Over the past six decades, China has been experimenting with radically different forms of health care systems.
As the country struggles to figure out the best way to get health care to 1.3 billion people, the rest of the world can learn from its past successes and failures, researchers wrote Wednesday in The New England Journal of Medicine.
Back in 1949, health care was free to everyone in China. The communist state operated all clinics and hospitals, and it employed all doctors, nurses and health workers.
Then in 1984, the government started implementing free-market reforms. People lost their free medical care. And by 1999, only 7 percent of those living in rural regions had health insurance.
Hospitals began to act like for-profit companies. Doctors and nurses were often rewarded for increasing hospital profits. So they started acting like entrepreneurs.
To patients, it seemed like everyone was just out to make a buck — or a yuan. And the public became increasingly angry and distrustful of doctors.
In 2008, the government began to abandon a system based largely on free-market principles and made a commitment to providing affordable health care for all by 2020. About 95 percent of the population had health insurance in 2012.
Dr. David Blumenthal, a coauthor of the NEJM commentary, spoke to us about the rapid evolution of China's health care system. Blumenthal is the president of The Commonwealth Fund, a private foundation in New York City that supports research on health care issues and policies around the world.
What projects worked well in China and might be something for other countries to try?
One success was using community care workers. China pioneered what it called "barefoot doctors." These people were not highly trained technically, but they received training in primary and preventive care and maternal and child health.
Barefoot doctors provided health services in rural areas at the village level and in underserved areas. They improved the basic health of people living in those areas. Barefoot workers really knew their patients. They were their friends and neighbors.
Barefoot doctors made dramatic improvements in the health of China. For instance, they helped drop the infant mortality rate in the country from 200 per 1,000 births to 34 deaths per 1,000 births between 1952 and 1982. Could barefoot doctors be helpful in developed countries, such as the U.S.?
The idea of community health workers has gained a lot of traction in both the developing world and in developed countries. The idea has spread to the point where it's no longer even considered innovative. Community health workers, like nurse practitioners, provide needed primary care in rural and underserved areas in developed countries.
When China switched from universal health care under communism to a largely free market system, millions of people were left without insurance coverage. What were the consequences?
One caution that emerges from China is that if you leave patients totally unprotected against the cost of illness, while at the same time organizing the delivery of services around maximum profit, you create a very damaging cycle. Patients feel vulnerable and increasingly suspicious of doctors' motives. The result can be extreme public dissatisfaction with political consequences.
How extreme was the distrust of health providers?
About 10 years ago, I began hearing stories about patients attacking their doctors physically, even killing them. There was civic unrest in rural areas and riots caused by the distrust of medical care and physicians.
In your letter, you say China lacks a history and a culture of medical professionalism. What do you mean?
In China, there has been no definition of what the roles of health care professionals are compared to businessmen, merchants and industrialists.
In the West, we tend to assume that physicians will abide by professional norms and standards. The standards are self-perpetuating. They include an appreciation of learning, a commitment to self-improvement and a condemnation of taking advantage of patients financially. Physicians, nurses and other providers don't always live up to the standards, but they believe in them. They learn them in school and early in their practices.
In China, those norms and standards didn't have a chance to develop. Confucian society was followed by communist society followed by capitalist society. Professionalism wasn't given a chance to develop in any of these societies.
Medical professionalism is a great gift that we in the West underappreciate.
What hurdles lie ahead for China's health care system?
I do think the coverage side is going well. But they haven't figured out how to create a genuine primary care system. There are village health workers, and then there are specialists. The culture assumes the only good care is from a specialist in a hospital.
And it's a communist, single-party system with corruption. The Ministry of Health is very close to the hospital industry, which runs like a for-profit industry. The industry has been successful in limiting efforts to reform the system and in encouraging market forces to reassert themselves. That's like pouring oil on fire.