Nigel Crisp, a crossbench member of the House of Lords, the UK, and former Chief Executive, National Health Service, will share insights on how people of all walks of life can play to build a healthy and health creating society.
The PRC has shown how buses can be used to dramatically increase the number of people vaccinated against COVID-19. The region should follow their example.
They look like sleek, bright tour buses, some vaguely insect-like with long-necked rearview mirrors. But the people lined up outside them in the PRC aren’t sightseers.
From Beijing in the north to Haikou in the southern island of Hainan; from Shanghai on the east coast to Xidu, Hunan and Wuhan, Chongqing, and Wuxi in the interior; and in many other towns and cities, the buses bring COVID-19 vaccinations to people who can’t easily make the trip to sometimes inaccessible vaccination centers.
It’s not just people living in remote mountainous areas such as Ouhai in Wenzhou, Zhejiang who benefit but also urban office workers, who don’t have to take time off to get their shots, and the elderly and handicapped.
The buses are kitted out with vaccination stations, smart medical refrigerators that keep temperatures at 2–8°C and send an alert to the Chinese Center for Disease Control and Prevention if they deviate, and first-aid facilities in case of an adverse reaction. Vaccinated people are screened, registered, inoculated, and observed afterward. Regulators can monitor the information remotely.
The buses speed up inoculation, efficiently bringing millions of doses to downtown neighborhoods and more remote locales. The PRC has reason to make haste. Its population of about 1.4 billion is spread across more than 9.3 million square kilometers, including coasts and mountains and everything in between and some regions that are harder to get to than others.
In April, Nature reported that the country was vaccinating about 5 million people a day on average. In June, for more than a week, that number swelled to 20 million a day on average. As of 6 June, the journal stated, 778 million doses had been administered.
In the first week of October, according to Reuters, the average daily number of doses administered was about 1.42 million. A total of at least 2,218,826,000 doses, enough for about 79.4% of the population, have been administered.
The news outlet said that the country has had 96,374 infections and 4,636 COVID-19–related deaths since the pandemic began in late 2019. New infections reportedly average 24 a day, or 1% of the highest daily average reported in February 2021.
The remarkable feat of vaccinating more than a billion people in less than two years was made possible by the decision to produce its own vaccines rather than rely on other countries and by getting the vaccines to its people efficiently. The vaccination buses are part of this logistically extraordinary achievement.
Health facilities have often been stretched to capacity, transport can be inefficient, and vaccination centers can be difficult to reach and expensive to build.
The buses speed up inoculation, efficiently bringing millions of doses to downtown neighborhoods and more remote locales.
Some other parts of Asia have been using vans and buses for health work. In the Philippines, for example, mobile x-ray machines serve tuberculosis patients, family-planning caravans have delivered contraception to communities, and now mobile clinics bring COVID-19 vaccination to cities and villages.
In September, Thailand rolled out its first vaccination bus, in Bangkok, which needs only six people to operate it and to inoculate 1,000 people a day. Pekanbaru, Indonesia launched its vaccination buses on 1 June and doubled their number to 10 within 2 weeks.
In July, the Cambodia government delivered 10 vaccination vans to the defense ministry, which was already inoculating people, and promised one or two vans each to the provinces, depending on their population.
In India, the Karnataka government and the private sector launched the 4–6-month Vaccination on Wheels in August. In Fiji, Rights, Empowerment and Cohesion for Rural and Urban Fijians (REACH) Project buses started bringing vaccines to communities in early 2020.
Some of the least developed countries might not have the high technology that the PRC does, but they use the technology on hand to get the job done. Health workers can use cellphones to inform residents of mobile clinic arrivals, register vaccinees, remind them of vaccination schedules, and transmit information to government agencies. Smart refrigerators might not always be an option, but solar panels can keep the cold chain going.
The World Health Organization and United Nations Secretary-General António Guterres appealed to the leaders attending the 76th UN General Assembly, held in September, to ensure that poor and rich countries have equitable access to COVID-19 vaccines. An impassioned secretary-general called vaccine equity “the biggest moral test before the global community.”
Continuing imbalanced access means not only that not enough vaccines are reaching the least developed countries but also that their health systems are deficient. Even if the countries were to receive more vaccines than they are, of what use would they be if they expire in warehouses or at ports because they cannot be distributed? Or, in the case of one brand, if they cannot be kept at minus 70°C?
To reach levels of success seen in the PRC, other countries need stronger health systems, more vaccines, and greater vaccine outreach.
WHO and the UN are right to be alarmed. Only 47.7% of the world’s population has received at least one dose of the COVID-19 vaccine but only 2.5% of people in low-income countries.
Vaccination buses are just one solution and an effective one. They do traverse some countries, but not enough of them and in not enough countries. Imagine what fleets of them could do.
In the People’s Republic of China, reducing the risk of illness-induced poverty entails raising the poor’s financial protection and health system reforms.
By achieving near-universal population coverage of social insurance, the People’s Republic of China (PRC) has improved access to and use of health services and reduced the proportion of out-of-pocket (catastrophic) spending. Yet among the country’s poor people, catastrophic health expenses are still high despite the government’s attempt to provide additional financial protection.
The current insurance system should target underprivileged populations to enhance financial protection in the country. Such targeting requires a clear and integrated policy encompassing the basic social health insurance schemes, catastrophic medical insurance, medical aid, and improved healthcare efficiency. To break the vicious cycle of illness-induced poverty and return to poverty because of illness, the protection of poor people from health care costs should be regarded as an important element of poverty alleviation in the PRC. Increased spending on health, however, will not improve financial protection without further measures to increase health system efficiency, strengthen primary care, and reform provider payment systems.
The United Nations Sustainable Development Goals in 2016 committed countries to achieve universal health coverage by 2030 with a focus on essential health services and financial protection. Universal health coverage means that all individuals and communities should get the quality health services they need without incurring financial hardship. It has three dimensions: population coverage, covering all individuals and communities; service coverage, reflecting the comprehensiveness of the services that are covered; and cost coverage, the extent of protection against the direct costs of care.
In 2009, the PRC began implementing comprehensive health system reforms. A major goal of these reforms was to achieve universal health coverage by building a social health insurance system. According to a 2017 monitoring report by the World Health Organization and the World Bank, the PRC had a fairly high score for coverage of essential health services on 16 health indicators but a low score for financial protection to reduce the risk of illness-induced poverty.
This policy brief examines the PRC’s progress in enhancing the financial protection of social health insurance and identifies the main gaps yet to be filled to fully achieve universal health coverage. It is based on a paper by Hai Fang, Karen Eggleston, Kara Hanson, and Ming Wu, published in volume 19 of the journal BMJ.
The 2009 health system reforms proposed a universal health insurance system that consisted of three main social health schemes in each locality: Urban Employee Basic Medical Insurance, Urban Resident Basic Medical Insurance, and Rural New Cooperative Medical Scheme, with other supplementary insurance and private insurance. The reforms aimed to cover the entire population with one of the three basic schemes to give them greater financial protection. In 2016 with some heterogeneity by locality, the urban resident and rural schemes merged to form the Urban—Rural Resident Basic Medical Insurance to improve administrative efficiency.
To give added protection to patients with critical illnesses, catastrophic medical insurance (also called critical illness insurance or Da Bing Yi Bao) was initially launched in 2012 and implemented nationally in 2015. It covers patients with critical illnesses whose out-of-pocket expenses are more than the average disposable income per capita in the local area, providing extra reimbursement and removing the benefit ceiling.
The medical aid program (also called medical financial assistance or Yi Liao Jiu Zhu), which was launched in 2003 in rural areas and expanded to urban areas in 2005, provides a further safety net. It was designed to provide medical aid to the poorest people by paying their medical insurance premiums and reducing out-of-pocket expenses after receiving reimbursement from the basic social health insurance schemes and catastrophic medical insurance.
The national health reforms of 2009 consolidated a fragmented health insurance system, creating an expanded public health service package that provides basic population health services to all Chinese. Recent mergers of insurance risk pools—such as raising benefit levels of the New Cooperative Medical Scheme to those of the Urban Resident Basic Medical Insurance—and implementation of catastrophic supplementary insurance within local social health insurance systems are encouraging trends for closing gaps in risk protection.
Over the past 2 decades, health spending has grown considerably as the economy experienced unprecedentedly rapid growth. By 2017, the government share of spending represented slightly over 9% of overall government expenditures. The money to invest in the expansion of healthcare came from a mix of central and provincial budgets, with per capita budget allocations that include higher central government subsidies for lower-income provinces. Funding for the medical aid program comes mainly from governments, welfare lotteries, and social donations. Meanwhile, a governance reshuffle consolidated the purchaser role for social health insurance schemes under the newly created National Medical Security Administration, with most other functions assigned to a rechristened National Health Commission.
The PRC also invested a substantial amount of public funds in health services. Government health care budgets financed construction and renovation of government primary care facilities, subsidies to replace provider revenues generated from drug dispensing, purchase of medical equipment for public hospitals, expansion of public health services, and training and continuing medical education.
The increased health spending—directly on healthcare infrastructure and subsidizing social health insurance for the rural and urban non-employee populations—substantially reduces the burden on families. Furthermore, the PRC’s world-leading technological prowess in multiple fields spanning digital commerce to artificial intelligence—and accompanying innovative business models for online consultations that have not yet been fully integrated into the health system—hold promise for supporting higher quality and more convenient health care for the country’s 1.4 billion citizens.
Reforms over the past 2 decades have brought the health care system closer to a level of reliability and accessibility commensurate with the country’s new affluence. The consolidation of the social health insurance system ensured coverage of the entire population for basic health services, contributing to a surge in health care utilization while reducing out-of-pocket costs to patients.
The percentage of people who reported a need for hospital admission but did not receive inpatient care decreased from 29.6% in 2003 to 25.1% in 2008 and 17.1% in 2013. The average number of outpatient visits per capita increased from 1.7 in 2003 to 5.9 in 2017, and the annual inpatient hospital admission rate increased from 3.6% in 2003 to 17.6% in 2017. The use of outpatient services was comparable with the global average, but admission rates were much higher. Furthermore, the government’s investments into the public health system substantially increased the number of health workers and hospital beds and helped keep the prices of health care services low.
The expansion of health insurance coverage reduced the share of out-of-pocket health expenses in total health expenditures from 56% in 2003 to 29% in 2017. It is projected to decrease to 25% by 2030.
Catastrophic medical insurance and medical aid were effective in supplementing the basic social health insurance schemes and provided extra financial protection to a range of vulnerable groups, including people who are poor, chronically ill or disabled, disadvantaged by geographical factors, very young, or frail and old. By 2017, catastrophic medical insurance covered more than a billion people in the PRC and 11 million people received extra benefits of more than ¥30 billion (about $4.3 billion).
The insurance reduced the average proportion of out-of-pocket expenses after reimbursement from basic social health schemes by about 10%. In 2017, through medical aid, 56.2 million people (4% of the population) received subsidies to pay for their social health insurance premiums. For the same year, 35.2 million people (2.5%) received on average ¥757 (around $118.84) or about 12% of average inpatient spending per admission to cover out-of-pocket expenses.
Center for Health Statistics and Information, National Health and Family Planning Commission. 2015. An Analysis Report of National Health Services Survey in China, 2013. China Union Medical University Press.
Central Committee of the Communist Party of China and the State Council. 2009. Opinions on Deepening Health System Reform.
Chinese Ministry of Finance and Ministry of Civil Affairs. 2013. Announcement about Management Methods of Urban Rural Medical Aid Funding. 23 December.
H. Fang et. al. 2019. Enhancing Financial Protection under China’s Social Health Insurance to Achieve Universal Health Coverage. BMJ. 365: l2378.
H. Li and J. Jiang. 2017. Catastrophic Medical Insurance in China. Lancet. 390: 1724–5.
From the earliest stages of COVID-19, ADB provided immediate support for Mongolia to improve preparedness and response, prevent domestic violence, manage food insecurity risk, and protect livelihoods of wheat farmers.
This included a COVID-19 Rapid Response Program loan of $100 million to help the government mitigate severe health and economic impacts, deliver medical equipment and supplies, and improve infection control and testing capacities. ADB also approved a $30 million health sector project to improve the capacity and hygiene of hospitals and committed $26.4 million for cash transfers to needy households affected by the pandemic.
ADB’s COVID-19 work in Mongolia continued in 2021 with another $100 million loan to strengthen the country’s health security, and $73 million to expand cash grants for children in Mongolia. ADB is working closely with the Government and key development partners to urgently support the access and deployment of COVID-19 vaccines in Mongolia.
Rapid urbanization and aging in many countries have highlighted the urgency of making cities healthier and more accessible for the elderly and also more friendly for children. A new ADB report offers an operational framework for creating an urban society fit for four generations in the People’s Republic of China – and elsewhere.
In 2018, the United Nations reported that 55% of the world’s population resided in urban areas, a proportion that is expected to increase to 68% by 2050. In the People’s Republic of China (PRC), the urban population has been increasing at a particularly high speed, from 17.9% in 1978 to 60.6% at the end of 2019.
Urbanization in the PRC is coinciding with an aging of society, with about 20% of the urban population projected to be over 60 years old by 2030; and many of these older people will live to very advanced ages.
As the world and the PRC continue to urbanize, sustainable development will depend on making cities livable, environmentally sustainable, low-carbon, climate resilient, and socially and age-inclusive.
“Integrating health and aging as part of sustainable city planning and urban design will deliver specific additional health and urban livability benefits,” says ADB Senior Urban Development Specialist Stefan Rau. “It is a great opportunity to bring together many agencies and specialists to use the emerging four-generation urban world as an opportunity for transforming urban community life.”
Health and well-being have been shaping urban development since cities existed and they can now be considered critical factors contributing to competitiveness of cities, especially in high-income and upper-middle-income countries such as the PRC.
A new ADB publication, Healthy and Age-Friendly Cities in the People’s Republic of China, proposes health impact assessments as well as healthy and age-friendly city action and management plans as holistic tools to improve urban livability, services, and public spaces. Integrated with urban planning, these practical tools can help make cleaner, healthier, and safer cities that are more pleasant for people of all ages, and more attractive for businesses, and economic development.
Healthier cities and integrating the needs of the elderly and also children
According to the report, making cities healthier requires clean and walkable environments, accessible health-care services, and infrastructure that improves the urban environment and promotes healthy lifestyles. All of these will help ease public health management in an era when infectious diseases such as the coronavirus disease (COVID-19) pandemic, noncommunicable diseases, and the challenges of increasingly aging populations are converging, as is the case of the PRC.
“Well-planned, decentralized, and conveniently located urban health services ideally within walking distance to many residents and public transport, early detection of infectious diseases, and measures for vulnerable groups such as the elderly can help reduce noncommunicable diseases, control infectious diseases, and promote well-being,” says ADB Health Specialist Najibullah Habib.
Cities need to combine an age-friendly public transport system with safe and convenient sidewalks, bicycle parking, parks, public spaces, and public service facilities. This effort needs to be integrated with universal urban design to ensure that public spaces, sidewalks, parks, and buildings are accessible for people of all ages and the physically impaired. This much-needed low-carbon, climate-resilient urban planning and design would also contribute to improved health from reduced emissions and lessened risk of climate-related disasters such as flooding, droughts, heat waves, and storm surges, which also endanger lives and safety.
“Cities would greatly benefit if they govern, plan, and invest holistically in the promotion of public and community health, healthy lifestyles, gender and age equality, disease prevention, and improved social services,” says Susann Roth, ADB Chief of Knowledge Advisory Services Center.
Figure 1: A Hierarchy of Urban Health and Well-being
The report says healthy cities should first ensure that basic health needs are met (i.e., physiological needs and safety, and the elimination or reduction of exposure to infectious diseases). Then, healthy lifestyles and healthy communities should be promoted, and the risks of noncommunicable diseases such as cardiovascular diseases and cancer should be reduced, resulting in longer life expectancies (Figure 1).
Healthy cities should enable a high quality of living; heathy lifestyle choices that are easy to make; and the self-fulfillment of citizens, families, and communities. The planning of healthy cities should consider all aspects of physical and mental health, vibrant and diverse human interactions, and culture and education to ensure that all urban residents can develop to their full potential.
The framework combines two practical tools for urban planners and city governments: a health impact assessment (HIA) and a healthy and age-friendly city action and management plan (HACAMP) as step-by-step guide. The framework is applicable to existing urban areas and proposed urban master plans for new areas and projects. It builds on city health sector plans, fits within the context of sector operations and plans, and contributes to urban master development plans and local institutional arrangements and responsibilities.
“While the initial target country of this report is the PRC, the objectives and framework developed here could also be applied to other countries in Asia and the Pacific and beyond,” the report says. “They are highly relevant for cities at all development stages, especially given the recent pandemic and the demographic transition that has been occurring for some time.”