Intended for healthcare professionals


China's health challenges

BMJ 2006; 333 doi: (Published 17 August 2006) Cite this as: BMJ 2006;333:365
  1. Tao Liu, associate professor (cctaoliu{at}
  1. Traditional Chinese Medicine Department, Second Teaching Hospital, Jilin University, Changchun 130041, Jilin Province, People's Republic of China

    Cannot be solved in a day

    As a result of China's rapid but asymmetric economic growth, health gaps are widening between urban and rural areas and poor and rich population groups.1 China's rapid economic growth and the consequent improvement in living conditions, nutrition, and health care have resulted in decreased infant and maternal mortality and increased life expectancy. Nonetheless, with the serious health threats brought on by the increasing prevalence of chronic diseases (such as cardiovascular disease, cancer, and chronic respiratory disease) and an ageing population,2 3 weaknesses in China's health system are hampering the achievement of improved health in the country. As a less developed country with the largest population in the world, China's reform of its health system is attracting the world's attention.4

    China's old health system provided equal and universal health care for all, but one suited to the new market economy has yet to be established. A health vacuum is emerging for disadvantaged groups within the population. This is caused by the growing social and economic inequities that result from rapid economic growth (such as increasing prevalence of obesity in the cities, while some people still have malnutrition in remote rural areas), in addition to an increasing prevalence of chronic diseases and a less socially inclusive health insurance system than before market reform. Worse still, the neglect of the primary care system during the past two decades5 means that community based services have gradually stopped functioning as primary care providers. China's government is now planning to rebuild the previously prosperous community health system and provide patients with cheaper and easier health care, especially for elderly and disabled people and patients with chronic diseases.

    Currently, large hospitals are overcrowded with patients and cannot provide the quality and quantity of health care needed,6 while most community based services are far less than fully used. Most patients with minor illnesses do not choose to use cheaper and more convenient community based services—they prefer to be seen by doctors in large hospitals even though they have to pay more.5 Why? They have no confidence in the quality of health care provided by community based services. Imperfect distribution of health resources mainly accounts for this situation: financial inputs and high quality human resources have been overwhelmingly gathered in large hospitals in big cities during the past two decades.

    Much effort is being made to re-establish patients' expectations and confidence in community services. For example, government at different levels is encouraging experienced specialists from large hospitals to work regularly in community based services as visiting experts to help improve the health care provided there. However, the keys to resolving this problem are sustainable financing of community based services and good policies to recruit, train, motivate, and retain high quality health workers who are willing to work in community based services.

    Health services, whether hospital based or community based, are expected to provide the highest attainable standards of health care for the lowest price, but this will be hard to achieve.7 Demands and resources are mismatched even in the best resourced health settings, such as the United States,8 let alone in China which has relatively limited health resources. As the mainstay of China's health system, large hospitals are increasingly open to criticism. Substantial pressures are inflicted on hospitals not only from the outside (the public demands high quality care at low prices) but also from the inside (hospitals have to maximise their income to ensure their future development).

    Now that hospitals and other service providers will consistently have to depend on user fees and profits from drug sales for most of their income4—at least for the foreseeable future—healthcare providers' professional behaviour must be subject to strict and appropriate regulations to reduce unnecessary prescriptions of expensive drugs and use of costly diagnostic tests. In this respect China can learn from other countries' experiences.7 China does not have a group with a role analogous to that of the National Institute for Health and Clinical Excellence (NICE) in the UK, which accesses all health technologies and clinical management strategies to produce guidelines and appraisals with respect to their costs and clinical effectiveness.9

    China's government faces unprecedented health challenges, and health is a high priority on the government's agenda. Though many promising measures and policies are in place, essential changes cannot be expected to happen in a day. China's government has a long way to go in coping with its health problems.


    • Competing interests None declared.


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