Health Research for Policy, Action and Practice - The INCLEN Trust

Several features of China’s management of transition have influenced the kinds ofresearch undertaken. One is the rapidity of change. As China radically changes itseconomic system it is simultaneously urbanizing, industrializing and undergoing ademographic and epidemiological transition. The political leadership has coped withthese multiple challenges by defining broad objectives for sector development, whilstgiving localities considerable freedom of manoeuvre [Liu and Bloom, 2002]. Thisapproach attaches great importance to local innovation. Researchers have played animportant role in alerting government to emerging problems and assessing theperformance of innovative approaches.The example of health finance can be used to illustrate the evolution of healthsystems research. In urban areas, the pre-existing system has come under increasingpressure due to ageing of the insured population, rising costs of medical care and thefinancial pressures on the many state-owned enterprises through which health andsocial care is still commonly provided. The central government encouraged citygovernments to test new models of health insurance. Towards the end of the 1990s itdecided to shift responsibility for urban health insurance to the Ministry of Labourand Social Security. Studies have documented the increasing difficulties experiencedby people on lower incomes in paying for health care [Liu et al, 2002; Dong, 2003;Chen et al, 2004]. The research also documents the unsustainably high costsgenerated by a combination of a rapidly ageing population and the dependence onhospital-based care for the elderly. These findings have stimulated efforts to makeservices more cost-effective and provide a safety net for the poor.A number of studies have documented the dependence of rural health facilities onuser charges. They have shown how health workers give increasing priority tocurative care and the sale of drugs [Zhan et al, 1997; Dong et al, 1999]. During theperiod of the command economy the communes had organized the so-calledcollective medical system, which reimbursed a proportion of the costs of hospitalcare and other services. By the mid-1980s, studies had documented the collapse ofmost of these schemes. The Government has encouraged localities to test alternativefinancial models.During the 1990s there were several experiments with rural health insurance. Theearly focus was on the design of benefit packages. There was extensive discussion ofthe advantages and disadvantages of covering routine care and major illness. Itturned out to be unexpectedly difficult to establish new schemes, for a number ofreasons. Some local government units diverted resources for other purposes. Someoverstaffed health facilities sold more drugs or acquired new equipment to generatemore revenue. Many schemes eventually lost public support and recent studies havehighlighted the importance of public trust in insurance schemes and the healthfacilities that provide services [Wang et al, 2001; WHO, 2003]. They emphasize theneed to make schemes more accountable to the population.Health Research for Policy,14Module I, Unit IAction and Practice