ABSTRACT

Over the past sixty years, China’s health care system has changed dramatically. The issue of inaccessible and expensive medical services has been increasingly debated by the domestic and international press since the mid-1990s. In order to address this pressing social issue, the Chinese government began health reforms in the early part of this century, and intensified them in 2009 by launching its most ambitious ever reform plan, including accelerating the construction of a grassroots medical system and promoting access to basic public health services. The development of a community health service system in urban areas is recognised as a key element in bringing about reform. Given the impact that Chinese health reform could have on its people, com-

prising one-fifth of the world’s population, as well as on its economic growth and social issues, the reform has attracted great attention and interest at home and abroad. Studies of China’s health care system are not limited tomedical and health policy researchers, but are also seen as important in academic fields such as sociology, anthropology and geography. This chapter aims to review the development of, and current issues in, the community health service (CHS) system that has recently been introduced in urban China, and to provide a geographical case study of access to the CHS in China’s Jinan City.

The rapid economic and industrial development taking place in China over the past three decades has been recognised globally. To a large extent, this is due to the national reform and opening-up policy that was initiated after the Cultural Revolution in the late 1970s (Chen 2002). However, since the mid1990s the development of China’s health system has largely fallen behind that of its economy, and has even been negatively influenced by economic reform that has moved the country from a planned to a market economy (Browne 2001; Eggleston et al. 2008). Despite the fact that advanced technologies are continually introduced into health services, inequality and inequity in health care have increased. Along with other important social well-being issues, such as the income and wealth gap, housing prices and government corruption,

issues relating to health services are increasingly debated by the general public. According to the annual China Comprehensive Social Conditions Survey carried out by the Chinese Academy of Social Sciences, inaccessible and expensive medical services has consistently been among the top three issues of concern to the public (CASS 2011). Health care expenditure has continued to rise rapidly over the past few years – an issue regarded as important by over 42 percent of respondents. Nevertheless, the issue of inaccessible and expensive medical services is

currently misunderstood by many people. The fact is that it has become more difficult and more expensive for patients to see expert doctors in elite hospitals, in part because that is where people overwhelmingly tend to go, not that there is a general problem of lack of medical resources across the country. The problem of access to elite hospitals also reflects the poor structure of China’s health system. Health care at the primary level has been much neglected, and most health services have to rely on hospitals. The problems with China’s health system have emerged in tandem with the country’s socio-economic development. From 1949 to the mid-1990s, the planned economy model was followed in China because of the country’s limited economic strength. During this period, health care services were organised according to administrative divisions. A patient had to see a doctor in a local clinic in the first place and was not allowed to go to a district hospital directly unless the problem could not be treated at the clinic. If the problem could not be treated in a district hospital, the patient would then be referred to a hospital at the city or provincial level. Under this model, the delivery of health services was well ordered, and the usage of limited medical resources at various levels was relatively appropriate. With a market economy model replacing the planned economy in the early 1990s, the administrative boundaries of the health service system gradually disappeared, allowing freedom of choice for all patients. Understandably, people tend to prefer to see medical experts in the best hospitals, and this has contributed to the development of large hospitals in cities. More and more importance has been attached to hospital services, giving rise to a proliferation of specialists and the excessive use of drugs and high-technology diagnostic tests, whilst cost-effective primary care services have been neglected by the national health sector, health care providers and the general public. As a result, large hospitals have become overcrowded and the cost of medical services has also increased significantly. In addition, the positive consequences of economic development, such as increasing awareness of preventive health care, and of the negative consequences of industrial development, such as environmental pollution and traffic injuries, have also contributed to the population’s need and demand for health services from medical experts in large hospitals. It has been widely recognised that there are two significant direct consequences of this: uneven allocation and usage of health services; and the collapse of health service providers such as small district hospitals and local clinics.