China’s Capacity to Manage Infectious Diseases CENTER FOR STRATEGIC & Global Implications CSIS INTERNATIONAL STUDIES A Report of the CSIS Freeman Chair in China Studies 1800 K Street | Washington, DC 20006 PROJECT DIRECTOR Tel: (202) 887-0200 | Fax: (202) 775-3199 Charles W. Freeman III E-mail: [email protected] | Web: www.csis.org PROJECT EDITOR Xiaoqing Lu March 2009 ISBN 978-0-89206-580-6 CENTER FOR STRATEGIC & Ë|xHSKITCy065806zv*:+:!:+:! CSIS INTERNATIONAL STUDIES China’s Capacity to Manage Infectious Diseases Global Implications A Report of the CSIS Freeman Chair in China Studies PROJECT DIRECTOR Charles W. Freeman III PROJECT EDITOR Xiaoqing Lu March 2009 About CSIS In an era of ever-changing global opportunities and challenges, the Center for Strategic and Inter- national Studies (CSIS) provides strategic insights and practical policy solutions to decisionmak- ers. CSIS conducts research and analysis and develops policy initiatives that look into the future and anticipate change. Founded by David M. Abshire and Admiral Arleigh Burke at the height of the Cold War, CSIS was dedicated to the simple but urgent goal of finding ways for America to survive as a nation and prosper as a people. Since 1962, CSIS has grown to become one of the world’s preeminent public policy institutions. Today, CSIS is a bipartisan, nonprofit organization headquartered in Washington, D.C. More than 220 full-time staff and a large network of affiliated scholars focus their expertise on defense and security; on the world’s regions and the unique challenges inherent to them; and on the issues that know no boundary in an increasingly connected world. Former U.S. senator Sam Nunn became chairman of the CSIS Board of Trustees in 1999, and John J. Hamre has led CSIS as its president and chief executive officer since 2000. CSIS does not take specific policy positions; accordingly, all views expressed in this publica- tion should be understood to be solely those of the author(s). © 2009 by the Center for Strategic and International Studies. All rights reserved. Library of Congress Cataloging-in-Publication Data CIP information available on request. ISBN 978-0-89206-580-6 Center for Strategic and International Studies 1800 K Street, N.W., Washington, D.C. 20006 Tel: (202) 775-3119 Fax: (202) 775-3199 Web: www.csis.org 2 contents Acknowledgments v Introduction vii Charles W. Freeman III Part I. The Current Situation 1. Infectious Disease Challenges in China 3 Joan Kaufman Part II. Challenges in China’s Infectious Disease Management 2. Managing Infectious Diseases among China’s Migrant Populations 17 Janet Vail 3. The Challenge of Tuberculosis Control in China 26 Xiaoqing Lu 4. The Anatomy of China’s Public Health System 33 Yuanli Liu Part III. China’s Efforts to Reform Its Health Care System 5. Beijing’s Perspective: The Internal Debate on Health Care Reform 51 Gordon G. Liu 6. China’s Health Care Reform Redux 59 Drew Thompson Part IV. The Regional and Global Dimensions of China’s Reform Efforts 7. The Experience of Hong Kong 83 Thomas H. F. Tsang 8. China’s New Health Diplomacy 86 Yanzhong Huang 9. The Prospects for Engaging China with Global Health Issues 93 J. Stephen Morrison About the Contributors 97 | iii acknowlegments This volume is a compilation of papers that were written for an October 6, 2008, conference, “China’s Capacity to Manage Infectious Diseases and Its Global Implications,” which was hosted by the CSIS Freeman Chair in China Studies, in cooperation with the CSIS Global Health Policy Center. The conference was held at CSIS in Washington, D.C. We would like to thank our commissioned experts for their chapters as well as their partici- pation in the conference. We are grateful to Dr. Kent R. Hill, USAID assistant administrator for global health, who delivered keynote remarks. We would also like to thank Savina Rupani, program coordinator of the CSIS Freeman Chair in China Studies, and See-Won Byun and David Szerlip, research interns with the CSIS Freeman Chair, for their help with the conference and this publication. We are deeply grateful to our copy- editor, Alfred F. Imhoff, for his editorial assistance and advice. The conference and this publication were made possible by the generous support of the Bill & Melinda Gates Foundation. The report was produced by CSIS, but the views expressed in each chapter are solely the responsibility of the individual author and do not reflect the views of any institution. | v introduction Charles W. Freeman III During the Seventeenth Party Congress in October 2007, improving health care in China had clearly become a political priority for the country’s leadership. Three decades of double-digit economic growth had not been matched by developments in China’s ability to prevent and treat diseases. The Maoist-era health care infrastructure, rudimentary as it was, had largely collapsed in the reformist years of Deng Xiaoping and Jiang Zemin. That infrastructure, particularly in rural China, was in tatters by the time President Hu Jintao took office in 2002. Given the current health care system, nearly four in five farmers are unlikely to see a doctor during their lifetimes. The na- tion’s hospital and clinic system is understaffed, underfunded, overmatched, and overlooked. All this has unfolded at a time when the socioeconomic changes wrought by China’s economic explosion and openness to the outside world have created enormous new health care challenges and strains on the country’s capacity to manage these challenges. Increasingly, the lack of adequate health care is becoming a source of significant public disgruntlement. Thus it is small wonder that, as part of his government’s efforts to reduce social inequities resulting from 30 years of runaway growth, Hu Jintao has focused on improving China’s health care system as a political priority. So in October 2007, when Hu Jintao pledged to “establish a basic medical and health care sys- tem and improve the health of the whole nation,” offered sweeping changes in the medical meth- odological order, and assembled a group of top ministers to promise universal health care by 2020, it was a significant gambit. The popular legitimacy of the Communist Party as the sole political authority in China rests in no small part on its ability to reverse the downward spiral in national health. In many respects, Beijing’s effort to prevent and treat infectious diseases only hints at its full goal of restoring public confidence in the health care system. The severe acute respiratory syn- drome (SARS) crisis of 2003 was a catalyzing period for China’s political elite in this regard, and since then Beijing’s blueprint for national health care has been drawn and redrawn any number of times. The problems are deep and multifaceted; identifying solutions is not an easy task, no matter how clear a priority a task it might be. But China’s efforts to manage its health care challenges, particularly with respect to infectious diseases, have more than domestic political significance. China’s particular medical diagnostic and therapeutic practices and its dynamic social changes are, effectively, laboratories for both new health care risks and solutions. Health issues in China thus have global implications. In earlier eras, when China’s population was largely stationary and problems related to sanitation were less prevalent and more localized, containment of spreading diseases could be more easily achieved. No more. These days, Chinese are more mobile and their environment is more hazardous. This is an increasingly target-rich environment for infectious diseases. | vii China’s efforts to manage infectious diseases thus have global implications. On the one hand, if China cannot meet the challenge, it will further tax an already strained international infrastruc- ture with both new patients and, almost certainly, new strains of disease. On the other hand, if China is successful, China cannot only short-circuit an international spread of disease but also begin to become a net donor to the global health community. To that end, and with the generous contributions from the Bill and Melinda Gates Foundation, the Freeman Chair in China Studies at the Center for Strategic and International Studies in Wash- ington has assembled a group of international experts to address some of the issues facing China and the world as China tackles the problems of infectious diseases. This book is intended as a tool to help international policymakers and practitioners, and Chinese officials and academics in the field of health care reform, as they meet the challenges of health care in China head on. In part I, Joan Kaufman of Harvard University reviews in chapter 1 the current status of infectious disease challenges in China, noting the progress made over the first 40 years since the founding of the People’s Republic, as contrasted with some of the more recent trends in significant infectious threats. Despite some clear improvements in social awareness and government attention since the SARS crisis in 2003, managing some particularly difficult challenges like tuberculosis and sexually transmitted diseases (and emerging challenges like HIV/AIDS and avian influenza) are increasingly problematic. In part II, we examine challenges in China’s infectious disease management, looking at three areas in particular. In chapter 2, Janet Vail of PATH looks at the unique considerations in health care management raised by China’s migratory “floating population,” which is 150 million strong (though not uniform). In chapter 3, Xiaoqing Lu of CSIS’s Freeman Chair in China Studies looks at significant challenges of tuberculosis and related serious diseases to China’s efforts to manage its infectious disease burden. And in chapter 4, Yuanli Liu of Harvard University’s School of Public Health examines the structure of China’s health care system and its capacity to manage current and future challenges.