Healthy policy
It is an honor to introduce the first issue of the online journal Health Policy & Politics,
published by the Institute of Health Policy and Politics, a key research unit within the
College of Health at Lehigh University, directed by Professor Eduardo J. Gómez. Like the
journal, the College of Health at Lehigh University is relatively new, having opened in
2020 in the early months of the COVID-19 pandemic. No event in my lifetime has better
demonstrated the profound influence of politics on health policy, and thus on health
outcomes of people across the globe. It is fitting, then, that both the Institute and the journal
of Health Policy & Politics examine the effects of politics and policy on human health.
The mission of the College of Health is to improve outcomes for populations, communities,
and individuals through research, teaching, and service. Much of our faculty research
focuses on upstream causes of health and disease–the multiple determinants of health–
including the political determinants of health. And, experiential learning, including
research with faculty is a core feature of our teaching. In keeping with this last point, each
essay in the inaugural issue of Health Policy & Politics represents a collaboration between
a faculty researcher and student author, or, in one case, a former student who is now himself
a professor. Impressively, the journal itself is edited by a team of student editors.
The essays address the impact of policy and politics on health outcomes worldwide over
the last thirty years. Michael Gusmano and Cheryl Qin analyze the effect of 2009 healthcare
reform in China on access, the workforce, quality of services, and more. Xiaohui Guo,
Chad Meyerhoefer, and Lizhong Peng examine elementary and middle school students’
health and academic outcomes related to enrollment in Pennsylvania’s Children’s Health
Insurance Program (CHIP). Sameen Basha highlights the failure of governments around
the world to make lasting changes that will enable healthcare workers to provide effective
care. And, Eduardo J. Gomez and Lanie Fenster point to a particular failure; they diagnose
a public health side effect of COVID-19 pandemic policy as an increase in obesity rates–
and offer concrete policy actions to mitigate this failure.
I hope you will join me in celebrating and learning from the inaugural edition of Health
Policy & Politics.
,HPP Vol 1. Issue 1
Professor Elizabeth Dolan
Dean, College of Health
Lehigh University
Table of Contents
Cheryl Qin and Michael Gusmano, “China’s Healthcare Systems - A Status Update from
the 2009 Major Health Care Reform.”
Sameen Basha, “Healthcare and Political Obstacles in the Way of Quality Healthcare.”
Xiaohui Guo, Chad Meyerhoefer, and Lizhong Peng, “The Effects of Continued
Enrollment in the Children’s Health Insurance Program on Health and Educational
Outcomes.”
Eduardo J. Gómez and Lanie Fenster, “The Commercial Determinants of Health in the
Context of COVID 19.”
China’s Healthcare Systems- A Status Update from the 2009 Major Health Care
Reform
1
,HPP Vol 1. Issue 1
Cheryl Qin and Michael Gusmano
College of Health
Lehigh University
Abstract
China’s healthcare has undergone several transformations. For the past 15 years, China has
tried to expand insurance and improve access to appropriate pharmaceuticals. These
efforts; however, have been undermined by inadequate funding and decentralization of
responsibility to the provinces, leading to uneven implementation of reform throughout the
country. In this article, we present a brief history of the Chinese health system and then
present findings from a systematic literature review focused on the implementation of the
2009 reform. Within this review, we explore the impact of reform on access and use of
health care services, changes to the health care workforce, the quality of health care, the
expansion of insurance coverage, drug regulations, health care financing, efforts to improve
the efficiency of the system, and public opinions on the reform effort. We conclude that,
while reforms have noticeably improved China’s health system, several problems persist.
In 2009, after years of debate, China adopted a major reform of its health system. The goals
of reform included expanding health insurance, reducing health care disparities, increasing
the use of primary care, improving the use of pharmaceuticals, and strengthening the public
health workforce (Wang et al. 2011). The government’s aim was to reduce inequities in the
use of health care and strengthen access to essential services by 2020. In this paper we
assess the implementation of health reform in China based on findings from a systematic
review of the English language literature. We find that China has succeeded in expanding
insurance and reducing regional variation in the use of health care. Efforts to strengthen
the primary care system, increase the size of the workforce, and regulate pharmaceuticals,
however, have been less successful. To achieve the health reform goals articulated more
than a decade ago, China must make additional investments in primary care and its public
health infrastructure.
In the next section of the paper, we provide a brief overview of the Chinese health
system and its evolution since 1949. Next, we describe how we conducted our literature
review and summarize its findings. We conclude with some reflections on the status of
health reform in China.
Background
Following the establishment of the People’s Republic of China under Mao Zedong, the
state provided public medical care and labor insurance and relied on two types of hospitals
(Li and Li, 2019). Government-owned hospitals were open to the general public, receiving
full compensation from the government, and state enterprise-owned hospitals were only
open to enterprise employees- those who work on behalf of government-owned assets and
2
, HPP Vol 1. Issue 1
their families (Wang et al., 2011). This system created inequities because most people
working for government agencies lived in urban areas. While these populations were able
to enjoy free healthcare, those in rural regions oftentimes lacked access to medical
treatment, including government-owned hospitals. To improve the situation, Mao
attempted to increase overall access to care in rural surroundings in 1965 with the rise of
the Rural Cooperative Medical System and training of barefoot doctors, or village doctors
(Li and Li, 2019). The Cooperative Medical Scheme also established a health care system
with three tiers: the first level consisted of these barefoot doctors who had basic medical
training, the second tier consisted mostly of clinics usually funded by local residents for
emergency related cases, and the third tier consisted of large city hospitals reserved for
serious medical situations (Daemmrich, 2013).
Market Reforms
In 1979, Deng Xiaoping ushered in the next phase health reform by introducing
marketoriented policies. This took place in a larger context in which the role of markets
was expanded in several sectors, not just health care (Li and Li, 2019). This led to a
reduction of subsidies for state owned first level hospitals, which resulted many hospital
closures and a reduction in access to care (Wang et al., 2011). Similarly, enterprise owned
first-level hospitals withdrew from providing primary healthcare services because of
insufficient revenue. From 1997-2001, higher level hospitals increased in number as first-
level hospitals decreased (Wang et al., 2011). To increase revenue, the remaining first-level
hospitals shifted away from primary care and emphasized drug prescriptions. These
facilities came to be known as symbols of low-quality service where doctors were seen as
being overall less competent and reliable than those employed in larger hospitals (Wang et
al. 2011).
The WHO, SARS, and Calls for Reform
The SARS outbreak in 2002 had a profound influence on Chinese health policy (Huang
2004). The disaster alarmed the Chinese government to the pressing need for better public
health infrastructure and basic healthcare at the community level. SARS also reinforced
China’s reaction to a WHO report in 2000, which ranked the country’s healthcare system
188th out of 191 evaluated countries (Wang et al., 2011). The report brought attention to
the weaknesses of the system and embarrassed the government. SARS reaffirmed the
system’s problems, including the inadequacy of its epidemiological surveillance, a weak
outpatient care system, limited funding for primary care, and large out-of-pocket expenses
that discouraged people from seeking needed care.
2009 Health Reform
In response to these issues, the country officially launched a plan focused on ensuring more
equitable access to services in 2009. The government set out to increase public health
spending and expand social insurance coverage for almost 95% of the population (Ma et
al., 2015). Later, the government adopted additional measures designed to enhance
efficiency and quality of care, including new drug regulations. To assess the impact of these
reforms to date, this paper presents findings from a systematic literature review, which
synthesizes findings about the implementation of Chinese health reform since 2009.
3
It is an honor to introduce the first issue of the online journal Health Policy & Politics,
published by the Institute of Health Policy and Politics, a key research unit within the
College of Health at Lehigh University, directed by Professor Eduardo J. Gómez. Like the
journal, the College of Health at Lehigh University is relatively new, having opened in
2020 in the early months of the COVID-19 pandemic. No event in my lifetime has better
demonstrated the profound influence of politics on health policy, and thus on health
outcomes of people across the globe. It is fitting, then, that both the Institute and the journal
of Health Policy & Politics examine the effects of politics and policy on human health.
The mission of the College of Health is to improve outcomes for populations, communities,
and individuals through research, teaching, and service. Much of our faculty research
focuses on upstream causes of health and disease–the multiple determinants of health–
including the political determinants of health. And, experiential learning, including
research with faculty is a core feature of our teaching. In keeping with this last point, each
essay in the inaugural issue of Health Policy & Politics represents a collaboration between
a faculty researcher and student author, or, in one case, a former student who is now himself
a professor. Impressively, the journal itself is edited by a team of student editors.
The essays address the impact of policy and politics on health outcomes worldwide over
the last thirty years. Michael Gusmano and Cheryl Qin analyze the effect of 2009 healthcare
reform in China on access, the workforce, quality of services, and more. Xiaohui Guo,
Chad Meyerhoefer, and Lizhong Peng examine elementary and middle school students’
health and academic outcomes related to enrollment in Pennsylvania’s Children’s Health
Insurance Program (CHIP). Sameen Basha highlights the failure of governments around
the world to make lasting changes that will enable healthcare workers to provide effective
care. And, Eduardo J. Gomez and Lanie Fenster point to a particular failure; they diagnose
a public health side effect of COVID-19 pandemic policy as an increase in obesity rates–
and offer concrete policy actions to mitigate this failure.
I hope you will join me in celebrating and learning from the inaugural edition of Health
Policy & Politics.
,HPP Vol 1. Issue 1
Professor Elizabeth Dolan
Dean, College of Health
Lehigh University
Table of Contents
Cheryl Qin and Michael Gusmano, “China’s Healthcare Systems - A Status Update from
the 2009 Major Health Care Reform.”
Sameen Basha, “Healthcare and Political Obstacles in the Way of Quality Healthcare.”
Xiaohui Guo, Chad Meyerhoefer, and Lizhong Peng, “The Effects of Continued
Enrollment in the Children’s Health Insurance Program on Health and Educational
Outcomes.”
Eduardo J. Gómez and Lanie Fenster, “The Commercial Determinants of Health in the
Context of COVID 19.”
China’s Healthcare Systems- A Status Update from the 2009 Major Health Care
Reform
1
,HPP Vol 1. Issue 1
Cheryl Qin and Michael Gusmano
College of Health
Lehigh University
Abstract
China’s healthcare has undergone several transformations. For the past 15 years, China has
tried to expand insurance and improve access to appropriate pharmaceuticals. These
efforts; however, have been undermined by inadequate funding and decentralization of
responsibility to the provinces, leading to uneven implementation of reform throughout the
country. In this article, we present a brief history of the Chinese health system and then
present findings from a systematic literature review focused on the implementation of the
2009 reform. Within this review, we explore the impact of reform on access and use of
health care services, changes to the health care workforce, the quality of health care, the
expansion of insurance coverage, drug regulations, health care financing, efforts to improve
the efficiency of the system, and public opinions on the reform effort. We conclude that,
while reforms have noticeably improved China’s health system, several problems persist.
In 2009, after years of debate, China adopted a major reform of its health system. The goals
of reform included expanding health insurance, reducing health care disparities, increasing
the use of primary care, improving the use of pharmaceuticals, and strengthening the public
health workforce (Wang et al. 2011). The government’s aim was to reduce inequities in the
use of health care and strengthen access to essential services by 2020. In this paper we
assess the implementation of health reform in China based on findings from a systematic
review of the English language literature. We find that China has succeeded in expanding
insurance and reducing regional variation in the use of health care. Efforts to strengthen
the primary care system, increase the size of the workforce, and regulate pharmaceuticals,
however, have been less successful. To achieve the health reform goals articulated more
than a decade ago, China must make additional investments in primary care and its public
health infrastructure.
In the next section of the paper, we provide a brief overview of the Chinese health
system and its evolution since 1949. Next, we describe how we conducted our literature
review and summarize its findings. We conclude with some reflections on the status of
health reform in China.
Background
Following the establishment of the People’s Republic of China under Mao Zedong, the
state provided public medical care and labor insurance and relied on two types of hospitals
(Li and Li, 2019). Government-owned hospitals were open to the general public, receiving
full compensation from the government, and state enterprise-owned hospitals were only
open to enterprise employees- those who work on behalf of government-owned assets and
2
, HPP Vol 1. Issue 1
their families (Wang et al., 2011). This system created inequities because most people
working for government agencies lived in urban areas. While these populations were able
to enjoy free healthcare, those in rural regions oftentimes lacked access to medical
treatment, including government-owned hospitals. To improve the situation, Mao
attempted to increase overall access to care in rural surroundings in 1965 with the rise of
the Rural Cooperative Medical System and training of barefoot doctors, or village doctors
(Li and Li, 2019). The Cooperative Medical Scheme also established a health care system
with three tiers: the first level consisted of these barefoot doctors who had basic medical
training, the second tier consisted mostly of clinics usually funded by local residents for
emergency related cases, and the third tier consisted of large city hospitals reserved for
serious medical situations (Daemmrich, 2013).
Market Reforms
In 1979, Deng Xiaoping ushered in the next phase health reform by introducing
marketoriented policies. This took place in a larger context in which the role of markets
was expanded in several sectors, not just health care (Li and Li, 2019). This led to a
reduction of subsidies for state owned first level hospitals, which resulted many hospital
closures and a reduction in access to care (Wang et al., 2011). Similarly, enterprise owned
first-level hospitals withdrew from providing primary healthcare services because of
insufficient revenue. From 1997-2001, higher level hospitals increased in number as first-
level hospitals decreased (Wang et al., 2011). To increase revenue, the remaining first-level
hospitals shifted away from primary care and emphasized drug prescriptions. These
facilities came to be known as symbols of low-quality service where doctors were seen as
being overall less competent and reliable than those employed in larger hospitals (Wang et
al. 2011).
The WHO, SARS, and Calls for Reform
The SARS outbreak in 2002 had a profound influence on Chinese health policy (Huang
2004). The disaster alarmed the Chinese government to the pressing need for better public
health infrastructure and basic healthcare at the community level. SARS also reinforced
China’s reaction to a WHO report in 2000, which ranked the country’s healthcare system
188th out of 191 evaluated countries (Wang et al., 2011). The report brought attention to
the weaknesses of the system and embarrassed the government. SARS reaffirmed the
system’s problems, including the inadequacy of its epidemiological surveillance, a weak
outpatient care system, limited funding for primary care, and large out-of-pocket expenses
that discouraged people from seeking needed care.
2009 Health Reform
In response to these issues, the country officially launched a plan focused on ensuring more
equitable access to services in 2009. The government set out to increase public health
spending and expand social insurance coverage for almost 95% of the population (Ma et
al., 2015). Later, the government adopted additional measures designed to enhance
efficiency and quality of care, including new drug regulations. To assess the impact of these
reforms to date, this paper presents findings from a systematic literature review, which
synthesizes findings about the implementation of Chinese health reform since 2009.
3
