Academic journal article China Perspectives

Healthcare for Migrants in Urban China: A New Frontier

Academic journal article China Perspectives

Healthcare for Migrants in Urban China: A New Frontier

Article excerpt

The growth in Gross Domestic Product (GDP) has been accompanied by an expansion in healthcare expenditure. From under 3 percent of GDP in 1980, this grew to 5.3 percent in 2000,<2) increasing even more rapidly in urban than in rural areas. As the percentage of migrants in cities increases, their access to education and healthcare has become an increasingly central issue in China. Who has healthcare coverage? This paper proposes some answers by focusing on rural-urban migrant workers with formal jobs and in regular situations.

On top of their existing 103 million urban migrants, Chinese cities continue to experience a steady migration inflow. In terms of health, one consequence is a falling proportion of the rural population living in extreme poverty, and improvements in the level of nutrition. Life expectancy at birth in 2010 was 74.51 years,<3) which is eight years hi^ier than the world average. As the disastrous famine in the late 1950s resulted in high mortality, the current life expectancy figure represents an enormous improvement within China. Other health indicators such as the infant mortality rate, the underfive mortality rate, and the maternal mortality rate have also registered improvements.<4>

However, this expansion of healthcare is for the most part unequally distributed. Economic reforms have had positive effects on GDP and the level of nutrition, but have led to the collapse of the public healthcare network and universal access to basic healthcare. The result is an increase in healthcare inequality. The World Health Organization (WHO) periodically ranb countries according to the inequality of their healthcare systems, in particular their healthcare insurance system. According to the last WHO country classification, the Chinese health sector ranked close to the bottom in terms of the fairness of financial contributions.

To help understand this deterioration, we here present a brief description of the healthcare-insurance system before the economic reforms and its subsequent evolution. In China, before the economic reforms, the healthcare-insurance system was not homogeneous. In urban areas, it depended on large state-owned enterprises (SOE) that took care of workers' medical needs; healthcare in rural areas was determined locally. However, out-of-pocket expenses were close to zero, whatever the healthcare setup.

In urban areas, the dismantling of the large state-owned enterprises (SOE) led to healthcare supplied by smaller-size units. These units quickly ran into difficulties financing their own social insurance. There are two main reasons for this: first, they were smaller than before, so the insurance pool was based on a smaller number of individuals; second, they were responsible for making a profit (with no intervention from the state), but part of that profit was used for social in- surance. Facing the risk of collapse in the economic framework, the government was forced to react. It introduced a kind of social insurance with far lower coverage than before. In rural areas, farmers were themselves made responsible for social insurance through a pooling system at the village level. The rapid privatisation of farming was therefore disconnected from the financial burden of social insurance for rural inhabitants. Farms were not obliged to use part of their profits for social insurance, and there was therefore no risk of collapse for the agricultural sector. As such, the government did not have to step in to provide an insurance system for the rural population as it did for the urban population. The result was a degradation and sometimes complete disappearance of the healthcare-insurance system in rural areas.

There is by now a large body of literature addressing the question of health inequality around the world.(5) Various methods of analysis have been developed, some making use of advances in the literature on income distribution and taxation. Works have focused on individual countries as well as on comparing many different countries. …

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