《中国医疗保险制度的转型发展与创新》课程教学资源（参考资料）世界银行：Deepening Health Reform In China Building High-Quality And Value-Based Service Delivery

HEALTHY CHINA DEEPENING HEALTH REFORM IN CHINA BUILDING HIGH-QUALITY AND VALUE-BASED SERVICE DELIVERY World Bank Group World Health Organization Ministry of Finance,National Health and Family Planning Commission, Ministry of Human Resources and Social Security, The People's Republic of China np WORLD BANK GROUP World Health Organization

World Bank Group World Health Organization Ministry of Finance, National Health and Family Planning Commission, Ministry of Human Resources and Social Security, The People’s Republic of China HEALTHY CHINA DEEPENING HEALTH REFORM IN CHINA BUILDING HIGH￾VALUE-BASED SERVICE DELIVERY QUALITY AND

Deepening Health Reform In China Building High-Quality And Value-Based Service Delivery Policy Summary China Joint Study Partnership World Bank Group,World Health Organization, Ministry of Finance,National Health and Family Planning Commission,Ministry of Human Resources and Social Security 2016

Deepening Health Reform In China Building High-Quality And Value-Based Service Delivery Policy Summary China Joint Study Partnership World Bank Group, World Health Organization, Ministry of Finance, National Health and Family Planning Commission, Ministry of Human Resources and Social Security 2016

Contents Forew0rd.·····… Acknowledgements Executive Summary...·····. Abbreviations..····· XXV Introduction............. xxvii Background:Impressive Gains in Health Outcomes, but Substantial Challenges Ahead Aging,chronic disease,and risk factors..................................... 2 Quality of care…………… 6 Inefficient service delivery:hospital-centrism,fragmentation and Distorted incentives..................................................... 6 Risk of low value care:Diminishing gains in health with escalating Health spending....… 10 Spending projections.………… 11 Part I Service Delivery Levers 17 Shaping tiered health care delivery system in accordance with People-Centered Integrated Care Model (Lever 1) 19 Introduction .................. 19 DEEPENING HEALTH REFORM IN CHINA 计

DEEPENING HEALTH REFORM IN CHINA iii Contents Foreword ............................................................... ix Acknowledgements .......................................................xi Executive Summary ...................................................... xv Abbreviations .......................................................... xxv Introduction .......................................................... xxvii Background: Impressive Gains in Health Outcomes, but Substantial Challenges Ahead 1 Aging, chronic disease, and risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Quality of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Inefficient service delivery: hospital-centrism, fragmentation and Distorted incentives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Risk of low value care: Diminishing gains in health with escalating Health spending . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Spending projections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Part I Service Delivery Levers 17 Shaping tiered health care delivery system in accordance with People-Centered Integrated Care Model (Lever 1) 19 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

iv DEEPENING HEALTH REFORM IN CHINA Challenges.............................................................23 Core action areas and corresponding implementation strategies for developing and implementing PCIC-based service delivery model: lessons from international and national experience............................ 24 Improving Quality of Care in Support of People-Centered Integrated Care (Lever 2) 35 Introduction.................. 35 Challenges to Improving Quality of Care in China.................. 36 Recommendations for Improving the Quality of Care................. 40 Engaging Citizens in Support of the People-Centered Integrated Care Model (Lever 3) 49 Introduction… 49 Challenges to engaging citizens............................................ 50 Recommendations:Strengthening Citizen Engagement.........................51 Reforming Public Hospitals and Improving their Performance (Lever 4) 65 Introduction..........................................................65 Challenges and lessons in Public Hospital Governance and Management in China....66 Recommendations for moving forward with public hospital reform: Lessons from Chinese and international experience............................70 Part ll Institutional and Financial Environment Levers 77 Realigning Incentives in Purchasing and Provider Payment (Lever 5) 79 Introduction 79 Key Challenges in Purchasing Health Services and Paying Providers...............80 Recommendations for Realigning Incentives in the Health System in China.........82 Strengthening Health Workforce for People-Centered Integrated Care (Lever 6) 89 Introduction ................. 89

iv DEEPENING HEALTH REFORM IN CHINA Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Core action areas and corresponding implementation strategies for developing and implementing PCIC-based service delivery model: lessons from international and national experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Improving Quality of Care in Support of People-Centered Integrated Care (Lever 2) 35 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Challenges to Improving Quality of Care in China . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Recommendations for Improving the Quality of Care . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Engaging Citizens in Support of the People-Centered Integrated Care Model (Lever 3) 49 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Challenges to engaging citizens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Recommendations: Strengthening Citizen Engagement . . . . . . . . . . . . . . . . . . . . . . . . . 51 Reforming Public Hospitals and Improving their Performance (Lever 4) 65 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Challenges and lessons in Public Hospital Governance and Management in China . . . . 66 Recommendations for moving forward with public hospital reform: Lessons from Chinese and international experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Part II Institutional and Financial Environment Levers 77 Realigning Incentives in Purchasing and Provider Payment (Lever 5) 79 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Key Challenges in Purchasing Health Services and Paying Providers . . . . . . . . . . . . . . . 80 Recommendations for Realigning Incentives in the Health System in China . . . . . . . . . 82 Strengthening Health Workforce for People-Centered Integrated Care (Lever 6) 89 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

CONTENTS Key Challenges in the Human Resource Management in China...................90 Recommendations for Moving Forward with Human Resources Reform: Lessons from Chinese and International Experience............................93 Strengthening Private Sector Engagement in Production and Delivery of Health Services (Lever 7) 97 Introduction.................. 97 99 Key Challenges,。。。,..。.·。。。·。。。。·。··。·················yy Recommendations for Strengthening Private Sector Engagement in Production and Delivery of Health Services:Lessons from Chinese and International Experience...… .102 Modernizing Health Service Planning to Guide Investment (Lever 8) 107 Introduction.· 107 Key Capital Investment Challenges in the Health Sector in China................... 108 Recommendations for Moving Forward with Service Planning Reform: Lessons from Chinese and International Experience............................110 Part Ill Moving Forward with Implementation 117 Strengthening Implementation of Service Delivery Reform 119 Introduction...…· ..119 Implementation Challenges...............................................119 An Actionable Implementation Framework....................................121 Moving Forward:Spreading Effective and Sustainable Implementation at the Local Level...........................123 Toward a sequential reform implementation plan for reaching full scale in China......132 Annexes....········ 135 Annex 1 Levers and Recommended Core Actions.............................136 Annex 2 Government Policies In Support of the Eight Levers.................... 138 Annex 3 New Policy Guidelines on Tiered Service Delivery (Guo Ban Fa [2015]NO.70)and Recommended Core Actions............142 Annex 4 Nomenclature and Summaries of 22 PCIC Performance Improvement Initiatives......... 144 Annex 5 Impact Frequency of Studies on PCIC Initiatives(no.of studies)........... 147 References..···…· 149

CONTENTS v Key Challenges in the Human Resource Management in China . . . . . . . . . . . . . . . . . . . 90 Recommendations for Moving Forward with Human Resources Reform: Lessons from Chinese and International Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Strengthening Private Sector Engagement in Production and Delivery of Health Services (Lever 7) 97 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Key Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Recommendations for Strengthening Private Sector Engagement in Production and Delivery of Health Services: Lessons from Chinese and International Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Modernizing Health Service Planning to Guide Investment (Lever 8) 107 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Key Capital Investment Challenges in the Health Sector in China . . . . . . . . . . . . . . . . . . . 108 Recommendations for Moving Forward with Service Planning Reform: Lessons from Chinese and International Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Part III Moving Forward with Implementation 117 Strengthening Implementation of Service Delivery Reform 119 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Implementation Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 An Actionable Implementation Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Moving Forward: Spreading Effective and Sustainable Implementation at the Local Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Toward a sequential reform implementation plan for reaching full scale in China . . . . . . 132 Annexes .............................................................. 135 Annex 1 Levers and Recommended Core Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Annex 2 Government Policies In Support of the Eight Levers . . . . . . . . . . . . . . . . . . . . 138 Annex 3 New Policy Guidelines on Tiered Service Delivery (Guo Ban Fa [2015] NO.70) and Recommended Core Actions . . . . . . . . . . . . 142 Annex 4 Nomenclature and Summaries of 22 PCIC Performance Improvement Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Annex 5 Impact Frequency of Studies on PCIC Initiatives (no. of studies) . . . . . . . . . . . 147 References ............................................................ 149

vi DEEPENING HEALTH REFORM IN CHINA Boxes L.1 What is Value in Health Care?.....................................xxviii L.2 Suggestions of the CPC Central Committee on the 13th Five-year Plan for National Economic and Social Development on the promotion of a "Healthy China"(pp.42-43,English translation).......................xxix L.3 Report Structure......... L.4 Nomenclature,Name and Location for Commissioned Case Studies........xxxiv 2.1 Defining People-Centered Integrated Care...............................20 2.1 Impacts of PCIC-like models..........................................21 2.1 The Potential Benefits of People-Centered Integrated Care...................22 3.1 What is Quality?Why Quality is important?.............................37 3.2 Existing evidence of over-utilization of drugs and health interventions.. ..39 3.3 Core action areas and implementation strategies to improve healthcare quality...40 4.1 Why is citizen engagement important?..................................51 4.2 Citizen Engagement to improve health care:core action areas and corresponding implementation strategies.................................52 4.3 Health Education in the UK:Skilled For Health...........................54 4.4 Social marketing in China:Prevention and control of Hepatitis B............. 5 4.5 The Million Hearts Campaign...... .56 4.6 Encouraging self-management of health:Examples from the UK and India......59 4.7 Improving patient involvement at the Beth Israel Deaconess Medical Center 4.8 Decision Aid for Stable Coronary Heart Disease by the Informed Medical Decisions Foundation 4.9 Health Coaching to Coordinate Care in Singapore......................... 61 4.10 Examples of using nudging and regulation to change target behaviors..........64 5.1 Management Practice Domains... .68 6.1 Examples of provider payment reforms in China ............ …85 9.1 Distinguishing Features of an Effective Service Planning Approach...........108 9.2 Horizon's Three Step Model.........................................111 9.3 Physical Redesign of Northern Ireland's Health System Model .115 10.1 Government Administrative Reforms and International Experience... .127 Figures ES.1 8-in-1 Interlinked Reform Levers..................................... xviii ES.2 Reform Implementation Roadmap................................... xxiv 1.1 Share of the Elderly in China will Rapidly Catch up with the OECD …2 1.2 Prominence of NCDs in the Burden of Disease and Causes of Mortality 3 1.3 Management of Hypertension and Diabetes.................... .4 1.4 Smoking and Alcohol Consumption in China Compared to Other Nations.......5 1.5 Hospital beds in China compared to OECD,2000-2013.....................7 1.6 Rapid Growth in the Number of Hospitals and Shift toward Higher Level Facilities...................................................... 1.7 Rising Health Care Cost in China......................................11 1.8 Health Care Expenditure Growth Rate in China..........................13 1.9 Composition of Health Spending in China,1997-2013............ ….14 1.10 Trend in Life Expectancy Compared to Total Spending on Health,1995-2015...14 1.11 Diverse Paths to Better Health.........................................15 2.1 Illness Burden Scorecard to risk stratify patients...........................26

vi DEEPENING HEALTH REFORM IN CHINA Boxes I.1 What is Value in Health Care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxviii I.2 Suggestions of the CPC Central Committee on the 13th Five-year Plan for National Economic and Social Development on the promotion of a “Healthy China” (pp. 42–43, English translation) . . . . . . . . . . . . . . . . . . . . . . . xxix I.3 Report Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxi I.4 Nomenclature, Name and Location for Commissioned Case Studies . . . . . . . . xxxiv 2.1 Defining People-Centered Integrated Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 2.1 Impacts of PCIC-like models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 2.1 The Potential Benefits of People-Centered Integrated Care . . . . . . . . . . . . . . . . . . .22 3.1 What is Quality? Why Quality is important? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 3.2 Existing evidence of over-utilization of drugs and health interventions. . . . . . . . . .39 3.3 Core action areas and implementation strategies to improve healthcare quality . . .40 4.1 Why is citizen engagement important? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 4.2 Citizen Engagement to improve health care: core action areas and corresponding implementation strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 4.3 Health Education in the UK: Skilled For Health . . . . . . . . . . . . . . . . . . . . . . . . . . .54 4.4 Social marketing in China: Prevention and control of Hepatitis B . . . . . . . . . . . . .55 4.5 The Million Hearts Campaign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 4.6 Encouraging self-management of health: Examples from the UK and India . . . . . .59 4.7 Improving patient involvement at the Beth Israel Deaconess Medical Center in the US . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 4.8 Decision Aid for Stable Coronary Heart Disease by the Informed Medical Decisions Foundation 4.9 Health Coaching to Coordinate Care in Singapore . . . . . . . . . . . . . . . . . . . . . . . . .61 4.10 Examples of using nudging and regulation to change target behaviors . . . . . . . . . .64 5.1 Management Practice Domains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 6.1 Examples of provider payment reforms in China . . . . . . . . . . . . . . . . . . . . . . . . . .85 9.1 Distinguishing Features of an Effective Service Planning Approach . . . . . . . . . . .108 9.2 Horizon’s Three Step Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 9.3 Physical Redesign of Northern Ireland’s Health System Model . . . . . . . . . . . . . . .115 10.1 Government Administrative Reforms and International Experience . . . . . . . . . . .127 Figures ES.1 8-in-1 Interlinked Reform Levers .....................................xviii ES.2 Reform Implementation Roadmap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiv 1.1 Share of the Elderly in China will Rapidly Catch up with the OECD . . . . . . . . . . . .2 1.2 Prominence of NCDs in the Burden of Disease and Causes of Mortality . . . . . . . . .3 1.3 Management of Hypertension and Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 1.4 Smoking and Alcohol Consumption in China Compared to Other Nations . . . . . . .5 1.5 Hospital beds in China compared to OECD, 2000–2013 . . . . . . . . . . . . . . . . . . . . .7 1.6 Rapid Growth in the Number of Hospitals and Shift toward Higher Level Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 1.7 Rising Health Care Cost in China . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 1.8 Health Care Expenditure Growth Rate in China . . . . . . . . . . . . . . . . . . . . . . . . . .13 1.9 Composition of Health Spending in China, 1997–2013 . . . . . . . . . . . . . . . . . . . . .14 1.10 Trend in Life Expectancy Compared to Total Spending on Health, 1995–2015 . . .14 1.11 Diverse Paths to Better Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 2.1 Illness Burden Scorecard to risk stratify patients . . . . . . . . . . . . . . . . . . . . . . . . . . .26

CONTENTS vii 2.2 Responsibilities of PACT team members.................................27 2.3 PACE Continual Feedback Loop.......................................33 5.1 Scores by Management Practice,China 2015 (n=110 hospitals)...............69 6.1 Composition of Total Health Expenditure in China,by facility or provider (percent)................................................82 7.1 Health Workers Compensation across levels of Care and Providers,China 2013..91 8.1 Growth in Hospitals by Ownership.....................................98 8.2 Growth in PHC Facilities by Ownership (2005 to 2012)....................98 8.3 Growth of Hospital Admissions by Ownership,2005-2012 (in 10,000)........98 8.4 Growth of Outpatients Visits by Ownership,2005-2012(in 10,000)..........99 10.1 Proposed Oversight,Coordination and Management for Service delivery Reform Implementation and Scale-Up...........................124 10.2 The Transformation Learning Collaborative (TLC)model in three different arrangements.....................................................129 Tables 1.1 Hypertension diagnosis,treatment and control(age 35-84):international comparison.........................................................4 2.1 Core actions areas and implementation strategies to achieve PCIC.............24 5.1 Hospital Governance Models in Selected Countries........................73 8.1 Percent of Health Workers in Private Facilities by Type.....................102 10.1 Examples of Policy Implementation Monitoring Guidelines for China's Value-Driven Future...............................................125 10.2 Examples of monitoring indicators by reform goal........................131 10.3 Scoring System for Transformation Learning Collaboratives................132 10.4 TLC Provincial Roll Out by Phase,Time Interval and Jurisdiction............133

CONTENTS vii 2.2 Responsibilities of PACT team members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 2.3 PACE Continual Feedback Loop . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 5.1 Scores by Management Practice, China 2015 (n=110 hospitals) . . . . . . . . . . . . . . .69 6.1 Composition of Total Health Expenditure in China, by facility or provider (percent) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82 7.1 Health Workers Compensation across levels of Care and Providers, China 2013 . .91 8.1 Growth in Hospitals by Ownership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98 8.2 Growth in PHC Facilities by Ownership (2005 to 2012) . . . . . . . . . . . . . . . . . . . .98 8.3 Growth of Hospital Admissions by Ownership, 2005–2012 (in 10,000) . . . . . . . .98 8.4 Growth of Outpatients Visits by Ownership, 2005–2012 (in 10,000) . . . . . . . . . .99 10.1 Proposed Oversight, Coordination and Management for Service delivery Reform Implementation and Scale-Up . . . . . . . . . . . . . . . . . . . . . . . . . . .124 10.2 The Transformation Learning Collaborative (TLC) model in three different arrangements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .129 Tables 1.1 Hypertension diagnosis, treatment and control (age 35–84): international comparison . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 2.1 Core actions areas and implementation strategies to achieve PCIC . . . . . . . . . . . . .24 5.1 Hospital Governance Models in Selected Countries . . . . . . . . . . . . . . . . . . . . . . . .73 8.1 Percent of Health Workers in Private Facilities by Type . . . . . . . . . . . . . . . . . . . . .102 10.1 Examples of Policy Implementation Monitoring Guidelines for China’s Value-Driven Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125 10.2 Examples of monitoring indicators by reform goal . . . . . . . . . . . . . . . . . . . . . . . .131 10.3 Scoring System for Transformation Learning Collaboratives . . . . . . . . . . . . . . . .132 10.4 TLC Provincial Roll Out by Phase, Time Interval and Jurisdiction . . . . . . . . . . . .133

Foreword During the last three decades,there has take a huge toll on health,and non-commu- been a momentous social transformation in nicable diseases account for more than 80 China,with 600 million people pulled out of percent of 10.3 million deaths every year.At poverty.At the same time,China has made the same time,with higher economic growth, impressive strides in health.Since the launch increased personal incomes,and fast changes of a new round of reforms in 2009,China in consumption patterns,people are demand- has invested substantially in expanding ing more and better health care.As a result of health infrastructure,achieved nearly uni- all these factors,expenditures on health care versal health insurance coverage,promoted have been increasing continuously.China is more equal access to public health services, facing greater challenge as the high growth and established a national essential medicine rates of health expenditure in the past years system.These measures have significantly may be difficult to sustain under the eco- improved the accessibility of health services, nomic slow-down. greatly reduced child and maternal mortal- The Chinese government fully recognizes ity,incidence of infectious disease,and con- the need to make strategic shifts in the health siderably improved health outcomes and life sector to adapt to these new challenges. expectancy of the Chinese population.Aver- President Xi Jinping and Premier Li Keqiang age life expectancy of the Chinese people have placed great importance on health care reached 76.34 years in 2015,1.51 years lon- reform.As President Xi Jinping pointed out, ger than in 2010.China's overall health level it would not be possible to build a well-off has reached the average of middle-and high- society without universal health.He also indi- income countries,achieving better health cated that China should shift the focus and outcomes with less input.These achievements resources towards the lower levels of care, have been well recognized internationally. with an aim to provide its citizens with public China has now reached a turning point. health and basic health services that are safe, It is starting to face many of the same chal- effective,accessible,and affordable.Premier lenges and pressures that high-income coun- Li Kegiang has held several State Council tries face.Chinese over the age of 65 now Executive Meetings to set priorities in health number 140 million,and that cohort is care reform and asked for development of a expected to grow to 230 million by 2030. basic health care system covering all urban High-risk behaviors like smoking,sedentary and rural residents.The State Council has set lifestyles and alcohol consumption,as well as up a Leading Group for Deepening Health environmental factors such as air pollution, Care Reform to strengthen multi-sector DEEPENING HEALTH REFORM IN CHINA ix

DEEPENING HEALTH REFORM IN CHINA ix During the last three decades, there has been a momentous social transformation in China, with 600 million people pulled out of poverty. At the same time, China has made impressive strides in health. Since the launch of a new round of reforms in 2009, China has invested substantially in expanding health infrastructure, achieved nearly uni￾versal health insurance coverage, promoted more equal access to public health services, and established a national essential medicine system. These measures have significantly improved the accessibility of health services, greatly reduced child and maternal mortal￾ity, incidence of infectious disease, and con￾siderably improved health outcomes and life expectancy of the Chinese population. Aver￾age life expectancy of the Chinese people reached 76.34 years in 2015, 1.51 years lon￾ger than in 2010. China’s overall health level has reached the average of middle- and high￾income countries, achieving better health outcomes with less input. These achievements have been well recognized internationally. China has now reached a turning point. It is starting to face many of the same chal￾lenges and pressures that high-income coun￾tries face. Chinese over the age of 65 now number 140 million, and that cohort is expected to grow to 230 million by 2030. High-risk behaviors like smoking, sedentary lifestyles and alcohol consumption, as well as environmental factors such as air pollution, take a huge toll on health, and non-commu￾nicable diseases account for more than 80 percent of 10.3 million deaths every year. At the same time, with higher economic growth, increased personal incomes, and fast changes in consumption patterns, people are demand￾ing more and better health care. As a result of all these factors, expenditures on health care have been increasing continuously. China is facing greater challenge as the high growth rates of health expenditure in the past years may be difficult to sustain under the eco￾nomic slow-down. The Chinese government fully recognizes the need to make strategic shifts in the health sector to adapt to these new challenges. President Xi Jinping and Premier Li Keqiang have placed great importance on health care reform. As President Xi Jinping pointed out, it would not be possible to build a well-off society without universal health. He also indi￾cated that China should shift the focus and resources towards the lower levels of care, with an aim to provide its citizens with public health and basic health services that are safe, effective, accessible, and affordable. Premier Li Keqiang has held several State Council Executive Meetings to set priorities in health care reform and asked for development of a basic health care system covering all urban and rural residents. The State Council has set up a Leading Group for Deepening Health Care Reform to strengthen multi-sector Foreword

X DEEPENING HEALTH REFORM IN CHINA coordination,which provides strong institu- This report focuses not only on the top- tional guarantee for the reforms. level design for reform;it also addresses the In July 2014 in Beijing,the Chinese gov- important question of how to make reform ernment,the World Bank Group and the work on the ground.It builds on exten- World Health Organization committed to sive analysis of literature and case studies working together on a joint health reform from high-and middle-income countries, study with an aim to further improve the as well as on ongoing innovations in China policy formulation and to deepen the health that offer lessons and experiences for bring- reform.This report,Deepening Health ing about desired change.The report draws Reform in China,is the outcome of this joint upon cutting-edge thinking about science study.Following the successful model of pre- of delivery that can help scaling up health vious flagship reports such as China 2030 reforms-from prefecture to province,and and Urban China,this report offers a blue- ultimately,nationwide. print for further reforms in China's health Our hope is that this report will provide sector. the research,analysis and insight to help cen- The report's main theme is the need for tral and local authorities plan and execute China to transition its health care delivery major restructuring of the healthcare deliv- system toward people-centered,high quality, ery system in China during the 13th five-year integrated care built on the foundation of a development planning period.Getting this strong primary health care system.This sys- reform right is crucial to China's social and tem offers both better health care for its citi- economic success in the coming decades.We zens as well as better value for its economy. believe that China's experience with health The report offers a comprehensive set of eight service delivery reform carries many lessons interlinked recommendations that can pre- for other countries,and we hope this report pare the Chinese health system for the demo- can also contribute to a global knowledge graphic and health challenges it faces. base on health reform. 接伟 考趴 LOU Jiwei,Minister LI Bin,Minister YIN Weimin,Minister Ministry of Finance National Health and Ministry of Human P.R.C. Family Planning Commission Resources and Social Security P.R.C. P.R.C. M人 im Yong Kim Margaret Chan President Director-General The World Bank Group World Health Organization

x DEEPENING HEALTH REFORM IN CHINA coordination, which provides strong institu￾tional guarantee for the reforms. In July 2014 in Beijing, the Chinese gov￾ernment, the World Bank Group and the World Health Organization committed to working together on a joint health reform study with an aim to further improve the policy formulation and to deepen the health reform. This report, Deepening Health Reform in China, is the outcome of this joint study. Following the successful model of pre￾vious flagship reports such as China 2030 and Urban China, this report offers a blue￾print for further reforms in China’s health sector. The report’s main theme is the need for China to transition its health care delivery system toward people-centered, high quality, integrated care built on the foundation of a strong primary health care system. This sys￾tem offers both better health care for its citi￾zens as well as better value for its economy. The report offers a comprehensive set of eight interlinked recommendations that can pre￾pare the Chinese health system for the demo￾graphic and health challenges it faces. This report focuses not only on the top￾level design for reform; it also addresses the important question of how to make reform work on the ground. It builds on exten￾sive analysis of literature and case studies from high- and middle-income countries, as well as on ongoing innovations in China that offer lessons and experiences for bring￾ing about desired change. The report draws upon cutting-edge thinking about science of delivery that can help scaling up health reforms—from prefecture to province, and ultimately, nationwide. Our hope is that this report will provide the research, analysis and insight to help cen￾tral and local authorities plan and execute major restructuring of the healthcare deliv￾ery system in China during the 13th five-year development planning period. Getting this reform right is crucial to China’s social and economic success in the coming decades. We believe that China’s experience with health service delivery reform carries many lessons for other countries, and we hope this report can also contribute to a global knowledge base on health reform. LOU Jiwei, Minister Ministry of Finance P.R.C. Jim Yong Kim President The World Bank Group Margaret Chan Director-General World Health Organization LI Bin, Minister National Health and Family Planning Commission P.R.C. YIN Weimin, Minister Ministry of Human Resources and Social Security P.R.C

Acknowledgements This study was organized jointly by China's and Pacific Region Axel van Trotsenburg Ministry of Finance(MoF),National Health Timothy Grant Evans,Senior Director for and Family Planning Commission(NHFPC), Health,Nutrition and Population Global Ministry of Human Resources and Social Practice;Olusoji Adeyi,Director for Health, Security (MoHRSS),the World Health Nutrition and Population Global Practice; Organization(WHO),and the World Bank Bert Hofman,Director for China,Korea, Group (WBG).The study was proposed by Mongolia;Mara Warwick,Operations Premier Keqiang Li and the Vice Premier manager for China,Mongolia and Koreaand Yandong Liu,Minister Jiwei Lou of MoF, Toomas Palu,Global Practice Manager for Minister Bin Li of NHFPC,Minister Weimin Health,Nutrition and Population Global Yin of MoHRSS,President of WBG Jim Yong Practice in East Asia and Pacific Region Kim and Director General Margaret Chan (WBG). provided valuable leadership and guidance at Valuable advice was provided by the the impetus as well as the critical junctions members of the External Advisory Panel of the study.In particular,Vice Premier Liu comprising:Michael Porter,Bishop William hosted two special hearings on the progress Lawrence University Professor at the Institute and main findings for the study in March of for Strategy and Competitiveness,based at the 2015and2016. Harvard Business School;Donald Berwick, Under the overall leadership of Minister President Emeritus and Senior Fellow, Jiwei Lou(MOF)and the Managing Director Institute for Healthcare Improvement,former and Chief Operating Officer Sri Mulyani President and Chief Executive Officer of the Indrawati of the World Bank Group,the Institute for Healthcare Improvement and report was overseen by the joint team in Administrator of the Centers for Medicare five participating organizations led by Vice and Medicaid Services;Winnie Yip,Professor Ministers Yaobin Shi,Weiping Yu (MOF); of Health Policy and Economics at the Vice Ministers Zhigang Sun,Xiaowei Blavatnik School of Government,University Ma (NHFPC);Vice Ministers Jun You, of Oxford;Ellen Nolte,Coordinator of the Xiaoyi Hu(MoHRSS);Regional Director European Observatory at the London School Shin Young-soo,Bernhard Schwartlander, of Economics and Political Science and WHO Representative in China;and,Vivian the London School of Hygiene Tropical Lin,Director of Division of Health Sector Medicine;Yanfeng Ge,Director-General, Development,Western Pacific Regional Office Department of Social Development Research, (WHO);Regional Vice-President of East Asia Development Research Center of the State DEEPENING HEALTH REFORM IN CHINA xi

DEEPENING HEALTH REFORM IN CHINA xi Acknowledgements This study was organized jointly by China’s Ministry of Finance (MoF), National Health and Family Planning Commission (NHFPC), Ministry of Human Resources and Social Security (MoHRSS), the World Health Organization (WHO), and the World Bank Group (WBG). The study was proposed by Premier Keqiang Li and the Vice Premier Yandong Liu, Minister Jiwei Lou of MoF, Minister Bin Li of NHFPC, Minister Weimin Yin of MoHRSS, President of WBG Jim Yong Kim and Director General Margaret Chan provided valuable leadership and guidance at the impetus as well as the critical junctions of the study. In particular, Vice Premier Liu hosted two special hearings on the progress and main findings for the study in March of 2015 and 2016. Under the overall leadership of Minister Jiwei Lou (MOF) and the Managing Director and Chief Operating Officer Sri Mulyani Indrawati of the World Bank Group, the report was overseen by the joint team in five participating organizations led by Vice Ministers Yaobin Shi, Weiping Yu (MOF); Vice Ministers Zhigang Sun, Xiaowei Ma (NHFPC); Vice Ministers Jun You, Xiaoyi Hu(MoHRSS); Regional Director Shin Young-soo, Bernhard Schwartländer, WHO Representative in China; and, Vivian Lin, Director of Division of Health Sector Development, Western Pacific Regional Office (WHO); Regional Vice-President of East Asia and Pacific Region Axel van Trotsenburg ; Timothy Grant Evans, Senior Director for Health, Nutrition and Population Global Practice; Olusoji Adeyi, Director for Health, Nutrition and Population Global Practice; Bert Hofman, Director for China, Korea, Mongolia; Mara Warwick, Operations manager for China, Mongolia and Koreaand Toomas Palu, Global Practice Manager for Health, Nutrition and Population Global Practice in East Asia and Pacific Region (WBG). Valuable advice was provided by the members of the External Advisory Panel comprising: Michael Porter, Bishop William Lawrence University Professor at the Institute for Strategy and Competitiveness, based at the Harvard Business School; Donald Berwick, President Emeritus and Senior Fellow, Institute for Healthcare Improvement, former President and Chief Executive Officer of the Institute for Healthcare Improvement and Administrator of the Centers for Medicare and Medicaid Services; Winnie Yip, Professor of Health Policy and Economics at the Blavatnik School of Government, University of Oxford; Ellen Nolte, Coordinator of the European Observatory at the London School of Economics and Political Science and the London School of Hygiene & Tropical Medicine; Yanfeng Ge, Director-General, Department of Social Development Research, Development Research Center of the State