China's supply of health resources is no longer low relative to its level of economic development
Relative to its level of economic development, China's supply of financial, human, and facility resources is at least not too low, while at the same time the degree of idleness of each resource is too high. Specifically, there are the following five indicators.
(1) Health financial resources ahead of the level of economic development
If the world's per capita health costs as a yardstick, in 2001, only 30 rich countries to meet the standard, including China's per capita share of health costs in more than 160 countries are lower than the world average.1. The combined population of the Group of Seven Western countries accounted for 11.4% of the world's total population, but consumes The combined population of the Group of Seven Western countries accounts for 11.4% of the world's total population, but consumes 77.0% of the world's total health resources; the per capita health resources of the United States are 10 times the world average, and the per capita share of resources in Canada is 4.5 times the world average. China's per capita health cost is only 1/10th of the world average and about 1/100th of the per capita cost in the U.S. However, if the per capita health cost and per capita GDP of 85 middle-income countries are used as parameters to predict China's total per capita health cost, China's actual incidence in 2002 is higher than the predicted value by 4% (in terms of the caliber of the official exchange rate) or 15% (in terms of the caliber of purchasing power parity). Using total health costs as a share of GDP as an indicator, it can also be seen that China's total health costs as a share of national income are already relatively high. in 2001, China's total health costs accounted for about 5.6 percent of GDP, while the average for more than 80 middle-income countries was about 5.1 percent, with the average for the five large developing countries with populations of hundreds of millions of people, such as Russia, Brazil, Indonesia, India, and Bangladesh, also averaging about 5.1 percent. The average weight of five large developing countries with hundreds of millions of people, including Russia, Brazil, Indonesia, India and Bangladesh, is also only about 5.1%.
(2) Public ****input basically conforms to the economic and demographic conditions
According to the statistics and caliber of the World Health Organization (WHO), in 2001, China's public ****input in health (including general budget input and social security expenditure on health) accounted for 36% of the total health expenditure, only half of the OECD average, and lower than the average proportion of all middle-income developing countries for nearly 20 percentage points. percent of all medium-sized developing countries. However, China's current share of public **** inputs is relatively close to the levels of the early 1990s in three of the OECD's more populous member countries (South Korea, Mexico, and the United States), and is also very close to the current average of the five most populous of the middle-income countries (Russia, Brazil, Indonesia, India, and Bangladesh) (about 38 percent), a difference of only 2 percentage points.
(3) Major health human resources ahead of the level of economic development
Compared with countries and regions with higher levels of economic development, China's number of practicing doctors per 1,000 population is not on a par with that of countries such as Turkey, Mexico, and South Korea, all of which have around 1.5, but is considerably higher than that of Thailand, which has implemented universal health care, and which has only 0.3 doctors per 1,000 population. Among health technicians, it is only the number of registered nurses per 1,000 population that is lower. The lower support staffing may reflect a bias in the implementation of China's health priorities. The actual focus has been on medical care at the expense of the development of preventive health care and rehabilitative care services, so that not as many nurses are needed.
(4) Configuration of health facilities is ahead of the level of economic development
Compared with highly economically developed countries and regions, there is still a large gap in China's per capita configuration of health facilities (including hospital beds, NMR***Vibrators and CTs). However, China's current level has already surpassed or approached that of countries with slightly higher levels of economic development. According to a 2005 Ministry of Health survey, China had 2.5 beds per 1,000 population, 1 MRI and 5 CTs per million population, and the per capita allocation of these facilities is higher than in higher-income countries such as Thailand and Mexico.
(E) The degree of idle resources of health entities is not commensurate with the level of economic development
Calculated according to the average work efficiency of doctors in OECD member countries, China's doctors currently have a surplus of 57%, with even higher human resource surpluses in urban streets and rural health centers. Based on the average utilization rate of hospital beds in seven large Western countries, China's hospital bed resources are currently about 10 percent idle or surplus. Compared with the UK, where health costs are better controlled, China's hospital bed surplus is currently around 20%, and the bed surplus in urban and rural health centers is also between 17% and 27%.
The actual workload of China's large-scale medical equipment, represented by CTs and MRIs, is less than half of its potential capacity. Even if you don't take into account the "big checkup" and other factors that induce consumption, there is still a 50%-60% waste of equipment capacity. In contrast, in developed countries such as Canada and the United Kingdom, there are still queues for the use of large medical equipment.
The root cause of China's serious deviation of health supply from demand lies in the lack of government intervention. Like many countries, China also has the problem of unmet medical needs and the contradiction between supply and demand, but China's problem has its own special characteristics, and the root cause of the problem is not the same.
(1) Unmet demand is a problem for all of China's society, and alternatives are more expensive
If demand for health care is the criterion, there is a contradiction between supply and demand for health resources in both developed and developing countries. In China, however, the contradiction is more prominent and specific.
In 2001, Americans, who accounted for 4.68% of the world's population, consumed 46.7% of the world's health resources, and the per capita expenditure on health was 4,873 US dollars, which rose to 5,274 US dollars in 2002; Canada, which accounted for 0.5% of the world's population, also consumed 2.22% of the world's health resources. The health resources of the United States and Canada can be said to be sufficient, but the joint health services survey conducted by the authorities of the two countries shows that in 2002/2003, 13% of Americans and 11% of Canadians did not have access to the necessary health services. It can be seen that unmet needs cannot be generalized as a basis for inadequate supply of total health resources. China's third national health service survey shows that in 2003, nearly half of the patients did not go to a medical institution, and the number of patients who were not hospitalized despite doctors' recommendation for hospitalization amounted to about 30%. Among them, more than one-third of all patients take self-medication, self-treatment (including drugstore purchase) costs up to higher than the average outpatient all costs (including transportation costs), 13% of all patients do not take any treatment measures.
The problem of lack of access to care in China is characterized by the following features: first, the problem of non-attendance is ubiquitous, affecting all types of people. Although the problem is more severe for low-income people than for high-income people, the rate of non-attendance is as high as 45% for the highest urban income group. Moreover, the more developed the healthcare conditions, the more severe the problem of non-attendance. In addition, the impact of the current health insurance system on the problem is not obvious. Second, the vast majority of non-attendees tend to choose self-medication, and the average cost of self-medication is higher than that of outpatient services in small and medium-sized cities and vast rural areas. Third, the problem of non-hospitalization in China
is also widespread, although it is more severe in less medically developed areas, among low-income earners, and among the unprotected.
(2) The structural problem of resource allocation is not the root cause of China's lack of medical care
After more than two decades of reform and opening up, China's urban and rural medical and health care services have, on the whole, emerged from the passive situation of "lack of medical care and lack of medicine". In terms of the composition of the elements, China's financial resources in the public **** input part of the slightly insufficient, human resources in the number of nurses on the low side, but these two resources of the small shortage can not explain China's serious "difficult to see the doctor, see the doctor expensive" problem. In terms of layout, it is true that the distribution of health resources between urban and rural areas in China is very uneven, especially since high-quality resources are concentrated in large cities and large hospitals. However, even in rural areas with fewer and poorer resources, the degree of idleness and surplus of resources in health centers is no less than that in urban hospitals; even in cities with more and better medical resources, the people's problem of access to medical care is no less serious than that in rural areas, and the majority of those who do not seek medical care are more inclined to opt for poor-quality and high-priced self-medicine. It can be seen that the structural problem of resource allocation can not explain China's "difficult to see the doctor, see the doctor expensive" problem.
(3) Inadequate or even inappropriate government intervention has created the problem of "difficult and expensive access to medical care"
First, let's analyze the problem of "difficult access to medical care", that is, the overcrowding of large hospitals. The third national health survey shows that part of China's unmet medical needs are indeed induced by doctors' attempts. For example, 41% of untreated patients feel that their illnesses are minor; 20% of those who are not hospitalized do not see the need for hospitalization. Moreover, some of the unmet medical needs are induced by irrational institutional design and policy practices, such as the government's investment in health care, which is mainly focused on large hospitals, and the urban basic medical insurance, which provides insured patients with an almost unlimited choice of doctors, and so on. Of course, some patients' active medical needs and behaviors also have unreasonable elements. For example, in order to "prevent" cardiovascular disease, some elderly people flock to hospitals in winter for infusion.
Then we look at the problem of "expensive medical care". According to the general law of economics, in an efficient market, excess supply will inevitably bring down prices and increase effective demand. However, in the medical services market, due to the information advantage of the supply side over the demand side, the invisible hand of the market fails, and the tangible hand of the supply side (the pen in the hands of doctors) may manipulate the market and provide excessive services. Therefore, government intervention is essential in any country, even if there is no oversupply. In China, almost all health service organizations and individuals have strong incentives (the power to generate revenue and self
ownership of surpluses), adequate conditions (large numbers of unused beds and equipment), and yet almost no worries (no diagnostic and treatment norms and no effective regulation) to provide unnecessary and inappropriate, but highly profitable, services. With inadequate macro-management (regional health resource planning is a sham, access is out of control, and regulations are inadequate) and improper micro-management (authorization or acquiescence of health service providers to dispose of surpluses on their own, and weak regulation), the potential for supply-side abuses becomes a reality. Over-servicing inevitably leads to higher health care costs and affects accessibility of health care services; in order to maintain revenue levels in the face of lower health care utilization, the supply side is bound to increase over-servicing. In the long run, more and more patients will lose trust in their healthcare providers and use alternative services whenever possible; only as a last resort will they use healthcare services. The result is that minor illnesses become major ones that are more difficult and expensive to treat.
Three New Ideas for China's Health Development and Reform
Over the past two decades, by design or by accident, the development of China's health sector has in fact taken a path that focuses on treating major diseases, developing large hospitals, delegating responsibilities to both doctors and patients, and weakening the regulation of behavior on the supply side and the management of expectations on the demand side. One of the consequences of this is that "it is difficult and expensive to see a doctor". After clarifying this logical framework, the following can be the right medicine.
(1) Adapting to national conditions, basic health services should be prioritized
There are two ways of thinking about the development of China's health sector. The first believes that China's health resources are generally insufficient, health development lags behind economic development, and suggests that continuing to expand and strengthen health resources can enhance the competitiveness of the pharmaceutical industry externally, and internally to meet the growing demand for medical care at different levels by the general public. The second way of thinking recognizes that relative to the level of economic development, the total amount of health resources in China is already not low, but believes that there are still structural problems such as insufficient investment in public **** and lagging behind in the development of low-end service institutions, and suggests that increased investment in public **** to make health resources smaller and more appropriate (including
including the development of urban grassroots and rural health, the establishment of hospitals or wards for the poor, control of large-scale medical institutions and large-scale equipment, the use of appropriate technology, etc.). large equipment, the use of appropriate technology, and so on).
Following the first line of development, as predicted by the World Bank in 1984, China's health system is following the path of highly capital-intensive treatments imported from the West, which can only satisfy the medical needs of a few powerful groups. In the past year or two, there has been a welcome change in the guiding philosophy of health development, a gradual shift from bigger and stronger to smaller and more appropriate health resources. Limited by China's economic and demographic conditions, appropriate technology and basic health services are undoubtedly the long-term choices for China's health development. Therefore, the second guiding principle should be firmly
implemented.
(2) In the provision of basic health services, primary institutions should play a dominant role
In China's current health system, large hospitals actually play a dominant role, while the role of primary health institutions is limited, and there is a competitive relationship between institutions at different levels, and between institutions at the same level. Now the government proposes to vigorously develop community health services to play its fundamental role. However, this proposal does not solve the problems of continuity and coordination of the main body of health services. From the point of view of the effect of controlling costs and meeting the multiple health needs of the people, primary health care institutions should be responsible for setting up a platform for information ****sharing in the health system, for organizing and coordinating the provision of health services at all levels, and even for the allocation and use of health funds.
(3) In financing basic health services, the government should fund and purchase services
The development of basic health services faces two policy choices. The first is whether to build new service providers or to utilize existing ones; the second is the positioning of the government's functions, whether to set up a platform, purchase services, or organize them directly. With regard to the first issue, the relevant authorities preferred to integrate existing health resources and not to build new ones. This policy choice is in line with the basic situation of China's health resources; in general, China's resource allocation has exceeded the level of economic development, and there is a great deal of idleness and waste of existing resources. However, with regard to the positioning of the government's functions, the health sector hopes to directly organize relief hospitals or relief wards and community health service institutions, and to rebuild public institutions in the true sense of the word to provide basic medical services. Reconstructing public institutions to provide services can weaken the profit-oriented behavior of the service providers, but this policy option is fraught with problems such as huge government investment, inefficient use of public **** resources, and nepotism. Comparatively speaking, the government purchases services, the money goes with the person, can give full play to the consumer's right to "vote with their feet", can give full play to the effectiveness of limited government investment.
(4) Efforts in resource allocation can only alleviate the problem of "difficult and expensive access to health care"
Recently, the health sector has emphasized the strengthening of health resource planning, and strict access to large medical institutions and large-scale equipment, as well as increased government investment in the development of rural health and community health, with a view to meeting the needs of the public **** health of the people. people's demand for public **** health and basic medical services. From the standpoint of improving the allocation of health resources in China, all of these policy measures are undoubtedly correct. Efforts to develop and improve the allocation of health resources have also helped to solve the problem of "accessibility and affordability" for the general public. However, solving the problem of "difficult and expensive access to health care" also requires solving the problem of "willingness to use", i.e., increasing the people's confidence and willingness to consume. According to the third national health service survey, 3/4 of those who do not seek medical treatment are unwilling to use medical services, and 1/5 of those who have not been hospitalized do not accept the doctor's advice and refuse to be hospitalized. Rebuilding the trust of the people requires other efforts.
(E) To solve the problem of "difficult and expensive medical treatment", it is more necessary to regulate the behavior of medical services
The relevant departments have been relatively passive in regulating and supervising the behavior of medical services. There are two main reasons: first, the medical service institutions and individuals tend to profit-oriented attitude of sympathy, that the reduction of government investment has led to irregularities; the second is that it is technically difficult to regulate the implementation of the economy is very costly. In the process of reform and transition, as the share of government revenue in national income declines, it is inevitable that direct input into the socio-economic sphere will be reduced. In addition, China's current share of public **** investment in health is not too low compared to large middle-income countries. Therefore, it makes no sense to leave medical service behavior unregulated, or to let violations go unchecked, or to take the approach of dealing with major and minor issues. As the manager of public **** services, even if not a penny is invested, it should be justified to protect the safety, quality and price of public access to health care. On a technical level, there is no problem with regulation. The Labor and Social Security Department has already accumulated a great deal of experience in regulating medical institutions, and there are two points that need to be further improved. One is to extend regulation to individual health care providers, and the other is to expand the target of service from the insured
to all health care consumers. Economically, regulation costs money, but it is a cost that must be paid for the healthy operation of the medical services market. And, as the experience of the labor security sector shows, the cost is affordable.
(F) Solving the problem of "difficult and expensive medical treatment" also requires managing consumer expectations
In terms of medical service consumption, the government's responsibility is mainly to meet the basic medical needs of the general public. No country in the world can meet all the medical needs of every citizen. The government's management of demand should include the following aspects: first, it should control unreasonable consumption habits. For example, the country's habit of loving medicine. Second, it should control the freedom of consumers in the choice of basic medical services. Due to the serious problem of information asymmetry, the average consumer does not have the ability to directly choose a specialist, and can only choose a specialist through a community doctor. Therefore, the policy of "patients choosing doctors" should be confined to community doctors. Finally, in meeting the different levels of medical needs of the general public, attention should be paid to controlling the development of special needs services and their adverse impact on basic medical services. Although the allocation of health resources in China has exceeded the current level of economic development, the gap between China and developed countries in the allocation of many elements is still very obvious. Moreover, there is a wide gap in income levels between regions, between urban and rural areas, and between different groups of people in China, and the willingness and ability to consume can also vary greatly. Specialized services for a small number of people rely mainly on imported high technology, which is expensive to purchase and use, and may also bring about social and psychological imbalance. The government must take a cautious approach to its development.