Reconciling city and country: China's lessons for a divided world

Abstract

On Jan 12, China took an important step towards health equity. The State Council announced that two of China's three segmented health insurance schemes would merge by the end of the year. This welcome decision addresses a major cause of inequality in China: the rural–urban divide that separates the socioeconomically privileged east and southeast of the country from the less developed west and far north. Harmonising rural and urban insurance schemes is essential to achieve the country's goal of truly universal health coverage by 2020. In the 1980s, China was a mainly rural country. Subsequent economic success was driven by the migration of young, healthy workers to urban centres. In 2011, more than half of the 1·3 billion people in China lived in cities, a proportion that is expected to reach 75% by 2050. One consequence is that rural areas endure diminished financial and medical resources to care for a disproportionate number of elderly people and a greater burden of diseases than are found in cities. Conversely, the absence of sufficient urban planning and administration has meant that cities have become crowded and polluted. The demographic and urban dividends that China should be reaping are turning into all-too-vivid nightmares. Although urban centres attract medical excellence, the estimated 245 million migrant workers from rural China have been ineligible for many health services. Why? Because insurance schemes relate to a person's registered place of residence, and, as a result of living in an insurance no-person's land, migrants are vulnerable to the panoply of preventable illnesses, especially infectious diseases. The improvement in overall health in China is a matter of deserved pride. Under-5 mortality has plummeted by 70%, from 46 to 14 per 1000 births between 1996 and 2012; but that average disguises an almost three-fold urban–rural divide and counties that failed to meet the MDG-4 target. Likewise, although discrepancies in male life expectancy, which in 1990 was a gap of 19 years between the best (Shanghai, 74 years) and least well-performing areas (Tibet, 55 years), had improved by 2013, it was still substantial (80 years in Shanghai vs 68 in Tibet). Notwithstanding differences, the general gains in health and the convergence of life expectancy are a testament to the strong emphasis on public health and to deepening universal health coverage, accelerated by recent health-care reforms. The three existing insurance programmes in China are based either on rural or urban residency, or on urban payroll taxes. Each scheme is administered separately and pools funds differently, so the benefits vary but are less generous in rural areas where financial protection is also weaker. The announced changes will consolidate the new rural cooperative medical scheme and urban resident-based basic medical insurance, so that benefits will be standardised and migrants from rural areas become eligible for insurance in cities. However, urban employee-based basic medical insurance—the best funded scheme—remains separate. The result of integrated insurance plans will improve access to care for residents throughout China. However, additional changes are needed to make more substantial improvements to urban and rural health. While environmental concerns abound across China, her cities are infamous for poor quality air and water, roads clogged by traffic, and few open spaces. At present, only 258 of China's 653 urban centres have achieved the government's status as a hygienic city. Effort is needed to bring the remaining 395 cities to this standard, if not beyond it. Similarly, improved access to care alone will not close the gaps in health outcomes between poorer rural provinces and wealthier cities. Rural residents also need health services of good quality. To provide such services means a rethink of how primary care is organised and delivered, just as healthier cities require a greater appreciation of the environmental influence on health and a fundamental change in the design and use of urban spaces. These are not challenges unique to China, but 21st century phenomena present throughout the world, especially in developing countries with rapid urbanisation and those with a commitment to grow universal health coverage. Therefore, The Lancet this week announces two Commissions, our first in China, to inform policy and future research for healthy cities and for primary care. These will be Chinese-led international collaborations, ably coordinated by Peng Gong of Tsinghua University and Lixin Jiang of the National Center for Cardiovascular Diseases, respectively. The right to health should extend equally to all, irrespective of where they live. China's experiences today have direct lessons for low-income and middle-income countries facing similar predicaments tomorrow. For more on health insurance schemes in China see Lancet 2015; 386: 1484–92 For more on health insurance schemes in China see Lancet 2015; 386: 1484–92