban employees, that is the UEBMIS, is under the Ministry of Health and was launched in 1998 as mentioned in the previous section. Those included are government employees, private non-business units, and employees in informal sector may choose to enrol. The employer contributes 6 per cent of the salary and the employee contributes 2 per cent. Enterprises can volunteer to be part of this system and once they participate then it is mandatory to cover all employees. The benefit package of UEBMIS includes both in-patient and out-patient services. There are two models of payment for UEBMIS. In one model, payment is first done out of the individual s medical savings account and then followed by payment from the social pooling account. This has resulted in compartmentalising the payment mode where the individual s medical savings account pays for the out-patient while the social pool pays for in-patient (Brixi et al. 2011). The Basic Medical Insurance for Urban Residents (URBMIS) was introduced in 2007 and is a voluntary scheme for urban students, children and non-employed residents. This is under the Ministry of Health. Contributions are collected based on household size, pooled at city level and subsidised by the government. The benefit package varies and in some case richer provinces have access to more services than the poorer ones (Korolev 2012). Supplementary medical insurance gives space for enterprises to offer supplementary medical insurance over and above the insurance provided. Civil servants and employees of public service units enjoy medical allowance systems and are covered under government medical insurance system. Medical Assistance (MA) is targeted towards three groups and is under the Ministry of Civil Affairs. These are Te Kun (extremely poor households), Wu Bao (households that receive five guarantees, namely, food, health care, shelter, clothing and funeral costs) and Di Bao (households eligible for a new safety net programme and receive cash transfers). Revenue comes generally from government and donations from social sectors. Studies have shown that individuals apply for assistance once they have incurred medical expenses (Wagstaff et al. 2009). There is a move towards increasing the number of groups receiving MA but a lot still needs to be improved in this scheme as experiences largely vary across provinces and so do coverage of benefits (Mao et al. 2011). Including migrant workers under any health insurance scheme seems to have been the most challenging for the government. It has been difficult to provide insurance coverage for them in any of the above schemes as membership in rural insurance would mean urban migrant workers visiting the rural institutions for treatment and urban insurance premiums are too high for small and medium enterprises where the migrants generally work. But there have been several models that have been designed to reach out to this large population that are being piloted in some counties one model is to extend UEBMI for migrant workers, a second model is a CMS for migrant workers and third model is of an exclusive migrant workers system. In some provinces, UEBMI has been extended to self-employed and migrant workers but has not been able to provide coverage as premiums are high and there are

10 40 Madhurima Nundy issues of self-identification for these two groups. There was a Basic Medical Insurance for Migrants in 2007 that adopted different models and was introduced in several provinces but this did not seem to have taken off at a macro level. Apart from all the government initiatives mentioned earlier there is presence of few private insurance players. Private health insurance accounts for less than 2 per cent of the overall health expenditure and it serves 7 per cent of the population. It provides supplementary insurance for hospitalisation and chronic condition (Chen and Lin 2012). LESSONS FOR ACCESS According to reports, the number of insured people increased from 109 million in 2003 to 157 million in 2006 and in 2009 there were 219 million. From 2003 to 2008 total expenditure on social security increased from 44.6 billion yuan to billion yuan. The share of GDP increased from 3.28 per cent to 4.19 per cent. By 2009 NRCMS had reached an enrolment rate of 94 per cent but out-of-pocket payments had still not gone down uniformly (Korolev 2012: 53). In spite of these advances made by the state, the health care system still faces many challenges in terms of access and rising costs. As seen in the preceding section, there has been a move over the last decade to universalise health care coverage and draw everyone under an insurance scheme. The expanse of health insurance coverage is generally measured according to the depth (relating to the extent to which the range of services necessary to effectively address people s health needs is covered), breadth (refers to the proportion of the population that has financial protection and access to needed health services) and height (which concerns the portion of health care costs that is covered through pooling and prepayment mechanisms) of coverage. In China, while breadth of coverage is almost universal there is much to be achieved in terms of the depth and the height of coverage. Coverage, therefore, is very shallow and a sustainable financing mechanism is yet to be implemented. Most of the major insurance systems are still voluntary and not mandatory, which raise questions on universality of the schemes. Many enterprises do not provide a comprehensive coverage as that would mean they would have to incur more costs. Many migrants and unemployed residents are still not covered uniformly. The depth and height of coverage for this group is the least. Curbing the unreasonable rise of medical costs seems to be the main concern of the policies. As part of the total share of expenditure of health, the individual share may have decreased but studies have shown that out-of-pocket expenses further increased over time between 2000 and 2009 (Korolev 2012). There are huge variations across counties in terms of experiences with the insurance schemes especially with the NRCMS and the reimbursement rates have not exceeded per cent (Mao et al. 2011).

11 Health Insurance Schemes in China 41 The three phases of the health services system as demarcated in the article are distinct. During the beginning of reforms when the country ventured into a socialist market economy from a command economy, state funding to health services was badly hit. The institutions were asked to generate their own revenues and people started paying out-of-pocket for many services. Over the next two decades with increasing gaps between the urban and rural and the rich and poor there were severe access and equity issues in health services. The state responded to the iniquitous access by designing newer forms of insurance schemes so as to increase coverage. In spite of large coverage of population there are several issues that need attention in terms of rising costs of medical care, lack of depth and height in coverage, and out-of-pocket expenses that still exist. The insurance schemes in the present form functions in a market economy and hence, although provision is largely by state-run institutions they behave like the for-profit sector. This has resulted in over-medicalisation, irrational medical practices and overuse of technology. Insurance schemes functioning in a market economy invariably increase costs of medical care. There are huge gaps between the costs and benefit packages across the three insurance schemes and there is a need to reach greater cross subsidisation across rural and urban areas and integrate urban and rural insurance systems. The large development gaps between urban, rural and coastal inland China also mirror the state of health services system in these regions. Spending on health is higher in regions that are developed and insurance schemes in urban areas function better than those in rural areas. Although the central and local governments have increased their funding the costs have escalated over the last decade. In order to generate more funds for the institution and incentive payments, many hospitals behave like private hospitals. In some hospitals where casebased payments are being made, there has been a tendency to diagnose patients as more severe than they were to generate more resources resulting in cost escalation. There is fragmentation of the health services system in China. First, there are multiple players where different ministries handle different insurance systems; second, none of the insurance schemes are uniform in their implementation. Insurance mechanisms or models have largely come to dominate health financing in recent years. Insurance based financing is seen as an alternative to general taxation. An insurance system is progressive when it provides universal and uniform coverage to the population, covers all services and has no out-of-pocket expenditure at the point of delivery. This was seen during the period of collectivisation in China. The rural was covered through pre-payment mechanism and there was a process of cross subsidisation. The economic and political context has been very different in both phases although the larger objective of universal coverage for health services still holds. It is a clear shift from a social insurance system operating through the collectives to a medical insurance system for individuals in a market economy. In the past, preventive health was integrated with the curative services with a three-tier system and a comprehensive and universal system evolved. In the present times insurance has clearly shifted the focus to curative services and there is a lack

12 42 Madhurima Nundy of a comprehensive and integrated system. China today seems to be facing severe access issues in health services. There is clearly a need to achieve equity in terms of economic access. Financing of health services is an important component within the health services system today. In the context of recent debates on reforms and universalisation of health care, financing plays a major role but undermines a systemic view needed to build a comprehensive and equitable health system which was the path taken during the pre-reforms period. Most health policies have started approaching from the lens of financing rather than taking an overall view of the system. This results in fragmentation of a comprehensive system and gives undue priority to financial efficiency, hence undermining people s health needs and inequities that exist. Efficiency has therefore taken over equity in policy debates and this generally happens when market mechanisms play a dominant role in determining structures of financing and provisioning of health services. Efficiency was never a major concern when health systems were established in welfare states post Second World War provided everyone had equal access to services. The choice of health financing in a given socio-economic and political context tells us how the state addresses issues of fairness and equity. In China, human development that was achieved during the pre-reform period was very critical to make the dramatic shift to market reforms in Although they attained good human development indicators by 1978, China today stands as a society marred by inequities in terms of access to health services. REFERENCES 16 th National Congress of the Communist Party of China Full Text of Jiang Zemin s Report at 16 th Party Congress, (accessed on 15 February 2013). Acharya, Alka, Rama V. Baru and Geetha B. Nambissan The State and Human Development: Health and Education, in G.P. Deshpande and Alka Acharya (eds), 50 Years of India-China: Crossing a Bridge of Dreams. New Delhi: Tulika Publications, Full Text of Jiang Zemin s Report at 14th Party Congress, document/txt/ /29/content_ htm (accessed on 15 February 2013). Brixi, Hana, Yan Mu, Beatrice Targa and David Hipgrave Equity and Public Governance in Health System Reform: Challenges and Opportunities for China. The World Bank: East Asia and Pacific Region. Carrin, Guy, Aviva Ron, Yang Hui, Wang Hong, Zhang Tuohong, Zhang Licheng, Zhang Shuo, Ye Yide, Chen Jiaying, Jiang Qicheng, Zhang Zhaoyang, Yu Jun and Li Xuesheng The Reform of the Rural Cooperative Medical System in the People s Republic of China: Interim Experience in 14 Pilot Counties, Social Science and Medicine, Vol. 48, No. 7, Chen, Helen and Yanyan Lin The Rise of Private Health Insurance, China Economic Review, March, (accessed on 14 February 2013). Gu, Xing-Yuan and Shenglan Tang Reform of the Chinese Health Care Financing System, Health Policy, Vol. 32, No. 1 3,

13 Health Insurance Schemes in China 43 Hu, Shanlian, Shenglan Tang, Yuanli Liu Yuxin Zhao, Maria-Luisa Escobar, David de Ferranti Reform of How Health Care Is Paid for in China: Challenges and Opportunities, The Lancet, Vol. 372, Korolev, Alexander China s Healthcare: Developing a Universal Coverage Plan, Far Eastern Affairs, No. 1, pp , Minneapolis, USA. Liu, Yuanli, W.C. Hsiao and K. Eggleston Equity in Health and Health Care: The Chinese Experience, Social Science and Medicine, Vol. 49, No. 10, Ma, Jin, Mingshan Lu and Hude Quan From a National, Centrally Planned Health System to a System based on the Market: Lessons for China, Health Affairs, Vol. 27, No. 4, , doi: / hlthaff Mahtaney, P India, China and Globalisation: The Emerging Superpowers and the Future of Economic Development. New York: Palgrave Macmillan. Mao, Zhengzhong, Wei Fu, Xuefei Gu and Yuaping Wan China: Developing a Basic Rural Medical Security System, Sharing Innovative Experiences: Successful Social Protection Floor Experiences, UNDP, Global South-South Development Academy and ILO, Peng Xizhe Introduction, in Peng Xizhe and Guo Zhigang (eds), The Changing Population of China. London: Blackwell Publishers, Schram, Stuart Reynolds. (1974). Mao Tze Tung Unrehearsed: Talks and Letters. London: Penguin Books Ltd. Sidel, Ruth and Victor W. Sidel The Health of China. London: Zed Press. Tang, Sheng-lan, Qingyue Meng, Lincoln Chen, Henk Bekedam, Tim Evans and Margaret Whitehead Tackling the Challenges to Health Equity in China, The Lancet, Vol. 372, 25 October, Tang, Sheng-lan, Gerald Bloom, FengXue-Shan, Henry Lucas, Gu Xing-Yuan, Malcolm Segall, Garth Singleton and Polly Payne Financing Health Services in China: Adapting to Economic Reform. Brighton: Institute of Development Studies, Sussex Research Report 26. Wagstaff, Adam, Magnus Lindelow, Shiyong Wang and Shuo Zhang Reforming China s Rural Health System. Washington: The World Bank. Zhang Zhenzhong Healthcare Reform, in Wang Mengkui (ed.), Thirty Years of Reform. London and New York: Routledge and China Development Research Foundation,

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