Healthcare reform in China is absolutely pushed along by people, not politicians

Over on China/Divide I received a few comments about my post “Healthcare Knowledge as a Catalyst for Change in China”.  I submitted a response to one of the comments worthy of a stand alone post.

See our exchange, including my response to the healthcare question,  below.

King Tubby (commenter):

Dam­jam. Wel­come back, but your yel­low tie presents major sar­to­r­ial issues.

Keep­ing it dead short. Sure there is a grow­ing aware­ness among the mid­dle classes in major cities. How­ever, there is no pos­si­bil­ity for a slightly inclu­sive and half decent health care sys­tem, until the polit­i­cal regime and sys­tem of gov­er­nance is rad­i­cally reor­gan­ised. The for­mer will pro­ceed from the lat­ter, and not vice versa as I under­stand your piece.

My Response:

Thank you for the wel­come. It’s good to be back. My Gra­vatar is already in the green room chang­ing. This past Easter the sar­to­r­ial choice came down to either a yel­low or pink tie.…yellow won. It looked good in the sun, not so much on film.

KTubs, you may be sur­prised, but I agree with your state­ment because our two points of view are not mutu­ally exclu­sive. I will try to briefly explain why. Please take this as an incom­plete answer (I don’t have the time this morn­ing to pen a ten vol­ume trea­tise) and I wel­come you to con­tinue the dis­cus­sion until we’re both too tired to continue.

Some con­text:

At the onset of the People’s Repub­lic, China took a largely hands off pol­icy with health­care, putting the bur­den on com­mu­ni­ties to fund and build their own health ser­vices. This has resulted in high lev­els of health­care inequal­ity from one com­mu­nity to the next, and a major rift between rural and urban health ser­vices which have become defacto dis­tinct health­care systems.

While the aver­age per-capita expen­di­ture on health­care in China is roughly $400 dol­lars per year, a half bil­lion rural Chi­nese res­i­dents make do with a more mod­est 5-10$, while those rich enough to have pri­vate insur­ance, or (more typ­i­cally) pay out of pocket, can spend a lot more than the $400 dol­lar aver­age on a sin­gle visit to the doc­tor (the best of whom are increas­ingly work­ing in pri­vate hospitals).

Tak­ing a satellite-eye’s view of the sit­u­a­tion, China’s nation-level pol­icy mak­ers and health­care engi­neers have two dif­fer­ent health­care sys­tems to build. But as we get closer to sea level the actual task becomes more nuanced, requir­ing the tal­ents of ever more and more peo­ple, provin­cial and local gov­ern­ment offi­cials and health­care spe­cial­ists. And, of course, this effort needs a lot of money. Tremen­dous amounts of money.

Here, at the above water tip of the prob­lem, is where it is tempt­ing to say that the gov­ern­ment needs to be mas­sively reor­ga­nized before any­thing can be done, and that much more money needs to be avail­able. What’s the point of demand­ing bet­ter health­care from the gov­ern­ment if it is orga­ni­za­tion­ally impos­si­ble to coor­di­nate the type of effort needed to bring real change around?

Again, one has to look at what tran­spired sixty years ago. There remains a sys­temic expec­ta­tion for Chi­nese com­mu­ni­ties to help them­selves. The gears of change, in other words, are designed to move only when the peo­ple push.

It is not too cyn­i­cal to sug­gest that the coun­try author­ity is wired in such a way to just ignore the push, or even recoil like a pit viper against it. His­tory gives us plenty of rea­son to be cyn­i­cal of the authority’s stated desires to bet­ter the country’s social wel­fare sys­tems. But, it is also no exag­ger­a­tion to say that mak­ing bet­ter health­care avail­able to Chi­nese cit­i­zens is the authority’s top domes­tic pri­or­ity. Look­ing back again his­tor­i­cally, poor health in the pop­u­la­tion has often resulted in regime change.

Finally on the point of lessons that his­tory imparts, it’s impor­tant to remem­ber that just because some­thing was doesn’t mean it will con­tinue to be. Ret­ro­spec­tive analy­sis can only get us so far.

The sign of change I will refer to are the stated goals of just one piece of the cur­rent 900 Bil­lion RMB health­care reforms. In Jan­u­ary 2010 the plan to cover all Chi­nese peo­ple with health insur­ance was (finally) kicked off. The stated guid­ing prin­ci­ples were three fold -

(1) improve health sta­tus; (2) spread finan­cial risk/expand insur­ance cov­er­age of some type; (3) do 1 and 2 in a man­ner that improves sat­is­fac­tion of the Chi­nese peo­ple with their health care and health care system.

That third prin­ci­ple is the core of the mat­ter. It indi­cates that the cur­rent reforms are moti­vated in large part by the pro­fessed needs of the Chi­nese peo­ple, and are not being imposed upon them by an impro­vi­sa­tional troop of polit­i­cal grand­standers. The peo­ple brought them about. I am aware that the pos­si­bil­ity exists of that prin­ci­ple just being another exam­ple of the pre­vi­ously men­tioned empty talk, but sev­eral devel­op­ments, too com­pli­cated to go into in depth here have me think­ing that they express a gen­uine sen­ti­ment. (see China’s new drug list, and rural clinic reform pro­grams for more info).

Now, will the cur­rent reforms be per­fect? Likely they won’t be even close to it. They might not even be com­plete. I’ve writ­ten more times than I can count on cru­cial miss­ing com­po­nents of the reforms like the fail­ure of any of the pro­grams to address mis­aligned doc­tor incen­tives. But, by my reck­on­ing the reforms have already estab­lished one impor­tant result – short­en­ing the approved drug list – and started on another, the expand­ing on health insur­ance. So far so good. If the reforms can just now fol­low through on estab­lish­ing more med­ical schools, and train­ing more health­care work­ers of every ilk, then the coun­try is well on it’s way to half-decent.

The con­tin­ued exe­cu­tion of the reforms, in my opin­ion, rests on the people’s will­ing­ness to con­tinue push­ing for bet­ter health­care ser­vices, and this holds sev­eral order’s of mag­ni­tude more for rural areas, increas­ing in mag­nitued with each mile out from Beijing.

If this sen­ti­ment were not to be expressed, then pol­icy mak­ers, who are lets not for­get also politi­cians, would have no rea­son to do anything.