China’s demographic landscape is rapidly changing, and the government has responded by launching ambitious social and health service reforms to meet the changing needs of the country’s 1.3 billion people. This week, officials approved a five-year plan to develop a comprehensive nationwide social security network.

Karen Eggleston, the Asia Health Policy Program (AHPP) director and a Stanford Health Policy fellow, discusses the success of China’s health care reforms—including its recently established universal health care system—and the long road still ahead.

Why is the overall health and wellbeing of China’s population important globally?

There are many reasons why the health of China’s citizens matters within a larger global context. On the most basic level, China represents almost 20 percent of humanity. But it is also a major player in the world economy and it depends on having a healthy workforce, especially now that its population is aging more. The government’s ability to meet the needs of its underserved citizens contributes to a more productive and stable China, and works towards closing the huge gaps we see in human wellbeing across the world.

China also potentially offers a model for other developing countries, such as India, that may want to figure out how to make universal health coverage work at a tenth of the income of most of the countries that have put it into place before.

What are some of the biggest changes in China’s health care system since 1949?

One of the most significant changes is that China has achieved very basic universal health insurance coverage in a relatively short period of time.  

Throughout the Mao period (1949–1978) there was a health care system linked to the centrally planned economy, which provided a basic level of coverage via government providers with a lot of regional variation. When economic reform came in 1980, large parts of the system—particularly financing for insurance—collapsed. The majority of China’s citizens were uninsured during the past few decades of very rapid social and economic development.

China’s overall population is changing quite dramatically, which means it has different health care needs, such as treating chronic disease and caring for an increasingly elderly population. The central government is trying to establish a system of accessible primary care—a concept that China’s barefoot doctors helped to pioneer but that fell into disarray—and health services that fit these new needs. 

How does China’s basic health care system work? Are there segments of the population still not receiving adequate coverage and care?

China has had a system where people can select their own doctors. Patients usually want to go to clinics attached to the highest-reputation hospitals, but of course, when you are not insured you almost always by default go to where you can afford the care. “It is difficult to see the doctor, and it is expensive” has been the lament of patients in China, so an explicit goal of the health care reforms has been to address this.

The term “universal coverage” has different definitions. China initially put in place a form of insurance that only covers 20 or 30 percent of medical costs for the previously uninsured population, especially in rural areas. Benefits have expanded, but remain limited. As with the previous system, disparities in coverage still exist across the population. China not only has a huge population with huge economic differences, but within that there is a large migrant worker population. It is a challenge to figure out how to cover these citizens and how to provide them with access to better care. The government is quite aware there are segments of the population not receiving equal coverage, and it continues to strive to resolve the issue.  

What are the greatest innovations in China’s health care system in recent years?

One of the most remarkable things China has achieved is really its new health insurance system. Even if the current coverage is not particularly generous it is nearly universal, and mechanisms are put in place each year to provide more generous coverage. China is also working on strengthening its primary care and population health services, infusing a huge sum of government money into these efforts. It is the only developing country of its per-capita income that has achieved such results so far.

Interestingly, a lot of people assume China achieved its universal coverage by mandate, while in fact the central government did so by subsidizing the cost for local governments and individuals. This reduces the burden, for example, on poorer rural governments and residents, and is one innovative way China is trying to eliminate the disparity in access to care.

Eggleston has recently published a working paper on China’s health care reforms since the Mao era on the AHPP website, as well as an article in the Milken Institute Review.

Gordon Liu, a Chinese government advisor on health care and the executive director of Peking University’s Health Economics and Management Institute, spoke at Stanford on May 29 on the future of China’s health care system.

Imagine you are on the staff of the National Security Council (NSC) and a naval dispute breaks out on the Korean Peninsula while you are at home celebrating Thanksgiving. You have just three hours to prepare a detailed memorandum summarizing the situation and offering recommendations for how the United States should respond.

This is a major responsibility with a large number of interrelated issues that must be taken into account—how would you proceed?

Stanford students in the winter quarter course U.S. Policy toward Northeast Asia (IPS 244) had the opportunity to step into the challenging role of the NSC senior director for Asia and consider such a security situation. They wrote and presented memoranda on this and an East Asia trade crisis scenario in class, as well as a final memorandum to the president proposing a China policy for his second term. The assignments required students to consider a wide range of global, regional, and domestic factors—many pulled directly from current global events.

Each member of the team of Shorenstein Asia-Pacific Research Center (Shorenstein APARC) Asia experts teaching the course drew on decades of related expertise to write the scenarios.

• Michael H. Armacost, the Center’s Shorenstein Distinguished Fellow, previously served on the NSC, in the Defense Department, as U.S. ambassador to the Philippines and Japan, and as undersecretary of state for political affairs.
• Shorenstein APARC associate director for research Daniel C. Sneider, an Asia history expert, spent over 30 years as a journalist reporting on international affairs and security issues, including working as a foreign correspondent in Japan, Korea, India, and Russia.
• David Straub, associate director of Stanford’s Korean Studies Program, is a former State Department official with long-time expertise in U.S.-Korea relations and North Korea, including participation in the Six-Party Talks on North Korea’s nuclear program.
• Thomas Fingar, FSI’s Oksenberg-Rohlen Distinguished Fellow, is a China expert and has previously held numerous key U.S. intelligence posts, most recently as the first deputy director of national intelligence for analysis and, concurrently, as chairman of the National Intelligence Council. He also served as assistant secretary of the State Department’s Bureau of Intelligence and Research.

In the first assignment, students read about a proposed China-Japan-South Korea free trade agreement (FTA). Navigating through a web of regional and domestic issues, they advised on how the United States should respond to an appeal from Japan for certain trade concessions in exchange for its backing out of the FTA. The assignment described complex economic and political conditions in May 2013 after elections in the United States, South Korea, and Japan, and a leadership transition in China. The U.S.-Japan alliance was one of many key factors students took into account.

“It was my great pleasure to participate in this class—it truly broadened my views of U.S. foreign policy toward Northeast Asia. The substantive knowledge presented by both instructors and students during the class will undoubtedly contribute to a much safer, more peaceful, and unified world.”
-Heeyoung Kwon, Visiting Scholar, Korea Foundation

The next memorandum assignment described an inter-Korean naval dispute falling in the crucial weeks between the 2012 U.S. and South Korean presidential elections. It narrated the economic and political situation of each country in precise detail, and set the stage for the dispute with real-life events like the 2010 sinking of the South Korean navy ship the Cheonan. Students were asked to consider the possible role China could play in mediating with North Korea, and how U.S. tensions with Iran could limit its involvement in negotiations.

“In IPS 244…no conversation is irrelevant to current events in Northeast Asia…The memo assignments…are so detailed, so current, and so realistic, that even a seasoned diplomat would be challenged by them—I know this because there are seasoned diplomats taking the class.”
-Jeffrey Stern, MA Student, International Studies Program

Shorenstein APARC offers U.S. Policy toward Northeast Asia each winter quarter. The diverse mix of students, combined with the “in-the-field” expertise of the instructors, creates a lively and challenging class environment. IPS 244 goes beyond a traditional academic course to create assignments based on real-life events and global conditions, and place students in the position of thinking like a government official. For the many of them that will go on to pursue government careers, the course serves as an important first-step in training for “scenarios” very similar to those they address in class.

A new Shorenstein APARC event series will explore the complex ties between identity and the social, political, and economic status of Asia's Muslim minorities, with a focus on China, India, the Philippines, and Thailand.