Applied Health Economics and Health Policy

, Volume 15, Issue 6, pp 707–716 | Cite as

Towards Universal Health Coverage via Social Health Insurance in China: Systemic Fragmentation, Reform Imperatives, and Policy Alternatives

  • Alex Jingwei HeEmail author
  • Shaolong Wu
Current Opinion


China’s remarkable progress in building a comprehensive social health insurance (SHI) system was swift and impressive. Yet the country’s decentralized and incremental approach towards universal coverage has created a fragmented SHI system under which a series of structural deficiencies have emerged with negative impacts. First, contingent on local conditions and financing capacity, benefit packages vary considerably across schemes, leading to systematic inequity. Second, the existence of multiple schemes, complicated by massive migration, has resulted in weak portability of SHI, creating further barriers to access. Third, many individuals are enrolled on multiple schemes, which causes inefficient use of government subsidies. Moral hazard and adverse selection are not effectively managed. The Chinese government announced its blueprint for integrating the urban and rural resident schemes in early 2016, paving the way for the ultimate consolidation of all SHI schemes and equal benefits for all. This article proposes three policy alternatives to inform the consolidation: (1) a single-pool system at the prefectural level with significant government subsidies, (2) a dual-pool system at the prefectural level with risk-equalization mechanisms, and (3) a household approach without merging existing pools. Vertical integration to the provincial level is unlikely to happen in the near future. Two caveats are raised to inform this transition towards universal health coverage.


Compliance with Ethical Standards

This study is funded by the Early Career Scheme of the Research Grants Council, Hong Kong SAR Government (Ref. ECS859218), the Dean’s Research Fund of the Faculty of Liberal Arts and Social Sciences (Ref. ECR2), the Education University of Hong Kong, and the Early Career Faculty Research Training Program of Sun Yat-sen University (Ref. 13YKPY12). The authors are very grateful to Azad Singh Bali and anonymous reviewers for useful comments.

Conflict of interest

AJH and SW have no conflict of interest to declare.


  1. 1.
    Liang L, Langenbrunner JC. The long march to universal coverage: Lessons from China. Universal Health Coverage (UNICO) studies series, 9. Washington DC: World Bank; 2013.Google Scholar
  2. 2.
    Yip WC, Hsiao WC, Chen W, Hu S, Ma J, Maynard A. Early appraisal of China’s huge and complex health-care reforms. Lancet. 2012;379(9818):833–42.CrossRefPubMedGoogle Scholar
  3. 3.
    He JA, Meng Q. An interim interdisciplinary evaluation of China’s national health care reform: emerging evidence and new perspectives. J Asian Public Policy. 2015;8(1):1–18.CrossRefGoogle Scholar
  4. 4.
    Barber SL, Yao L. Development and status of health insurance systems in China. Int J Health Plan Manag. 2011;26:339–56.CrossRefGoogle Scholar
  5. 5.
    Meng Q, Fang H, Liu X, Yuan B, Xu J. Consolidating the social health insurance schemes in China: towards an equitable and efficient health system. Lancet. 2015;386(10002):1484–92.CrossRefPubMedGoogle Scholar
  6. 6.
    Liu Y. Reforming China’s urban health insurance system. Health Policy. 2002;60:133–50.CrossRefPubMedGoogle Scholar
  7. 7.
    Yip WC, Hsiao WC. The Chinese health system at a crossroads. Health Aff. 2008;27(2):460–8.CrossRefGoogle Scholar
  8. 8.
    Wen CP, Hays CW. Health care financing in China. Med Care. 1976;14(3):241–54.CrossRefPubMedGoogle Scholar
  9. 9.
    Hsiao WC. The Chinese health care system: lessons for other nations. Soc Sci Med. 1995;8:1047–55.CrossRefGoogle Scholar
  10. 10.
    Meng Q, Tang S. Universal health care coverage in China: challenges and opportunities. Proc Soc Behav Sci. 2013;77:330–40.CrossRefGoogle Scholar
  11. 11.
    Eggleston K, Li L, Meng Q, Lindelow M, Wagstaff A. Health service delivery in China: a literature review. Health Econ. 2008;17:149–65.CrossRefPubMedGoogle Scholar
  12. 12.
    Ma J, Lu M, Quan H. From a national, centrally planned health system to a system based on the market: lessons from China. Health Aff. 2008;27(4):937–48.CrossRefGoogle Scholar
  13. 13.
    Li H, et al. Overprescribing in China, driven by financial incentives, results in very high use of antibiotics, injections and corticosteroids. Health Aff. 2012;31(5):1075–82.CrossRefGoogle Scholar
  14. 14.
    World Health Organization. The World Health Report 2000—health systems: improving performance. Geneva: WHO; 2000.Google Scholar
  15. 15.
    Chinese Communist Party Central Committee and State Council. Opinions of the CPC Central Committee and the State Council on deepening the health care system reform [in Chinese]. Beijing; 2009.Google Scholar
  16. 16.
    Yang W. Catastrophic outpatient health payments and health payment-induced poverty under China’s New Cooperative Medical Scheme. Appl Econ Perspect Policy. 2015;37(1):64–85.CrossRefGoogle Scholar
  17. 17.
    Meng Q, Xu Y, Zhang Y, Qian J, Cai M, Xin Y, Gao J, Xu K, Boerma JT, Barber SL. Trends in access to health services and financial protection in China between 2003 and 2011: a cross-sectional study. Lancet. 2012;379(9818):805–14.CrossRefPubMedGoogle Scholar
  18. 18.
    Liu W, Liu G, Chen G. The Urban Resident Basic Medical Insurance: a landmark reform towards universal coverage in China. Health Econ. 2009;18(suppl 2):S83–96.PubMedGoogle Scholar
  19. 19.
    Wagstaff A, Lindelow M, Gao J, Xu L, Qian J. Extending health insurance to the rural population: an impact evaluation of China’s New Cooperative Medical Scheme. J Health Econ. 2009;28:1–19.CrossRefPubMedGoogle Scholar
  20. 20.
    Li X, Zhang W. The impact of health insurance on health care utilization among the older people in China. Soc Sci Med. 2013;85:59–65.CrossRefPubMedGoogle Scholar
  21. 21.
    Sun X, Sleigh AC, Carmichael GA, Jackson S. Health payment-induced poverty under China’s New Cooperative Medical Scheme in rural Shandong. Heath Policy Plan. 2010;25(5):419–26.CrossRefGoogle Scholar
  22. 22.
    Yang W, Wu X. Paying for outpatient care in rural China: cost escalation under China’s New Cooperative Medical Scheme. Health Policy Plan. 2015;30(2):187–96.CrossRefPubMedGoogle Scholar
  23. 23.
    Zhang Y. Seven provinces have consolidated SHI schemes but obstacles remain. Labor Soc Secur [in Chinese]. 2014;21:6–7.Google Scholar
  24. 24.
    Cheng JYS. Institutions, perceptions and social policy-making of Chinese local governments: a case study of medical insurance policy reforms in Dongguan. J Asian Public Policy. 2014;7(1):58–70.CrossRefGoogle Scholar
  25. 25.
    Bärnighausen T, Liu Y, Zhang X, Sauerborn R. Willingness to pay for social health insurance among informal sector workers in Wuhan, China: a contingent valuation study. BMC Health Serv Res. 2007. doi: 10.1186/1472-6963-7-114.PubMedPubMedCentralGoogle Scholar
  26. 26.
    Meng Q, Xu K. Progress and challenges of the rural cooperative medical scheme in China. Bull World Health Organ. 2014;92:447–51.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Qiu P, Yang Y, Zhang J, Ma X. Rural-to-urban migration and its implication for new Cooperative Medical Scheme coverage and utilization in China. BMC Public Health. 2011. doi: 10.1186/1471-2458-11-520.Google Scholar
  28. 28.
    Mou J, Cheng J, Zhang D, Jiang H, Lin L, Griffiths SM. Health care utilization amongst Shenzhen migrant workers: does being insured make a difference? BMC Health Serv Res. 2009. doi: 10.1186/1472-6963-9-214.PubMedPubMedCentralGoogle Scholar
  29. 29.
    Peng Y, Chang W, Zhou H, Hu H, Liang W. Factors associated with health-seeking behaviors among migrant workers in Beijing, China. BMC Health Serv Res. 2010. doi: 10.1186/1472-6963-10-69.PubMedPubMedCentralGoogle Scholar
  30. 30.
    Wu S, Wang P, Lin L. Factors associated with small- and median-size enterprises in enrolling migrant workers in the urban employee basic health insurance. Stud Hong Kong Macau [in Chinese]. 2012;37(4):54–66.Google Scholar
  31. 31.
    Zhang G, Wu S. Social insurance for migrant workers in the Pearl Delta Region: the informal employment perspective. China Popul Sci. 2012;4:88–94.Google Scholar
  32. 32.
    He JA, Huang G. Fighting for migrant labor rights in the World’s factory: legitimacy, resource constraints and strategies of grassroots migrant labor NGOs in South China. J Contemp China. 2015;24(93):471–92.CrossRefGoogle Scholar
  33. 33.
    Duckett J. Political interests and the implementation of China’s urban health insurance reform. Soc Policy Adm. 2001;35(3):290–306.CrossRefGoogle Scholar
  34. 34.
    National Audit Office. Audit Report of Social Insurance Funds [in Chinese]. Beijing; 2012.Google Scholar
  35. 35.
    Zhang G, Wu S. Multiple enrolment of basic health insurance: fragmentation, rational choice and bureaucratic administration. J Gansu Inst Public Adm. 2015;3:81–8.Google Scholar
  36. 36.
    Liu J. Unraveling the myth of multiple enrolment. China Soc Secur [in Chinese]. 2012;10:79–80.Google Scholar
  37. 37.
    Wang S. The problem of multiple enrolment in the Pei County. China Health Insur [in Chinese]. 2015;1:46–8.Google Scholar
  38. 38.
    Yu H. Universal health insurance coverage for 1.3 billion people: what accounts for China’s success? Health Policy. 2015;119:1145–52.CrossRefPubMedGoogle Scholar
  39. 39.
    Lu JFR, Hsiao WC. Does universal health insurance make health care affordable? Lessons from Taiwan. Health Aff. 2003;22(3):77–88.CrossRefGoogle Scholar
  40. 40.
    Carrin G, James C. Social health insurance: key factors affecting the transiting towards universal coverage. Int Soc Secur Rev. 2005;58(1):45–64.CrossRefGoogle Scholar
  41. 41.
    Carrin G, James C. Reaching universal coverage via social health insurance: key design features in the transition period. Department of Health System Financing, Expenditure and Resource Allocation discussion paper No. 2. Geneva: World Health Organization; 2004.Google Scholar
  42. 42.
    Söderlund N, Khosa S. The potential role of risk-equalization mechanisms in health insurance: the case of South Africa. Health Policy Plan. 1997;12(4):341–53.CrossRefPubMedGoogle Scholar
  43. 43.
    Kwon S. Thirty years of national health insurance in South Korea: lessons for achieving universal health care coverage. Health Policy Plan. 2009;24:63–71.CrossRefPubMedGoogle Scholar
  44. 44.
    Ramesh M, Wu X, He JA. Health governance and healthcare governance in China. Health Policy Plan. 2014;29(6):663–72.CrossRefPubMedGoogle Scholar
  45. 45.
    Hsiao WC. The political economy of Chinese health reform. Health Econ Policy Law. 2007;2(3):241–9.CrossRefPubMedGoogle Scholar
  46. 46.
    Wagstaff A, Lindelow M. Can insurance increase financial risk? The curious case of health insurance in China. J Health Econ. 2008;27(4):990–1005.CrossRefPubMedGoogle Scholar
  47. 47.
    Yip WC, Hsiao WC. China’s health care reform: a tentative assessment. China Econ Rev. 2009;20:613–9.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Department of Asian and Policy Studiesthe Education University of Hong KongTai PoHong Kong
  2. 2.School of Public HealthGuangzhouChina

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