Over the past decade China has tried hard to develop effective measures to control the rapid cost escalation of healthcare. This is especially important, as the Government of China has been implementing the strategy of universal health coverage and increased significantly financial input into the health systems strengthening. Experiences and lessons from many OECD countries over the past half century would be useful and valuable to the on-going reform of China's health care system. They would help China to look for more effective and evidence-based measures to tackle the issues, making its universal health coverage more sustainable, though considerations on different contexts, such as political, economic and cultural factors, are required in the exercise of "know-how".
Ensuring high quality and safety of health care is one precondition in discussing how containing health care cost. It is very encouraging to see that some Chinese health facilities, with the technical support from NICE in England, have adopted the standard clinical paths for the diagnosis and treatment of their patients. This would have to ensure the effectiveness of using both diagnostic tools and clinical interventions, and also avoid the provision of unnecessary services whose main purpose was to generate revenues for services providers, and which may do possible harms, rather than any good, to patients. In many OECD countries, medical associations, or health authorities are responsible for updates of the clinical guidelines and treatment standards, using available evidence. The practice of this kind was not common in China until recently. Ministry of Health of China have now recognized the importance of standard clinical guidelines and made great efforts in setting clinical guidelines and norms in recently years, particularly for primary health care facilities handling common diseases and health problems. Greater efforts should be made to expand the application of standard clinical paths in more Chinese hospitals. Furthermore, as presented in this paper, there is lack of sufficient evidence generated from these pilot studies to inform further development of policies and practices. Research on impact assessment, including monitoring and evaluation, need to be encouraged to provide robust evidence and sound knowledge aimed to improve quality of care in China.
It is critically important and essential to have clinical guidelines and standards that health service provider can apply in their practices. However, we all know that are not sufficient. Appropriate incentives must be developed to enable service providers to implement good practices of health services that are accessible and affordable to the people in need. As reported in this paper, many local health authorities in China have taken proactively roles in developing and implementing local initiatives aimed to provide health service providers with appropriate mechanisms and incentives for the delivery of health care services. SRES has become one of widely used mechanisms, particularly in financing of primary health care centres in urban cities of China. It seems that such a mechanism removes a perverse financial incentive to the over-prescription of diagnosis and drugs and delinks the income of community health workers with their revenue generation from service charges and drug prescriptions. As a consequence, rational prescription of diagnosis and drugs can be promoted to make essential healthcare more affordable. In addition, the fund for public health inventions can be protected from such an allocation of government health budgets. However, measures needs to be developed to ensure that the transfer of the government health budgets to these CHCs should be made in timely manner in order to operate community health centres in an effective and efficient way. Furthermore, how to develop innovative incentives (i.e. financial and professional) for community health workers is facing a new challenge.
As we know, there are no perfect provider payment methods exist. China has been in a right direction in reforming provider payment methods to tackle cost escalation of health care in recent years. Case-based payment method and flat unit rate payment have been increasingly used in China. Some cities, like Shanghai, have also started to use global budget to pay for health care. The implementation of case-based payment system in China must be done carefully, as only a number of diseases were often covered in such a system. The hospitals may shift the costs from the treatment of these selected diseases to the treatment of other health problems. In addition, as reported in this paper, there have also some concerns about the quality of services, under-treatment, and unnecessary patient referring seen in some hospitals in order to save the costs of care. That is not surprising. Our experiences also tell that service providers often developed their coping strategies to deal with any reforms or initiatives to regain their invested interests. It implies that the monitoring and evaluation of these reforms and their impacts on cost and quality of healthcare is critically important. And, the health authorities or health insurance management agencies should be well prepared to change policies or strategies every a couple of years. Furthermore, in order to achieve this, it is imperative to improve significantly technical capacities of the local health authorities and health insurance management agencies in China.
Drug expenditure as percentage of total health expenditure in China is substantial over the past three decades. In order to reduce the cost of drug expenditure, the management of pharmaceutical procurement system has been radically reformed in recent years, which has produced a positive impact on bringing the prices of many drugs down at the point of service delivery, as we have seen in Guizhou. What China should do more is that local health authorities (e.g. provincial or municipal levels) and/or health insurance fund management agencies at these levels ought to use their large collective bargaining power to get reasonably low prices of drugs, particularly for most generic ones, as Britain's NHS and other OECD countries has been doing. There is still a room for Chinese health authorities or health insurance schemes to do more in this area. Challenges facing the health sector in China include trade protections within different provinces, weak purchasing capacity of some health authorities and health insurance management agencies in less developed regions, and strong lobbying from international and local pharmaceutical manufacturers and wholesale agents. While it is imperative to improve the rational use of drug by developing and implementing appropriate incentives for both service users and providers, it is also equally important to ensure that these innovative pharmaceutical procurement systems, including those tendering practices aimed to low drug prices, would not jeopardize or discourage internal innovation in the Chinese pharmaceutical sector, and diminish enthusiasm of multi-national drug firms to participate in the China market. Overall speaking, the systems of drug distribution, procurement and use in China have been improved gradually.
China's health system reform is at a critical moment. Although both central and local governments have increased their funding for implementing universal health coverage over the past decade, and an increasing number of Chinese people have now enjoyed affordable essential healthcare, the task of cost control in the health sector is still formidably challenging. Without effective containment of health care cost, increased investments in health care would not be transferred to improved access to health care for Chinese people in need, and thus the goal of fully implementing universal health coverage by 2020 would have to be in jeopardy. More effective actions and measures on cost control are badly needed in China now than ever.