From A National, Centrally Planned Health System To A System Based On The Market:

Transcription

1 Lessons From China From A National, Centrally Planned Health System To A System Based On The Market: Lessons From China China has learned that an inappropriately designed health system and unfair economic incentives for physicians can lead to major social welfare loss. by Jin Ma, Mingshan Lu, and Hude Quan ABSTRACT: No other country has undergone health care reforms as dramatic as China s. Starting in 1978, China reformed its health system from a governmental, centrally planned, and universal system to a heavily market-based one. Now, three decades later, the Chinese government openly acknowledges that the reforms failed and seeks new directions. This paper adds to the literature by examining China s health care from a system perspective, describing its health services delivery, access, outcomes, and population health in the postreform era. It also identifies the main issues in the current system and highlights the key lessons learned from China s reform process. [Health Affairs 27, no. 4 (2008): ; /hlthaff ] Since 1978, china has implemented an open door policy, rapidly reforming its social-planning economy to a market-based one. This reform principle for public financing was applied not only to agricultural production, commerce, and industry, but also to the health care system. With government deregulation and decentralization, the previous centrally planned and universal health care system was reformed into a heavily market-based one, and public financing was replaced by private financing. Such dramatic reforms serve as a largescale natural policy experiment on private financing. Now, three decades later, China provides the world with an excellent opportunity to ask a fundamental question crucial to all health care professionals and policymakers: How is China doing in terms of health services delivery, access, and population health after the Jin Ma is a professor and executive dean in the School of Public Health, Shanghai Jiaotong University, in China. Mingshan Lu (lu@ucalgary.ca) is an associate professor in the Department of Economics, University of Calgary, in Alberta, Canada. Hude Quan is an assistant professor in the Department of Community Health Sciences, University of Calgary. HEALTH AFFAIRS ~ Volume 27, Number DOI /hlthaff Project HOPE The People-to-People Health Foundation, Inc.

2 Reform Goes Global reforms? China s experience may have important policy implications for marketbased health care reforms in other countries. The Chinese health care system and its reform have long been attracting international attention. 1 William Hsiao examined the system before and after reform and drew lessons learned. Therese Hesketh and Wei Zhu investigated China s health care market changes. David Blumenthal and Hsiao reviewed China s health care history and examined the Chinese government s responses to existing problems. Besides these systemwide descriptions, many studies have reported the impacts of reform on rural and urban populations. 2 Detailed descriptions of innovations to specific aspects of the system have also been reported, including financing, medical savings accounts (MSAs), and insurance. 3 With rapid economic growth and social change, it is imperative to reexamine Chinese health care from a system perspective. In this paper we describe the main issues in the current system, and we highlight key lessons learned from China in itsreformprocessbypresentingthemostup-to-dateevidenceonthesystem sefficiency and performance, as well as data on population health in China. We also discuss China s most recent health reform initiatives to address the main problems in the current system. Pre-Reform: China s Health Care System In The Central Planning Era ( ) Health care system. After the establishment of communist China in 1949 and before the economic reforms that started in 1978, there were no private clinics or hospitals in China. Its health care system, consisting mainly of hospitals, outpatient clinics, maternal and child care stations, epidemic prevention centers, and longterm care facilities, was owned and operated by various levels of the Chinese government. The system was designed to achieve the goal of equal access to the health care system for all, regardless of ability to pay. To achieve this goal, the Chinese government controlled budgets for all sectors in the public health care system and provided funding to each sector to cover its costs of construction and daily operation. Health care providers, including physicians, nurses, and administrators, were paid a fixed salary. To contain public health care spending at an affordable level, the prices of medication and services were set and adjusted periodically by the central government. Preventive medicine. To improve population health, a great emphasis was put on preventive medicine, integration of Western medicine and traditional Chinese medicine (TCM), and rural health. A well-organized preventive and epidemic system was established at each administrative level, from village to central government. The preventive system was responsible for reporting, monitoring, prevention and control of parasitic and infectious diseases, vaccination, food hygiene, and environmental and occupational health. Integration of traditional with Western medicine. TCM has a much longer history than 938 July/August 2008

3 Lessons From China Western medicine in China. TCM practitioners use locally available and less expensive approaches such as acupuncture and herbal remedies to treat patients. To optimize therapeutic effectiveness at the least cost, China actively promoted the integration of TCM and Western medicine. Parallel with the system of Western medicine, a TCM education and practice system was established, including schools, research institutes, and TCM hospitals in each province. There was a TCM department established at each Western medicine hospital. Rural health care. Given that a majority of the Chinese population resides in rural areas, rural health was made a national priority. Many so-called barefoot doctors were trained within a very short period to solve the problem of physician undersupply in rural areas. These community-based doctors became the principal suppliers of primary health care and health promotion to the vast rural population, meeting basic health care needs at a low cost. Health insurance. During this period, China implemented different health insurance schemes in urban and rural areas. In urban areas, two types of health insurance programs covered the majority of residents. The Government Insurance Scheme (GIS) covered officials and staff (and their dependents) at government agencies, schools and universities, and research institutes. The Labor Insurance Scheme (LIS) covered employees (and their dependents) at state-owned factories. The remaining urban residents were covered by poverty aid programs. 4 In rural areas, the majority of the population was covered by the Cooperative Medical Scheme (CMS), a collective-economy, prepaid health security program. The CMS covered about 85 percent of the rural population in Private insurance did not exist in either urban or rural areas. Post-Reform: China s Health Care System In The Market- Based Era (1978 To The Present) Health care system. With social structures in China starting to change in 1978, the central government gradually decentralized its power over the health care system. The government changed its financing and payment method from a flexible cost-reimbursement method to block grants. The amount of the block grant to each health system sector was usually much less than the actual operating costs. Jurisdictions were encouraged to do whatever they could to generate revenues and were allowed to retain the surplus, part of which could be paid to their staff as bonuses. Under such powerful economic incentives, all health professionals and decisionmakers were motivated to increase the supply of health care to generate higher economic profits. Tofurthermotivatepeopletomakehighprofitsusingtheirskills,thegovernment introduced a series of policies. For example, physicians were permitted to work in their leisure hours to earn extra income. The government also set high service fees for the use of newly introduced high-tech medical equipment. Jurisdictions were allowed to make their own decisions in purchasing expensive medical HEALTH AFFAIRS ~ Volume 27, Number 4 939

4 Reform Goes Global equipment and building luxury facilities. Recent hospital reforms in China allowed the entry of private for-profit hospitals,aswellasthetransferofexistinggovernmenthospitalstoprivateownership. In 2004 there were 2,545 private for-profit hospitals, accounting for 13.8 percent of all hospitals in China, and 145,375 private for-profit clinics, accounting for 72.0 percent of all clinics. 6 Although the percentage of private for-profit hospitals only provides a crude measure of their market share and may tend to exaggerate it, the measure does indicate that private for-profit hospitals and clinics have emerged as important players in China s health care market. These providers have further increased the competition for patients and profits. Health insurance. In urban areas, under the market economy, many stateowned enterprises either closed down or became private or joint-venture enterprises. The government therefore merged the LIS and GIS programs and created a new urban employee health insurance program. This new program covers all enterprise employees, no matter if they work in state-owned or private enterprises. However, employers no longer provide full insurance coverage to their employees. The MSA scheme is becoming increasingly popular in China, whereby employers provide their employees with a fixed amount of money per month to cover basic health services, and employees are responsible for the remaining costs. In addition, the employee insurance program no longer covers employees dependents. In rural areas, the government adopted a laissez-faire policy, and rural health care reverted to primarily private financing (self-pay). The previous CMS literally collapsed; in 1994, less than 10 percent of China s rural population still had CMS coverage, and that has likely decreased even more since then. 7 In addition, barefoot doctors,whoseserviceswerepreviouslyfundedunderthecms,becameeither full-time farmers or private practitioners to make a living. Township health centers and countryside hospitals are largely financed by fee-for-service, out-ofpocket payments. Access to health care in many rural areas is now governed by the ability to pay; many rural residents cannot afford even basic health care and choose to forgo treatment when they get sick. Starting in the early 1980s, commercial health insurance plans were introduced in both urban and rural areas. The development of the commercial or private health insurance market in China is still at a very preliminary stage. Although all major life insurance companies in China have started to offer health insurance, their business is limited. In 1996, health services expenditure was about 170 billion yuan. Within this amount, commercial health insurance accounted for only 1.3 billion yuan (only 1 yuan per capita, or 0.76 percent of total health services spending). Commercial health insurance coverage has increased in recent years yet is still at a low level. According to the Third National Health Services Survey in China, in 2003 only 5.6 percent of the population was covered by commercial health insurance July/August 2008

5 Lessons From China Main Issues And Lessons Learned Most of the distortions in China s health care system are likely to be the results of the heavy reliance on private financing and the dysfunctional payment system. Access to care. First, a majority of the population does not have access to the health care system because of financial barriers. During the past three decades, national health spending in China has risen, as have patients out-of-pocket payments. On the other hand, however, health services use has gone down. According to the results of the National Survey on Social Harmony and Stability conducted by the Chinese Academy of Social Sciences in 2006, the top social concern in China is high medical expenses. A recent study that analyzed the 2003 Third National Health Services Survey indicated that when sick, many patients (47 percent of rural and 32 percent of urban residents) chose self-treatment without consulting a physician. 9 From 1978 to 2004, China s national health spending dramatically increased from billion yuan to 7,590.3 billion yuan. Exhibit 1 presents the trends in government, social, and individual out-of-pocket health spending in terms of their percentages of national health spending in China. National expenditures on outpatient and emergency treatment per visit were 4.79 times higher in 1996 than in 1990; on each prescription, 4.36 times higher; and on inpatient treatment per visit, 4.62 times higher. 10 However, hospital bed use dropped continuously, from 80 percent in 1990 to 60 percent in Physician workload per physician also fell, from around 1,200 visits in 1990 to fewer than 400 visits in 1997 (Exhibit 2). Vulnerable populations. Second, inequalities in health care access are widening; rural residents, children, seniors, and low-income families are the most vulnerable. China s rural population, accounting for 57 percent of its entire population, has beenpayingthehighestpriceunderhealthcarereform.from1993to2003,health EXHIBIT 1 Change In Health Spending In China, Compared With 1978, By Source Percent Individual patient 0 Government Social programs SOURCE: China Ministry of Health, China Health Statistics Yearbook (Beijing: MOH, 2005). HEALTH AFFAIRS ~ Volume 27, Number 4 941

6 Reform Goes Global EXHIBIT 2 Average Number Of Outpatient Visits Per Physician At Village Clinical Centers Or Hospital Outpatient Departments In Cities And Counties, China, Number of visits 1,000 Village clinical centers Outpatient departments SOURCE: China Ministry of Health, China Health Statistics Yearbook (Beijing: MOH, 1997). insurance coverage in urban areas dropped from around 70 percent to 55 percent; the drop in the rural areas was far more dramatic (Exhibit 3). In 2003, only about 9.5 percent of the rural population was covered by some form of community-financed health care, down from a peak of about 85 percent in As a result, some 700 million rural Chinese must pay out of pocket for virtually all health services, potentially leading to the deferral of care, untreated illness, financial catastrophe, and poverty. Hospitals compete for patients by recruiting well-known physicians, prescrib- EXHIBIT 3 Health Insurance Coverage In Urban And Rural Areas In China, By Program, Selected Years Number of visits Other 75 Collective Commercial 60 Cooperative Medical Scheme Social insurance Urban areas Rural areas SOURCES: World Bank, Report on Health Care in Rural Areas of China (in Chinese), 2005, Chinese/content/BN3_cn.pdf (accessed 15 May 2008); and China Ministry of Health, The Third National Health Services Survey Report 1 (in Chinese) (Beijing: MOH, 2004). 942 July/August 2008

7 Lessons From China How to reduce disparities and protect vulnerable populations has become one of the biggest challenges for the Chinese government. ing multiple comprehensive diagnostic and laboratory tests, and encouraging patients to stay at luxury facilities. The fierce medical arms race has caused the centralization of physicians and an abundant supply of high-tech and expensive medical equipment and facilities in metropolitan areas to serve a small proportion of the population who can afford such expensive services. At the same time, health resources are lacking in rural areas, where more than half of the population resides. As mentioned before, barefoot doctors, whose services were previously funded under the CMS, have become less available to rural residents. Township health centers and countryside hospitals are largely financed by fee-for-service, out-ofpocket payments. It is difficult for many clinics and hospitals in rural areas to make a profit because of limited ability to pay the fees among the rural population. As a result, rural physicians have moved to urban areas, and rural hospitals cannot afford to renovate their facilities. Difficulty in attracting resources has led to a decline in the diversity and quality of health care services on which rural populations traditionally relied. Other than the vast rural population, those who are at high risk for noninsurance include socioeconomically disadvantaged groups who do not qualify for social welfare programs, such as children, people who are unemployed, the shortterm employed, and rural-urban migrant workers. How to reduce the disparities and better protect vulnerable populations has become one of the biggest challenges for the Chinese government. Qualityofcare.Third, without valid monitoring mechanisms, quality of care is not properly evaluated, nor are providers made publicly accountable for quality. Health decisionmakers in China have acknowledged that quality improvement is crucial for the health care system. However, in contrast to Western countries, China has been ranking hospitals mainly using hospital structure related indicators (such as size of facility, number of beds, and physician credentials), instead of the important components of structure, process, and outcomes. Because of the lack of valid information on outcomes in China, patients assume that hospitals with advanced diagnostic equipment provide better-quality care than those with less equipment. Therefore, hospitals actively purchase innovative, advanced medical equipment to compete with each other and attract more patients. In 2005, China imported $US60 billion worth of medical equipment; the cost for purchasing major medical equipment accounted for more than 60 percent of large hospitals fixed assets. From 2002 to 2005, the number of magnetic resonance imaging (MRI) machines increased 90.2 percent, and that of computed tomography (CT) scanners increased 55.4 percent. Such huge capital investment HEALTH AFFAIRS ~ Volume 27, Number 4 943

8 Reform Goes Global costs are eventually transferred to patients, to a large extent contributing to the increase in the price of health care. This costly equipment is largely underused. In 2006, the China Medical Equipment Association surveyed 500 hospitals on their use of ten types of equipment. The survey showed that CT scanners and MRI machines were used less than 40 percent of the time; 17 percent of CT requisitions and 27 percent of MRI requisitions were found to be inappropriate and could not be justified. 12 On the provider side, hospitals and physicians have reacted to the economic incentives introduced in the new payment methods, their behavior becoming largely profit driven. Without a proper system to monitor and assess outcomes, physician-induced demand has become a serious concern in China s health care system. Levels of public trust and satisfaction with the accountability of physicians and thehealthcaresystemareverylow. Health promotion/disease prevention. Fourth, health promotion and disease prevention are largely ignored in the current health care system. Under the reforms, government funding allocated to disease control and prevention was reduced from 0.11 percent of gross domestic product (GDP) in 1978 to 0.04 percent of GDP in Preventive medicine, as did the rest of the health care system, became profit driven. Public education and infectious disease monitoring are unprofitable and therefore largely ignored. Physicians who are not paid for providing disease prevention and health promotion services are reluctant to be consulted on primary preventive care, such as cancer screening, risk-factor reduction, health education, and regular physical exams. The direct consequences of ignoring preventive medicine are supported by alarming figures from several national surveys. In 2002, the smoking rate was 66.9 percent for males and 3.1 percent for females, and 16 percent of males and 1.5 percent of females drank alcohol daily. 14 Only 8 percent of the population was regularly carrying out non-work-related physical activity. 15 About 55 percent of hypertensive patients were not aware of their condition; only 30 percent took antihypertensive medication, and 8.1 percent achieved blood pressure control. 16 About 66 percent of diabetics were not aware of their condition; 27 percent took medication, and 10 percent achieved control. 17 Another well-known consequence of failing to pay attention to preventive medicine is the occurrence of severe acute respiratory syndrome (SARS) in China. The disaster was initiated by a virus in China and subsequently caused the SARS epidemic in many countries. The SARS outbreak provided the Chinese government with a valuable lesson on the importance of prevention and of responding to future public health challenges and emerging/reemerging infectious diseases. In 2003 the percentage of government input into the total budget for disease prevention and control reached 45.8 percent a large increase from its level of 38.7 percent in Population health. Fifth, population health is improving more slowly than be- 944 July/August 2008

9 Lessons From China fore. Certain infectious diseases are reemerging, and chronic diseases are prevalent. From 1980 to 1998, average life expectancy in China increased by two years. However, during the same period, average life expectancy in Australia, Japan, and New Zealand increased by four to six years; in Sri Lanka, by five years. 19 It is particularly alarming that the reported incidence of tuberculosis in China has been showing an upward trend starting from This may have been the result of a worsened economic situation and poverty in China s underdeveloped rural areas, as well as some patients inability to pay for treatment. SincethefirstreportedcaseofAIDSappearedinChinain1985,theAIDSepidemic has been showing a rapidly rising trend (Exhibit 4). Similarly, various sexually transmitted diseases (STDs), previously eliminated in China in the late 1970s, have emerged again. For example, in 2004, the incidence of gonorrhea reached people per 100,000 and that of syphilis reached 4.56 people per 100,000 (Exhibit 5). Prevalence of and mortality from various chronic diseases in China have also been increasing dramatically. For example, in the late 1990s, 160 million people suffered from hypertension; 20 million were overweight; 16 million had mental disorders; million new cases of cancer were diagnosed each year; and about 850,000 people died from injury each year. Risk factors related to chronic disease, such as smoking, imbalance in nutrition, lack of physical exercise, and aging and stress, are continuously increasing. The three leading causes of mortality in the country are now ischemic heart disease, cerebrovascular disease, and chronic obstructive pulmonary disease. 20 China s New Health Reform Initiatives The Chinese government has recognized the failure of its previous health care reforms and the magnitude of the various problems in the current health care system; it is in the process of seeking ways to redesign it. 21 The directions of the new EXHIBIT 4 Cumulative Number Of HIV/AIDS Cases In China, Thousands of cases 40 AIDS 30 HIV-positive SOURCE: China Ministry of Health, The Eleventh Next Five-Year Health Planning Conference (in Chinese) (Beijing: MOH, 2005). HEALTH AFFAIRS ~ Volume 27, Number 4 945

10 Reform Goes Global EXHIBIT 5 Reported Incidence Of Viral Hepatitis And Two Sexually Transmitted Diseases In China, Per 100,000 Population, Selected Years Cases per 100,000 Viral hepatitis Syphilis Gonorrhea SOURCE: China Ministry of Health, China Health Statistical Yearbook (various years, in Chinese) (Beijing: MOH, 1988, 2001, 2004, and 2006). reform include strengthening the government s role in the health care industry; increasing government investment in the health care sector; expanding health insurance coverage; no longer rewarding doctors based on the revenue they generate; and strengthening primary care, community health care, and disease prevention. To develop a new health insurance plan, the government solicited public opinion and consulted experts at academic institutions, the World Health Organization (WHO), and the World Bank. The new reform plan is to focus on the principle of health for all and reemphasize the government s responsibilities in public health and insurance coverage. The ultimate goal is to reduce financial barriers to access and disparities in health care. For urban residents, the new insurance plan was to have been piloted in seventy-nine urban areas in 2007, evaluated in 2008, and implemented nationwide during the following three years. The new plan will benefit vulnerable populations, including the unemployed, children, students, seniors, and the disabled, who were neglected under the current insurance program. It mainly provides coverage for hospitalizations and outpatient services for high-cost medical conditions. It is financed by individual premiums and government welfare to lowincome families. For rural areas, the government initiated a project to reestablish the CMS in 1994, piloting the project in fourteen counties; the New CMS (NCMS) was launched nationwide beginning in The premium under the NCMS is paid by three sources. In 2003, Chinese national and local authorities each contributed 10 yuan per person; individuals each contributed at least 10 yuan. In 2006, the government authorities contribution to the premium increased to 40 yuan per person, while residents contributions remained the same. As of March 2007, 685 million residents (79 percent of the rural population) were covered under the NCMS. 23 The target is for all of the rural population to be covered under the NCMS in July/August 2008

11 Lessons From China The chinese experience highlights two important facts: first, heavily relying on out-of-pocket spending that is, demand-side cost sharing leads to inequities in access to care and fails to protect disadvantaged populations from health risks. Second, health care providers do respond to economic incentives. Although market and economic incentives could be used to improve efficiency and quality in health care, an inappropriately designed health care system and economic incentives can lead to unintended results and social welfare loss. Extra caution is needed when heavily relying on demand-side cost sharing in financing, as well as when introducing economic incentives in how providers are paid. Although many other confounding factors may have also played their roles, the results presented in this paper suggest that the potential dangers of an inappropriately designed health care system might be that equity of access to the health system is damaged, the cost of health services is greatly increased, health services are overused inappropriately, and population health in terms of preventable diseases is impaired. This paper was presented at the international conference, Health Care in China: Progress and Prospects, July 2007, in Beijing. Part of the work was completed under a Visiting Scientist Award from the Alberta Heritage Foundation for Medical Research. Mingshan Lu gratefully acknowledges financial support from the Institute of Health Economics, in Alberta. NOTES 1. W.C. Hsiao, The Chinese Health Care System: Lessons for Other Nations, Social Science and Medicine 41, no. 8 (1995): ; T. Hesketh and W.X. Zhu, Health in China: The Healthcare Market, British Medical Journal 314, no (1997): ; and D. Blumenthal and W. Hsiao, Privatization and Its Discontents: The Evolving Chinese Health Care System, New England Journal of Medicine 353, no. 11 (2005): G. Bloom and G. Xingyuan, Health Sector Reform: Lessons from China, Social Science and Medicine 45, no. 3 (1997): ; M. Beach, China s Rural Health Care Gradually Worsens, Lancet 358, no (2001): 567; J. Watts, China s Rural Health Reforms Tackle Entrenched Inequalities, Lancet 367, no (2006): ; C.M. Grogan, Urban Economic Reform and Access to Health Care Coverage in the People s Republic of China, Social Science and Medicine 41, no. 8 (1995): ; and L. Xu et al., Urban Health Insurance Reform and Coverage in China Using Data from National Health Services Surveys in 1998 and 2003, BMC Health Services Research 7 (2007): W.C. Hsiao, Transformation of Health Care in China, New England Journal of Medicine 310, no. 14 (1984): ; Y. Liu et al., Transformation of China s Rural Health Care Financing, Social Science andmedicine 41, no. 8 (1995): ; W.C. Yip and W.C. Hsiao, Medical Savings Accounts: Lessons from China, Health Affairs 16, no. 6 (1997): ; Y. Liu, W.C. Hsiao, and K. Eggleston, Equity in Health and Health Care: The Chinese Experience, Social Science and Medicine 49, no. 10 (1999): ; and J.S. Akin, W.H. Dow, and P.M. Lance, Did the Distribution of Health Insurance in China Continue to Grow Less Equitable in the Nineties? Results from a Longitudinal Survey, Social Science and Medicine 58, no. 2 (2004): China State Council, The Regulations of Labor Insurance (in Chinese) (Beijing: Chinese State Council, 1951); Hsiao, The Chinese Health Care System ; L. Yin and M.H. Ren, The Medical Insurance System Reform (in Chinese) (Guangzhou: Guangdong Economy Press, 1999); and S. Huang and S. Li, Health Sectors in Contemporary China, vol. 2 (Beijing: China Social Sciences Press, 1986). 5. L.S. Wang and L.C. Zhang, The Experience and Lessons from China s Cooperative Medical Scheme, Chinese Health Economics 15, no. 8 (1996): (in Chinese). 6. China Ministry of Health, China Health Statistics Yearbook (in Chinese), 2004, newshtml/9963.htm (accessed 15 April 2008). 7. Z.Q. Zhang, A Retrospective Study on China s Rural Cooperative Medical Scheme, Chinese Journal of Rural HEALTH AFFAIRS ~ Volume 27, Number 4 947

12 Reform Goes Global Health Service Administration 14, no. 6 (1994): 4 9 (in Chinese). 8. China MOH, Main Results from the Third National Health Services Survey (in Chinese), Journal of Anhui Health Vocational and Technical College 4, no. 1 (2005): M. Liu et al., Rural and Urban Disparity in Health Services Utilization in China, Medical Care 45, no. 8 (2007): China MOH, China Health Statistics Yearbook (in Chinese) (Beijing: China MOH, 1997). 11. Centre for Health Statistics and Information, Ministry of Health: An Analysis Report of National Health Services Survey, 2003 (in Chinese) (Beijing: MOH, 2003). 12. D.R. Hu, CT Utilization Rate Lower than 40 Percent, Chinese Health News, 20 June 2006 (in Chinese); and H. Li et al., The Analysis of Large Medical Equipment in Henan Province (in Chinese), China Medical Equipment 2, no. 2 (2005): China State Council, Department of Policy Research, How to Improve Health Economics Policies (in Chinese) (Beijing: Chinese Economy Press, 1996). 14. G.H.Yangetal., SmokingandPassiveSmokinginChina,2002 (inchinese),chinese Journal of Epidemiology 26, no. 2 (2005): 77 83; and G.S. Ma et al., The Current Status of Drinking Behavior among Residents of China (in Chinese), Acta Nutrimenta Sinica 27, no. 2 (2005): G.S. Ma et al., The Description Analysis of Exercise Participation of Residents in China (in Chinese), Chinese Journal of Prevention and Control for Chronic Disease 14, no. 1 (2006): D. Gu et al., Prevalence, Awareness, Treatment, and Control of Hypertension in China, Hypertension 40, no.6(2002): Y.F. Wu et al., The Current Status on the Prevalence, Awareness, Treatment, and Control of Diabetes Mellitus in Several Chinese Subpopulations (in Chinese), Chinese Journal of Epidemiology 26, no. 8 (2005): China National Health Economics Institute, China National Health Account Report (in Chinese) (Beijing: NHEI, 2005). 19. S.G. Wang, The Crisis and Opportunity for Public Health in China (in Chinese), Comparative Studies, no. 7 (2003): 52 91; and United Nations Health Partners Group in China, AHealth SituationAssessmentofthePeople s Republic of China (Beijing: UN Health Partners, July 2005). 20. Ibid. 21. Y. Ge and Research Team of China State Development Institute, Evaluation and Suggestions to China Healthcare System Reform (in Chinese), China Development Evaluation and Discussion (2005); and L. Li and J. Jiang, Turning Point of Chinese Health Care Reform (in Chinese), Chinese Health Economics 126, no. 4 (2007): G. Carrin et al., The Reform of the Rural Cooperative Medical System in the People s Republic of China: Interim Experience in Fourteen Pilot Countries, Social Science and Medicine 48, no. 7 (1999): ; and A. Wagstaff et al., Extending Health Insurance to the Rural Population: An Impact Evaluation of China s New Cooperative Medical Scheme, Policy Research Working Paper no (Washington: World Bank, March 2007). 23. C.L. Nie, The Construction and Development of China s New Rural Cooperative Medical System (in Chinese) (Keynote speech at the International Conference on China Rural Health Insurance and Farmer Economic Behavior, Beijing, China, July 2007). 948 July/August 2008