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CHINA is not substantially more expensive than usual care for patients. Information on patients’ emergency visits is not routinely sent to their primary care doctors. Hospitals: Hospitals can be public or private, nonprofit or for-profit. Most township hospitals and community hospitals are public, but both public and private secondary and tertiary hospitals exist in urban areas. Rural township hospitals and urban community hospitals are often regarded as primary care facilities, similar to village clinics rather than ‘true’ hospitals. In 2013, there were 13,396 public hospitals and 11,313 private hospitals (excluding township hospitals and community hospitals), of which 17,269 were not-for-profit and 7,440 were for-profit (National Health and Family Planning Commission, 2014). In 2013, there were 487,802 public primary care facilities and 427,566 private village clinics (National Health and Family Planning Commission, 2014). Hospitals are paid through a combination of out-of-pocket payments, health insurance compensation, and, in the case of public hospitals, government subsidies—the latter representing 13.5 percent of total revenue in 2013 (National Health and Family Planning Commission, 2014). A significant number of patients pay 100 percent out-of-pocket, because they receive out-of-network services. Although fee-for-service is dominant, DRGs, capitation, and global budgets are becoming more popular in selected areas. Local health authorities set fee schedules, and doctor salaries and other payments are included in hospital reimbursement. Mental health care: Mental health care, including disease diagnosis, treatment, and rehabilitation services, is provided in special psychiatric hospitals and psychological departments of tertiary hospitals. Patients with mild illness are often treated at home or in the community; only severe mentally ill patients are treated in psychiatric hospitals. Both outpatient and inpatient mental health services are covered by insurance, with benefits subject to lower copayment rates. In 2013, there were 28 million mental health patient visits to special psychiatric hospitals, and on average one psychiatrist treated 4.6 patients per day (National Health and Family Planning Commission, 2014). Mental health is not integrated with primary care. Long-term care and social supports: In accordance with Chinese tradition, long-term care is provided mainly by family members at home. There are very few formal long-term care providers. Family caregivers are not entitled to financial support or tax benefits, and long-term care insurance is virtually nonexistent; expenses for care in long-term care facilities are paid almost entirely out-of-pocket. Government may provide some subsidies to long-term care facilities. On average, conditions in long-term care facilities are poor, and there are long waiting lists for enrollment in high-end facilities. Formal long-term care facilities usually provide only housekeeping, meals, and basic services like transportation, but very few health care services. Some long-term care facilities may coordinate health care with local township or community hospitals, however. There were 4.94 million beds for aged and disabled people in 2013 (National Bureau of Statistics, 2014). Some hospice care is available, but it is normally not covered by health insurance (Chen, 2014). What are the key entities for health system governance? In 2013, the Ministry of Health and the National Population and Family Planning Commission were merged into the National Health and Family Planning Commission as the main agency for health controlled by the State Council (central government). The State Administration of Traditional Chinese Medicine is affiliated with the new Commission. The National People’s Congress is responsible for health legislation. However, major health policies and reforms may be initiated by the State Council and the Central Committee of the Communist Party as well, and these are also regarded as law. The National Development and Reform Commission, which has been heavily involved in the recent health care system reform, oversees health infrastructure plans and competition among health care providers. The Ministry of Finance provides funding to government health subsidies, health insurance contributions, and health system infrastructure. The Ministry of Human Resource and Social Security runs urban employment-based basic insurance and urban resident basic insurance. The China Food and Drug Administration is responsible for drug approvals and licenses, but health technology assessment or cost-effectiveness have not played a significant role yet. The China Center for Disease Control and Prevention is administrated by the National Health and 34 The Commonwealth Fund
CHINA Family Planning Commission, though it is not a government agency. The Chinese Academy of Medical Science, under the National Health and Family Planning Commission, is the national center for health research. The National Health and Family Planning Commission directly owns some hospitals in Beijing, and national universities directly administrated by the Ministry of Education also own affiliated hospitals. Local government health agencies, usually the Bureau of Health or Health and Family Planning Commission in each province, may have a similar structure and often own provincial hospitals. Local governments (for prefectures, counties, and towns) may have departments of health and own hospitals directly. Centers for Disease Control and Prevention also exist in local areas and are administered by the local bureaus or departments of health. At the national level, the China Center for Disease Control and Prevention provides technical support to the local centers only. Both national and local Health and Family Planning Commissions have comprehensive responsibilities for health quality and safety, cost control, provider fee schedules, health information technology, and clinical guidelines. What are the major strategies to ensure quality of care? The Department of Health Care Quality within the Bureau of Health Politics and Hospital Administration and overseen by the National Health and Family Planning Commission is responsible for quality of care at the national level. The National Health Service Survey is conducted every five years (the latest in 2013), and a report is published after each survey highlighting data on selected quality indicators. Hospitals must obtain licenses from local health authorities for hospital accreditation. Physicians get their practice licenses through hospitals, and they have to renew their licenses after a certain period. Several national hospital rankings are available from third parties too, but there are no financial incentives for hospitals to meet quality targets (Dong et al., 2015). Following release of the “Temporary Directing Principles of Clinical Pathway Management” by the former Ministry of Health in 2009, clinical pathways are now regulated nationally and used in a similar manner as clinical guidelines are in Western countries. Previously, pathways were created at the hospital, rather than national, level. What is being done to reduce disparities? There are still severe disparities in accessibility and quality of health care, although China has made significant improvements in the past decade. Income-related disparities in health care access were serious before the reform of the health insurance system more than 10 years ago, as most people did not have any coverage at all. Today, publicly financed insurance coverage is now nearly universal and there are safety nets for the poor (see above); as a result, income-related disparities have been reduced substantially. Remaining disparities in access are mainly because of variation in insurance benefit packages, urban and rural factors, and income inequality. Urban employment-based basic insurance offers broader benefit packages than the other two insurance schemes. To improve benefit packages and reduce disparities, central and local governments intend to consolidate insurance schemes, an effort that has already been piloted in selected areas, such as Dongying City in Shandong Province and Jinhua City in Zhejiang Province. In addition, central and local government subsidies to urban resident basic insurance and the rural newly cooperative medical scheme have increased in recent years. Most good hospitals (particularly tertiary hospitals) are located in urban areas, where there are better-qualified health professionals. Village doctors are often undertrained. To help bridge the urban–rural health care divide, the central government and local governments sponsor training for rural doctors in urban hospitals and require new medical graduates to work as residents in rural health facilities. Nevertheless, the China Health and Family Planning Statistical Yearbooks show that substantial disparities remain. International Profiles of Health Care Systems, 2015 35
Page 1 and 2: JANUARY 2016 2015 International Pro
Page 3: 2015 International Profiles of Heal
Page 6 and 7: Table 1. Health Care System Financi
Page 8 and 9: Table 3. Selected Health System Per
Page 11 and 12: The Australian Health Care System,
Page 13 and 14: AUSTRALIA low-income adults, childr
Page 15 and 16: AUSTRALIA In 2013, the federal gove
Page 17 and 18: What is being done to reduce dispar
Page 19: References AUSTRALIA Australian Bur
Page 22 and 23: CANADA What is covered? Services: T
Page 24 and 25: CANADA funding to 145 not-for-profi
Page 26 and 27: CANADA Organization of the Health S
Page 28 and 29: CANADA provides recommendations to
Page 30 and 31: CANADA Health Council of Canada (20
Page 32 and 33: CHINA Private health insurance: Com
Page 36 and 37: CHINA Organization of the Health Sy
Page 38 and 39: CHINA References Chen, X. (2014).
Page 40 and 41: DENMARK In addition, nearly 1.5 mil
Page 42 and 43: DENMARK Social psychiatry and care
Page 44 and 45: DENMARK Quality data for a number o
Page 46 and 47: DENMARK portion is small, it makes
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Page 50 and 51: ENGLAND immunization, and vaccinati
Page 52 and 53: ENGLAND Hospitals: Publicly owned h
Page 54 and 55: ENGLAND Organization of the Health
Page 56 and 57: ENGLAND How are costs contained? Ra
Page 58 and 59: ENGLAND Organisation for Economic C
Page 60 and 61: FRANCE VHI finances 13.8 percent of
Page 62 and 63: FRANCE The average income of primar
Page 64 and 65: FRANCE What are the key entities fo
Page 66 and 67: FRANCE inequities in prevention rel
Page 68 and 69: FRANCE Nolte, E., C. Knai, and M. M
Page 70 and 71: GERMANY There were 42 substitutive
Page 72 and 73: GERMANY The 16 state governments de
Page 74 and 75: GERMANY management system, by the s
Page 76 and 77: GERMANY What major innovations and
Page 78 and 79: INDIA Private health insurance: The
Page 80 and 81: INDIA provide after-hour care, reim
Page 82 and 83: INDIA are provided by other ministr
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INDIA How are costs contained? Ther
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ISRAEL Together, these two types of
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ISRAEL Primary care physicians are
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ISRAEL Organization of the Health S
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ISRAEL • Using electronic health
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ITALY during hospitalization (Thoms
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ITALY Some regions are promoting ca
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ITALY Organization of the Health Sy
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ITALY although the degree of evolut
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ITALY The author would like to ackn
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JAPAN What is covered? Services: Al
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JAPAN incentives for providers to c
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JAPAN Organization of the Health Sy
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JAPAN The author would like to ackn
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THE NETHERLANDS receive faster acce
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THE NETHERLANDS Hospital payment ra
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THE NETHERLANDS Organization of the
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THE NETHERLANDS References Organisa
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NEW ZEALAND provided in GP clinics.
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NEW ZEALAND management (e.g., clean
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NEW ZEALAND including such informat
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NEW ZEALAND largely through efficie
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NORWAY Primary, preventive, and nur
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NORWAY Patients are free to choose
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NORWAY What are the major strategie
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NORWAY The National System for the
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SINGAPORE Medifund is the governmen
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SINGAPORE Public hospital funding i
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SINGAPORE Public consultation: The
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SINGAPORE To keep demand for servic
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SWEDEN What is covered? Services: T
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SWEDEN Hospitals: There are seven u
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SWEDEN Care, which promotes use of
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SWEDEN What major innovations and r
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SWITZERLAND Insurers offer premiums
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SWITZERLAND Hospitals: About 70 per
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SWITZERLAND Organization of the Hea
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SWITZERLAND To control pharmaceutic
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UNITED STATES What is covered? Serv
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UNITED STATES Administrative mechan
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UNITED STATES The Institute of Medi
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UNITED STATES adopted at least a ba
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The COMMONWEALTH FUND Affordable, q
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