Madhurima Nundy, PhD, Associate Fellow, Institute of Chinese Studies
The political report delivered by Xi Jinping at the 19th Congress of the CPC is open to analysis and many interpretations. Indeed, it is a lengthy and comprehensive report where Xi attempts to cover all aspects of development in the last five years and challenges that face China today, apart from his take on socialism entering a new era. Health and wellbeing of the population is an integral component of human development which gets articulated in various sections.
It is accepted universally, that the determinants of health and wellbeing are not restricted to access to health services alone but includes social, economic, environmental and cultural factors that influence the health of the population. As a prelude to his speech, Xi gave an overview of the overall socio-economic development and that 60 million people have been lifted above poverty. There is emphasis and acknowledgement of the contradictions of Chinese development and growth as a result of unbalanced and inadequate development. The report goes on to state that there are large disparities in development between rural and urban areas, between provinces, in income distribution, and that people face difficulties in areas of employment, education, healthcare, housing and elderly care. It clearly states that quality of growth must take precedence over speed of growth.
In Xi’s speech, social security, health and wellbeing have been covered under the section on ‘protecting people’s livelihood; improving wellbeing and strengthening and developing new approaches to social governance’. The section covers important themes like protecting the rights of education, employment and raising income levels, improving social security systems, alleviating poverty, rural vitalisation and food security, better health services and strengthening social governance. From the speech one gathers that there is a holistic understanding of wellbeing – all of these are determinants for attaining a secured life and a healthy population which in turn is key to a prosperous and strong nation.
China had attained enviable health indicators by 1978 because of its universal and comprehensive socio-economic development and access to basic healthcare. But the health sector became one of the most neglected sector post 1980s with inequalities in income, access to basic services and high medical costs that resulted in stagnating health indicators. It was during the 16th Party Congress in 2002, after over two decades of economic reforms that there was a call to urgently address access to health services. High costs of medical care were pushing people into poverty especially in rural China. For almost two decades now, the CPC has taken measures to improve accessibility by universalising health insurance. Since 2009, they have opted for a path of course correction to address gaps in other important sub-systems of the health sector – medicines, institutions and research. While a lot of this has led to rectification of policies, they have come with new perils and challenges.
Within the sub-section on health services, Xi highlighted the following challenges:
Public hospital reforms: Xi reports that the profits made by hospitals by selling overpriced drugs will be put to an end. There is a realisation that there is yet a lot that needs to be achieved under public hospital reforms. Rise in medical costs and catastrophic expenditure has been one of the major causes of impoverishment in China. A large proportion of out-of-pocket expenditure is for purchasing medicines. Many public hospitals in China still function commercially despite the 2009 ‘deepening of healthcare system reforms’ where one of the pillars of reform was creating a national essential drug list and corresponding hospital reforms so as to remove all profit mark-ups linked to the selling of medicines in hospitals.
Primary healthcare: The report emphasises on strengthening community health services and increasing the cadre of general practitioners at the primary level. One aspect of the healthcare system that has received much attention in the last five years has been building of primary healthcare services. This has been one of the key pillars of reforms and course correction. The breakdown of primary healthcare and overdependence on tertiary care had led to irrational, expensive and skewed services. People had lost faith in primary level care which was China’s backbone till the early 1980s.
Preventive health services: There was a brief mention of carrying out extensive patriotic health campaigns and preventing major diseases. One does not get the sense of what these patriotic health campaigns would entail or the diseases that are in focus, but a significant point made here is ensuring food security and that every plate must be full. Food and nutrition are components that one tends to overlook when talking about preventive health services that otherwise become more focused on immunisation and other supplements. Food is a vital determinant of a healthy population.
Private investments: In one line Xi’s report states that the CPC will support private health sector and industries without getting into details. In the last two decades, much of the government subsidies have gone towards maintaining the health insurance schemes to universalise coverage than investing in public hospitals. To fill this gap, public hospitals are opening up to private sector investments and forming partnerships. The direction of reforms of public hospitals seems to be edging towards greater privatisation. Since Xi took up his position as the Party General Secretary in 2012, the private sector has received greater attention. There has been liberalisation of policies to invite private sector investments in many aspects of health services especially for establishing wholly owned foreign hospitals at the tertiary level of care in leading cities. Before, none of the so-called private hospitals were completely private as they were joint ventures with a government company having at least 30 percent share. While these investments have been opened for companies from Macau, Taiwan, Hong Kong and Singapore to begin with, investments in senior citizen homes and assisted living for elderly have seen investors from several other countries. The market share in healthcare sector is clearly set to increase under Xi, though entering Chinese market is said to be a laborious process due to which private investors are very cautious of making investments in what they see as a ‘constrained’ environment. This is one domain that one needs to observe closely and study the implications of privatisation on access.
Population and demography: There is mention of population ageing and elderly care that has been and will remain a challenge in the coming decades. Xi does mention fostering a secure environment for the elderly along with integrated health and medical services. At the fifth plenum of the 18th Party Congress in 2015, there was a shift from the one-child policy to a two-child policy. There is no mention of the outcome of this policy change and whether there would be further relaxation, except an ambiguous statement that “we will… ensure that our childbirth policy meshes with related economic and social policies and carry out research on the population development strategy”. Recently, it was noted that fertility rates, which is an important indicator of population growth, was removed from the China Statistical Yearbook for 2017 and there is no reason given for this deliberate omission.
Xi covered in brief the major challenges that need to be addressed but over the years one observes that health service system in China is becoming increasingly complex and it will be important to see how it shapes up in the coming years. One of the omissions is the mention of burden of diseases, and in this context, the importance of regional cooperation for epidemics and infectious diseases like influenzas that could reach pandemic proportions. The report does touch upon the need to coordinate responses for non-traditional threat, but does not detail this out. The single-minded pursuit of economic growth has seen many social costs that Xi addresses in the report. There seems to be a proactive approach to address other development goals, including environment protection which impacts wellbeing, and receives considerable space in Xi’s report of the 19th Party Congress.