In 1949, the Chinese Communist Party established a state-run health care system that relied on community health workers to provide free primary care in villages across China. The system brought enormous public health gains to the nation’s 1.3 billion residents. Between 1952 and 1982, infant mortality fell from 200 to 34 per 1,000 live births, and many age-old scourges, including the parasitic disease schistosomiasis, were largely eliminated. Much of the credit went to state-funded “barefoot doctors” dispatched to rural villages across the country.
After market reforms in 1984, the state stopped paying community health workers. A now largely uninsured population was forced to bear the full economic cost of illness. Medical professionals functioned like private entrepreneurs. The resulting public backlash spurred another major shift: China’s health system today provides modest but comprehensive health insurance to 95 percent of residents, who access care through an extensive network of primary care clinics.
Lessons from China
The Commonwealth Fund’s David Blumenthal and coauthor William Hsiao of the Harvard School of Public Health identify important insights from China’s radical health system experimentation:
- In low-income countries—and perhaps in high-income ones as well—community health workers, like China’s barefoot doctors, can significantly improve the health status of local populations.
- Relying on pure market forces to fund and distribute health care can put a heavy financial burden on patients and can lead to social instability.
- One legacy of China’s market experiment is a widespread perception that physicians put their economic welfare ahead of patients’ interests. This has complicated China’s efforts to create a health care workforce that leaders and the public trust. Physician professionalism may be an underappreciated element of effective modern health care systems, the authors note.
China has experimented boldly with diverse approaches to national health care. While its leaders have made missteps, their most recent attempts are now yielding gains, notably in establishing a solid primary care foundation. The Chinese health system will be interesting to watch as it continues to evolve and improve.