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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 November 10; 335(7627): 961.
PMCID: PMC2072004

China's health insurance system is failing poor people

China's vigorous attempts to provide its vast population with better access to health care in the past few years have largely misfired, a World Health Organization study concludes.

Although overall spending on health care has risen by an average of 15% to 22% a year since the 1990s, much has been absorbed by the soaring costs of hospital care rather than being used to create the safety net of comprehensive care that was intended, said a WHO official.

What's more, new health insurance schemes for both city and country areas have failed to make medical treatment affordable for poor people, says the report.

China's government has made it a priority to improve access of its poorer citizens to medical treatment, under the slogan of creating a more “harmonious society.” It is particularly concerned about health care and education for the 200 million or so former farmers who have left their villages to seek work in the cities, as well as peasants left behind by the urban east coast's rush towards first world status.

The problem is that China has largely adopted a “pay first, claim later” model of health insurance, and hospital costs have risen steeply, said Tang Shenglan, health and poverty adviser for WHO in China.

“Out of pocket payment for health care from individuals rose from some 20% in 1980 to 54% of total health expenditures in 2005,” Dr Tang told the annual meeting of the Global Forum for Health Research, which took place in Beijing last week.

It was therefore “not surprising,” he added, that “the use of professional care by the Chinese people has generally declined over the past decade or so.”

The percentage increase in spending on health care since the 1990s has far outstripped the annual increase in gross domestic product, which has averaged about 9%, Dr Tang said. However, despite China's spectacular economic growth and greater spending on health, WHO believes that there has been a “slowdown of improvements in population health,” which has “occurred concomitantly with a rise in disparities in health outcomes between urban and rural populations.”

The Rural Cooperative Medical Scheme has extended basic health insurance to 78% of China's rural population—some 685 million people—since 2003. Annual premiums paid by farmers to the scheme are as low as ¥20 (£1.30; €1.85; $2.70) per person, and these are matched by local and central government, although the pool of funds remains too shallow to meet needs in many areas.

In urban areas insurance coverage has actually fallen. Overall, health insurance coverage fell from 45% of the settled urban population in 1998 to 39% in 2003. Furthermore, only in the top two income brackets has the percentage of people who are insured risen from the 1998 level.

The problem is that China's health reforms are too reliant on the “pay first, claim later” model, although few can afford hospital care in the first place. “The catastrophic cost of medical care is a major cause of poverty,” Meng Qingyue, of the Centre for Health Management and Policy at Shandong University, told the forum. Repayment is not mandatory and entails complex application processes that can filter out poor, uneducated, and, often, seriously ill people. Dr Tang's study showed that the rate of reimbursement can be as low as 30%.

Furthermore, hospital treatment is ruinously expensive for poor people. At one hospital studied, the average cost of inpatient care climbed from ¥1500 in January 2006 to ¥2500 in March. Part of the reason is “perverse incentives that flow from ‘fee for service' as the major payment method,” said Dr Tang.


See Tessa Richards' blog from the Global Forum for Health Research at

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