Development of China's Public Health as an Essential Element of Human Rights

III. Public Health Service Capability Improving Steadily

The Chinese government gives priority to prevention while combining prevention with treatment, and makes great efforts to ensure the people's equal access to public health services. It devotes great efforts to preventing and controlling epidemic, chronic and endemic diseases, strengthening the quick response capacity on public health emergencies, and developing an increasingly equal and universal basic public health service system.

The coverage of basic public health services has been further expanded. The government has extended free vaccinations from children only to adults. By the end of 2015 the vaccination rate of every town or township was at least 90 percent and the incidence of and mortality from diseases that can be prevented by programmed vaccines had fallen to the lowest level ever. From 2010 to 2017, the state subsidy for basic public health services has increased from RMB15 to RMB50 per person, and the services have also expanded from 41 in nine categories to 47 in 12 categories. The 12 categories span a person's life circle, including citizens' health archives, health education, vaccination, children's health management, pregnancy and maternity health management, elderly people's health management, health management of chronically ill patients, management of patients with severe mental disorders, health management of tuberculosis patients, TCM health management, reporting and handling of epidemic diseases and public health emergencies, and assisting management and supervision on health and family planning. By the end of 2016, the government had set up digital health archives for 76.9 percent of Chinese citizens, covering 90.23 million hypertension patients and 27.81 million diabetes sufferers. At the same time, 91.6 percent of pregnant and lying-in women and 91.1 percent of children under the age of three were brought under systematic management.

The scope of beneficiaries of the basic public health services has expanded steadily. By 2012, China had eliminated tetanus among all newborn babies. In 2014 through injection of hepatitis B vaccine to newborn babies, the prevalence of hepatitis B surface antigen in children under five years of age decreased from 9.67 percent in 1992 to 0.32 percent in 2014, achieving the WHO's goal of reducing that figure to below 1 percent three years ahead of schedule. An increasing number of the floating population now have better access to basic public health services. Epidemic diseases have been effectively prevented and controlled among them, and more than 90 percent of their children have received vaccinations. Aiming at serious diseases, major risk factors affecting health and key groups, the state has formulated and implemented major public health service projects that cover nearly 200 million people, such as hepatitis B vaccination for people under 15 years of age who missed the vaccination earlier, nutrition improvement for children in impoverished areas, facilitating rural pregnant women's delivery in hospital, screening for cervical and breast cancers among women in rural areas, and construction of hygienic toilet in rural areas. In 2009 the government launched the Regaining Eyesight Program for a Million Impoverished Cataract Patients, and had subsidized surgery for more than 1.75 million cataract patients by the end of 2013.

The ability to control epidemic diseases has continuously improved.The Chinese government has established the world's largest online direct reporting system for notifiable epidemic diseases and public health emergencies. Reported incidence of epidemic diseases has dropped by 19.4 percent. The early detection and early warning capacities have been further improved. The epidemic disease reporting system covers 71,000 medical institutions, with 160,000 users and nine million annual individual reports. In 2016, the reported incidence and death rate of epidemic diseases in categories A and B was controlled below 215.7/100,000 and 1.31/100,000, respectively. The state has set up a laboratory network comprised of disease control and prevention institutions at national, provincial, city and county levels. The influenza, poliomyelitis, measles and meningitis B labs of the Chinese Center for Disease Control and Prevention have become WHO reference labs. On the whole, the epidemics are under control and there has been no widespread epidemic in China. The spread of HIV remains at a low level, and its rapid growth in certain areas has been checked. The efforts to prevent and treat tuberculosis have achieved good results, with a cure rate of over 90 percent. In 2016, the reported incidence of tuberculosis had decreased by 12.6 percent compared to 2011, and the mortality rate from tuberculosis had dropped to 2.3 per 100,000 patients, reaching the level of developed countries. In the same year, there were 3,189 malaria cases reported nationwide, with only three domestically infected. This was much lower than the 4,262 cases in 2010. The disease has now been eradicated in over 80 percent counties that once had a widespread malaria problem. The prevention and treatment of major parasitic diseases have achieved solid results. By the end of 2016, the transmission of schistosomiasis was brought under control in all the 453 counties where it once had been widespread.

The effects of China's practice in preventing and controlling chronic diseases have remarkably improved. China has set up a monitoring network for chronic diseases and risk factors. As a basic public health service, the health management of the aged and hypertension or diabetes patients is provided free to the public. The state runs many services, like screening for cerebral apoplexy and cardiovascular disease, comprehensive oral disease intervention, and early diagnosis and treatment of cancer. By the end of 2016, the service of screening for and intervention of cerebral apoplexy had been provided to more than 6.1 million people, 820,000 of whom were found to be at high risk, and 952,000 follow-up interventions were conducted. Early screening and comprehensive intervention of cardiovascular disease had been provided to 3.389 million people, 776,000 of whom were found to be at high risk, and 524,000 follow-up interventions were conducted. Comprehensive oral disease intervention had provided free oral examination to 100 million children. A total of 5.168 million children received free dental sealants treatment and 2.229 million children received free local fluoride varnish treatment. The early diagnosis and treatment of cancer service had been provided to 2.14 million high-risk people. Some 55,000 cancer patients were diagnosed through this service, and the overall early diagnosis rate reached 80 percent or above.

The spread of endemic diseases is under effective control. By the end of 2015, 90.8 percent of counties whose water sources contained excess iodine had reached the benchmark that 90 percent of salt consumed was iodine-free, and 94.2 percent of the nation's counties had eradicated iodine deficiency, ranking among the top of all 128 countries and regions officially using iodized salt. Kaschin-Beck disease has been eradicated in 95.4 percent of villages where it was once widespread, and Keshan disease has been put under control in 94.2 percent of the counties where it was once prevalent. In the counties that suffered from endemic fluorosis caused by coal burning, 98.4 percent of coal stoves have been transformed, and in the areas suffering from drinking water-caused endemic fluorosis, 93.6 percent of the rural population now have access to de-fluoridated drinking water. Areas suffering from arsenic poisoning through coal burning have had their stoves transformed, and all people in water-related arsenic poisoning areas now have access to safe drinking water.

Mental health services have been improved constantly. The state issued the Mental Health Law of the People's Republic of China, putting the related work within the legal framework. At the end of 2015, China had 2,936 mental health institutions with 433,000 beds - increases of 77.9 percent and 89.9 percent, respectively compared with 2010. There were 27,700 practicing (assistant) psychiatrists nationwide, an increase of 20.2 percent over the 23,100 at the end of 2012. Severe mental disorders have been included as serious diseases under the new type of rural cooperative medical care and basic medical insurance for non-working urban residents. The central government has provided subsidies to local hospitals to help with the management of and treatment for severe mental disorders. Special aid and treatment policies have been drawn up in some local areas. The patients' expenditures have been greatly reduced. The government has enhanced the management of patients with severe mental disorders, including case reporting and registration, assistance and treatment. Between 2012 and 2016, the number of registered patients with severe mental illnesses increased from 3.08 million to 5.4 million nationwide. From 59.1 percent to 88.7 percent, more and more patients were put under management. The state has enhanced the intervention in common mental disorders or psychological problems, like depression and anxiety. It has intensified the efforts to promptly detect and treat psychological problems among key groups, built up the psychological intervention capacity in emergency events, and promoted the community rehabilitation services for mental disorders.

The ability to quickly respond to public health emergencies has been strengthened in a comprehensive way. The legal system for emergency response has taken initial shape, and the response mechanism has been optimized. Thirty-six national teams and nearly 20,000 local teams, with over 200,000 members for four categories of emergencies, have been set up in different regions. In 2014, China's core public health emergency response capacity achieved 91.5 percent of the requirements of the International Health Regulations, better than the world's average of 70 percent. In recent years the state has accelerated the construction of a public health emergency response system, which not only effectively handled such epidemic emergencies as human infections of the avian influenza A (H7N9) virus, Ebola hemorrhagic fever, Middle East respiratory syndrome and Zika fever, but also promptly carried out emergency medical rescue and post-disaster epidemic prevention in such disasters and accidents as the 2008 Wenchuan earthquake and the 2015 Tianjin Port explosions.

IV. Great Improvement in the Quality of Medical and Health Services

China is committed to improving the accessibility and convenience of medical and health resources, and the quality and efficiency of medical services at the same time. It aims to accelerate the building of an integrated medical and health service system of good quality and high efficiency, and improve the medicine supply system. More and more people are satisfied with their visits to hospitals.

The resource factors of the medical and health-service system keep increasing. From 2011 to 2015, China invested RMB42 billion to support the building of 1,500 county-level hospitals, 18,000 town and township health centers, and more than 100,000 village clinics and community health centers. By the end of 2016, there were 983,394 medical and health institutions in China, among which 29,140 were hospitals (12,708 public hospitals and 16,432 private ones), 36,795 town and township health centers, 34,327 community health centers (stations), 3,481 disease prevention and control centers, 2,986 health inspection institutes (centers), and 638,763 village clinics; there were also 5.291 million items of medical equipment each worth RMB10,000 or more, among which 125,000 were worth more than RMB1 million each. In 2016, the number of beds in medical institutions increased by 395,000 compared with 2015 - 5.37 beds for every 1,000 people; the number of beds in hospitals increased by 358,000. There were 266 hospitals of ethnic healthcare, with 26,484 beds, providing 9.687 million treatment sessions annually, and the number of discharged patients reached 588,000.

Graphics shows beds in medical and health institutions for every 1,000 people written in the "Development of China's Public Health as an Essential Element of Human Rights" white paper, issued by the State Council Information Office. (Xinhua/Ma Yan)

Health personnel optimized. China has built a medical education system of the largest scale in the world. By the end of 2016, there were 922 medical colleges and universities in China, 1,564 secondary schools with medical courses, 238 organizations granting master's degrees, and 92 granting doctoral degrees. The number of students at these schools had reached 3.95 million, among whom 1.14 million were students of clinical majors and 1.8 million of nursing majors. Fourteen educational institutions now offer specialties in ethnic healthcare, and research into ethnic healthcare in TCM majors, with about 170,000 students. TCM colleges in Yunnan, Guangxi and Guizhou offer undergraduate specialties of healthcare of the Dai, Zhuang and Miao peoples. Some ethnic-healthcare colleges and TCM colleges cooperate to cultivate personnel specializing in ethnic healthcare. By the end of 2016, the number of health workers totaled 11.173 million, with 8.454 million technical personnel, and 2.31 physicians for every 1,000 people; practicing (assistant) physicians with a college degree or above made up 81.2 percent of the total. The number of high-caliber professionals is increasing year by year. The number of nurses for every 1,000 people has reached 2.54, and the ratio of doctors to nurses has reached 1:1.1.

The non-governmental sectors operating hospitals are growing. China supports non-governmental sectors in starting non-profit medical institutions, and promotes equal treatment between non-profit private hospitals and public hospitals. We encourage physicians to make use of their spare time, and retired physicians to work in community medical and health institutions or open clinics. Private hospitals now account for more than 57 percent of all hospitals, the number of beds in medical and health institutions operated by non-governmental sectors has increased by 81 percent compared with 2011, and their outpatient visits take up 22 percent of the total in China. Now, of the physicians who have obtained licenses that give them permission to work for more than one organization, more than 70 percent also work in medical institutions operated by non-governmental sectors.

Community and rural medical conditions further improve. China gives priority to community and rural medical development in terms of the establishment of medical and health systems, the setting up of medical service institutions and the team building of medical service personnel. It takes county-level hospitals as the medical and health centers of the county, and places them at the core of the three-tier rural medical and health service network at the county, township and village levels. It focuses on the operation of one or two county-level hospitals (including TCM hospitals) in each county (city). Now almost every town or township has a health center, every administrative village has a village clinic, and every 1,000 rural residents have a village doctor.

Medical and health service supply is becoming more refined and targeted. China has established a mechanism for serious illness prevention and control that combines professional public health institutions, general and specialized hospitals, and community medical and health institutions. We are enhancing the mechanism for information sharing and inter-connection, promoting the integrated development of chronic disease prevention, control and management, and realizing the combination of treatment and prevention. We are building a comprehensive classified diagnosis and treatment system, guiding the formation of a rational medical treatment order featuring primary treatment at the community level, two-way transfer treatment, interconnection between different levels and different treatments for acute and chronic diseases, and improving the service chain of treatment, rehabilitation and long-term care. The diagnosis and treatment rate based on appointments in Grade III hospitals has reached 38.6 percent, and nearly 400 medical institutions have set up ambulatory surgery centers. We are also providing family physician contracted services. More than 80 percent of citizens are satisfied with the skills and attitude of family physicians. The people's service experience has greatly improved.

The quality and the safety level of medical services continues to rise. We have formulated Medical Quality Management Measures, gradually established and improved the medical quality management and control system, released quality control indicators, and conducted informationalized quality monitoring and feedback. We have promoted clinical pathway management (CPM) by developing 1,212 clinical pathways, which cover almost all common and frequently occurring diseases. We have released and implemented the National Action Plan to Contain Antimicrobial Resistance (2016-2020), to resolve the problem of antimicrobial resistance in a comprehensive way. We have also strengthened supervision over prescription and drug use. In 2016, the rate of inpatients using antibacterial drugs was 37.5 percent, 21.9 percentage points lower than in 2011; the usage rate in outpatient prescriptions was 8.7 percent, a decrease of 8.5 percentage points compared with the rate in 2011. Medical liability insurance covers more than 90 percent of hospitals at Grade II and above. We attach great importance to blood safety and supply. By the end of 2015, we had realized the full coverage of nucleic acid tests in blood stations, with a blood safety level equivalent to that of developed countries. We also encourage voluntary unpaid blood donations and rational clinical use of blood. In 2016, 14 million people donated blood gratis, an increase of 6.1 percent over 2015 and almost satisfying the demand for clinical blood use. Donation has become the main source of organs for transplants.

The drug supply security system keeps improving. This system, based on the national basic drug system, has made great headway. Since the implementation of the policy, the prices of basic drugs have dropped by about 30 percent on average, and basic drugs have been sold in community-level medical and health institutions with zero markup, easing the financial burden on patients. We initiated the first round of pilot projects of national drug price negotiation, reducing the purchasing prices of drugs for hepatitis B and non-small-cell lung cancer by over 50 percent, making them the lowest in the world. By the end of 2016, the patients' expenses had been reduced by nearly RMB100 million. We have also improved the policy that ensures drug supply for rare diseases, and increased the free supply of special drugs, for instance, drugs for the prevention and treatment of HIV/AIDS. China encourages medical and pharmaceutical innovation, launching a key project named the National New Drug Innovation Program. From 2011 to 2015, 323 innovative drugs in China were approved for clinical research, 16 innovative drugs including Icotinib Hydrochloride Tablets were approved for production, 139 new chemical generic drugs entered the market, a total of more than 600 Active Pharmaceutical Ingredients (API) and over 60 pharmaceutical companies reached the international advanced GMP standard, and a number of large medical equipment such as PET-CT and 128-MSCT, and advanced implantable products including brain pacemaker, bioprosthetic valve and artificial cochlea have been approved and entered the market. We have promoted the building of a modern medical and pharmaceutical distribution network that covers both the urban and rural areas, and strengthened drug supply security at the community level and in remote areas.

TCM is receiving more support from the government. From 2013 to 2015, China invested a special fund of RMB4.6 billion to support the capacity building of TCM. In 2016, it issued the Outline of the Strategic Plan on the Development of Traditional Chinese Medicine (2016-2030). The revenue generated by Chinese medicine producers each with turnover over RMB20 million per annum reached RMB865.3 billion in that year, accounting for about one third of the total revenue generated by all the drug producers each with turnover over RMB20 million per annum in China. Since 2011, 49 achievements in TCM scientific research have received national science and technology awards. Artemisinin, medicines for curing acute promyelocytic leukemia and other TCM and Western medicine research findings have attracted worldwide attention.

V. Improvement of the National Medical Security System

China has been vigorously improving its national medical security system. Now a multi-layered and wide-ranging medical security system covers the whole population, mainly supported by basic medical security, and supplemented by various forms of supplementary insurance and commercial health insurance. The country has preliminarily realized basic healthcare for every citizen.

Basic medical insurance covers all urban and rural residents. The whole population is now covered by medical insurance, which is mainly composed of basic medical insurance for working urban residents, basic medical insurance for non-working urban residents, and the new type of rural cooperative medical care. By the end of 2016 basic medical insurance had more than 1.3 billion recipients nationwide - a coverage of above 95 percent. In 2016 China officially integrated basic medical insurance for non-working urban residents and the new type of rural cooperative medical care, to unify insurance coverage, funding policies, insured treatment, reimbursement catalogues, management of contracted medical institutions and fund management. In this way, the system of basic medical insurance for urban and rural residents was established step by step, so that urban and rural residents now enjoy equal access to basic medical insurance.

Support for basic medical insurance schemes and its sustainability have been increasing. The income and expenditure of the basic medical insurance fund for working urban residents in 2016 were RMB1,027.4 billion and RMB828.7 billion respectively - RMB421.2 billion and RMB341.9 billion more than those of 2012, representing an annual increase of 15.7 percent and 15.6 percent on average. The income and expenditure of the basic medical insurance fund for non-working urban residents were RMB281.1 billion and RMB248 billion, respectively - RMB193.4 billion and RMB180.5 billion more than those of 2012. In 2017 government subsidies for basic medical insurance for non-working urban and rural residents are increased, with annual per capita subsidies at all levels reaching RMB450.

Basic medical insurance benefits have been improved. In 2016 the payment caps of the basic medical insurance for working urban residents and for non-working urban residents were six times local employees' average salary of the year and local residents' per capita disposable income of the year, respectively; inpatient reimbursement rates from basic medical insurance were about 80 percent and 70 percent, respectively. In 2017 outpatient and inpatient reimbursement rates from the new type of rural cooperative medical care scheme are about 50 percent and 70 percent, respectively. The National Medicine List for Basic Medical Insurance, Industrial Injury Insurance and Maternity Insurance (2017) includes 2,535 items of Western medicines and Chinese patent medicines, with 339 more medicines than those in the previous list, or an increase of 15 percent, almost including all therapeutic medicines in the National Essential Medicine List (2012). As for expensive patent medicines with high clinical value, the government organized talks on medicines covered by the insurance and added 36 items to the National Essential Medicine List (2012) for the treatment of malignant tumors, and some rare and chronic diseases. Some newly added rehabilitation treatments are now covered by basic medical insurance.

Forms of reimbursements from basic medical insurance have been improved. More than 70 percent of regions in China are exploring new forms of payment from basic medical insurance, such as payment by a certain category of disease, by capitation or by Diagnosis Related Groups (DRGs). The country has been building a national network of basic medical insurance, promoting cross-province real-time reimbursement from basic medical insurance, and the use of all-purpose card. By the end of August 2017, real-time reimbursements had been realized for all areas covered by basic medical insurance across the country; real-time reimbursements for cross-region inpatient medical expenses within the same province had been basically realized in the country. A national real-time reimbursement network for cross-province inpatient expenses has been put in place, and all provinces (including Xinjiang Production and Construction Corps) have joined the national network of cross-province reimbursement of basic medical insurance. By the end of August 2017, China had a total of 6,616 designated medical institutions for real-time reimbursements of cross-province inpatient expenses.

Serious illness insurance for urban and rural residents has been improved. China has implemented serious illness insurance for urban and rural residents, aiming to cover large medical expenses, and improve medical security for serious illnesses. By the end of 2015 serious illness insurance for urban and rural residents covered all recipients of basic medical insurance. In 2016 serious illness insurance covered more than 1 billion urban and rural residents; according to provincial policies, the serious illness insurance reimbursement rates shall be more than 50 percent, and the actual reimbursement ratio was raised by 10 to 15 percentage points.

Medical assistance mechanisms have made marked progress. A medical assistance policy framework has been established; medical assistance programs dovetail nicely with serious illness insurance schemes; and medical assistance criteria and capacity have become consistent in both urban and rural areas. Medical assistance recipients have been expanded from subsistence allowance recipients and people in dire poverty to the poverty-stricken population, low-income household members and critically-ill patients in illness-stricken poor families. Trade unions at all levels have been organizing employees' mutual aid for medical expenses, to help employees with serious illnesses and reduce their financial burden. In 2016 China appropriated RMB15.5 billion in medical assistance subsidies (excluding illness emergency assistance subsidies), 92 percent of which went to central and western regions, and poverty-stricken areas, assisted 82.565 million cases, and helped 55.604 million people with financial difficulties to receive basic medical insurance. The proportion of inpatient recipients within the annual limit exceeded 70 percent. Medical assistance services have become more convenient, as 93 percent of the country has realized one-stop reimbursement from medical assistance funds and basic medical insurance. In 2013 China set up an illness emergency assistance fund to help unidentified patients who need immediate treatment, or identified patients who cannot afford the related medical expenses. By June 2017 some 640,000 patients had received help from the fund.

Medical security for the rural poverty-stricken population has been improved. In 2016 China started to implement poverty relief through healthcare. Now the rural poverty-stricken population is fully covered by both basic medical insurance and serious illness insurance for urban and rural residents. The inpatient reimbursement rates for the rural poverty-stricken population have been raised by more than five percentage points. China has mobilized over 800,000 medical workers to visit illness-and-poverty-stricken families, and investigate 93 major diseases with high occurrence, high treatment costs and severe impact on work and life, thereby keeping a record and setting up a database for poverty relief through healthcare. The country provides categorized treatment to rural poverty-stricken population suffering from serious illnesses and chronic diseases. By May 2017 China had given such treatment to over 2.6 million people. The country has adopted preferential policies favoring the rural poor with respect to reimbursement from serious illness insurance. China implements a policy of treatment before payment and one-stop reimbursement for rural poverty-stricken inpatients at county-level hospitals. In addition, China has designated 889 Grade III (top-level) hospitals to assist 1,149 county-level hospitals in all poverty-stricken counties across the country.