China’s demographic landscape is rapidly changing, and the government has responded by launching ambitious social and health service reforms to meet the changing needs of the country’s 1.3 billion people. This week, officials approved a five-year plan to develop a comprehensive nationwide social security network.

Karen Eggleston, the Asia Health Policy Program (AHPP) director and a Stanford Health Policy fellow, discusses the success of China’s health care reforms—including its recently established universal health care system—and the long road still ahead.

Why is the overall health and wellbeing of China’s population important globally?

There are many reasons why the health of China’s citizens matters within a larger global context. On the most basic level, China represents almost 20 percent of humanity. But it is also a major player in the world economy and it depends on having a healthy workforce, especially now that its population is aging more. The government’s ability to meet the needs of its underserved citizens contributes to a more productive and stable China, and works towards closing the huge gaps we see in human wellbeing across the world.

China also potentially offers a model for other developing countries, such as India, that may want to figure out how to make universal health coverage work at a tenth of the income of most of the countries that have put it into place before.

What are some of the biggest changes in China’s health care system since 1949?

One of the most significant changes is that China has achieved very basic universal health insurance coverage in a relatively short period of time.  

Throughout the Mao period (1949–1978) there was a health care system linked to the centrally planned economy, which provided a basic level of coverage via government providers with a lot of regional variation. When economic reform came in 1980, large parts of the system—particularly financing for insurance—collapsed. The majority of China’s citizens were uninsured during the past few decades of very rapid social and economic development.

China’s overall population is changing quite dramatically, which means it has different health care needs, such as treating chronic disease and caring for an increasingly elderly population. The central government is trying to establish a system of accessible primary care—a concept that China’s barefoot doctors helped to pioneer but that fell into disarray—and health services that fit these new needs. 

How does China’s basic health care system work? Are there segments of the population still not receiving adequate coverage and care?

China has had a system where people can select their own doctors. Patients usually want to go to clinics attached to the highest-reputation hospitals, but of course, when you are not insured you almost always by default go to where you can afford the care. “It is difficult to see the doctor, and it is expensive” has been the lament of patients in China, so an explicit goal of the health care reforms has been to address this.

The term “universal coverage” has different definitions. China initially put in place a form of insurance that only covers 20 or 30 percent of medical costs for the previously uninsured population, especially in rural areas. Benefits have expanded, but remain limited. As with the previous system, disparities in coverage still exist across the population. China not only has a huge population with huge economic differences, but within that there is a large migrant worker population. It is a challenge to figure out how to cover these citizens and how to provide them with access to better care. The government is quite aware there are segments of the population not receiving equal coverage, and it continues to strive to resolve the issue.  

What are the greatest innovations in China’s health care system in recent years?

One of the most remarkable things China has achieved is really its new health insurance system. Even if the current coverage is not particularly generous it is nearly universal, and mechanisms are put in place each year to provide more generous coverage. China is also working on strengthening its primary care and population health services, infusing a huge sum of government money into these efforts. It is the only developing country of its per-capita income that has achieved such results so far.

Interestingly, a lot of people assume China achieved its universal coverage by mandate, while in fact the central government did so by subsidizing the cost for local governments and individuals. This reduces the burden, for example, on poorer rural governments and residents, and is one innovative way China is trying to eliminate the disparity in access to care.

Eggleston has recently published a working paper on China’s health care reforms since the Mao era on the AHPP website, as well as an article in the Milken Institute Review.

Gordon Liu, a Chinese government advisor on health care and the executive director of Peking University’s Health Economics and Management Institute, spoke at Stanford on May 29 on the future of China’s health care system.

As incomes rise around the world, health experts expect a more troubling figure to increase as well: the number of diabetics in developing countries.

In China and India – two of the world’s most populous nations with fast-paced economies – the prevalence of diabetes is expected to double by 2025. Between 15 and 20 percent of their adult population will develop the disease as household budgets increase, diets change to include more calories and new health problems emerge.

But China, India and other developing countries are not fully prepared to deal with the rising trend of diabetes. And a growing number of diabetics aren’t getting the care they need to prevent serious complications, Stanford researchers say.

Even with insurance, many diabetics don’t have essential medications that could help them manage their conditions. In many cases, people are spending a great deal of their household incomes to pay for their treatment, said Jeremy Goldhaber-Fiebert, an assistant professor of medicine who led the research team.

“Public and private health insurance programs aren’t providing sufficient protection for diabetics in many developing countries,” said Goldhaber-Fiebert, a faculty member at Stanford Health Policy at the university’s Freeman Spogli Institute for International Studies. “People with insurance aren’t doing markedly better than those who don’t have it. Health insurance and health systems need to be re-oriented to better address chronic diseases like diabetes.”

Findings from the study are online and will be published in the Jan. 24 edition of Diabetes Care, the journal of the American Diabetes Association. The journal article was co-authored by Jay Bhattacharya, an associate professor of medicine and Stanford Health Policy faculty member; and Crystal Smith-Spangler, an instructor at Stanford’s Department of Medicine and an investigator at the Palo Alto VA Health Care System.

Failure to adequately manage diabetes will lead to more severe health problems like blindness, heart disease and kidney failure. It also harms the otherwise healthy, Goldhaber-Fiebert said.

Diabetes often strikes people at an age when they’re taking care of children and elderly parents. To sideline these primary caretakers as dependants will lead to a heavy burden for communities and create an obstacle for economic growth, he added.

Using responses to a global survey conducted by the World Health Organization in 2002 and 2003, Goldhaber-Fiebert and his colleagues examined data from 35 low- and middle-income countries in Asia, Latin America, Africa and Eastern Europe to determine whether diabetics with insurance were more likely to have medication than those without insurance.

They also wanted to know whether insured diabetics have a lower risk of “catastrophic medical spending,” a term the researchers define as spending more than 25 percent of a household income on medical care.

“Surprisingly, diabetics with insurance were no more likely to have the medications they need than uninsured diabetics,” Goldhaber-Fiebert said. “They were also no less likely to suffer catastrophic medical spending.”

There are many reasons why health insurance may not protect diabetics in developing countries against high out-of-pocket spending. In some cases, there’s a lack of sufficient medication – such as insulin – that regulate glucose levels. Without those drugs, there’s a greater risk of complications that often lead to more hospitalizations and more expenses.

In other cases, co-payments and deductibles are too high. Sometimes, drugs and medical services to prevent diabetes complications are not covered. And doctors and hospitals don’t always accept insurance.

“Better policies are needed to provide sufficient protection and care for diabetics in the developing world,” Goldhaber-Fiebert said.

Without medications to manage diabetes and prevent secondary complications, the condition will worsen and the burden of catastrophic spending will increase, he said.

“It’s important to get ahead of the curve and prepare so there’s an infrastructure in place to deal with these health and cost issues,” he said.

While preventing diabetes in the first place would be ideal, programs and policies must be established to care for the many cases that will surely continue to exist.

“There isn’t a single country that’s managed to entirely arrest or reverse the trend of diabetes,” he said. “Programs that focus on primary prevention are extremely important, but the reality is that the developing world faces hundreds of millions of diabetes cases that are unlikely to all be prevented.”

In an opinion piece for Al Jazeera, Rajaie Batniji uncovers the role of medical professionals involved in acts of torture. With a lens to the unrest in Syria, Batniji calls for an international body to identify, monitor, and disqualify those complicit in torture and genocide.

In an opinion piece for Al Jazeera, Rajaie Batniji uncovers the role of medical professionals involved in acts of torture. With a lens to the unrest in Syria, Batniji calls for an international body to identify, monitor, and disqualify those complicit in torture and genocide.

Doctors have a long history of complicity in torture, but the torture of political dissidents holds a privileged place.  In Saddam Hussein's Iraq, surgeons removed the ears of men who failed to report for military service or defected from the army. In the Soviet Union, psychiatrists held political dissidents in mental hospitals with false diagnoses, in order to isolate and punish them. It is in this tradition of medical torture of dissidents that the Syrian healthcare establishment may be heading.

A July 6 report by Amnesty International documents the treatment of Wassim, a 21-year-old protester in the Syrian town of Talkalakh. After an injury from a soldier's bayonet, Wassim was taken to al-Bassel hospital, which had been occupied by Syrian security forces. As he reported: "The nurses, men and women […] swore at me and beat me hard and one female nurse punched me repeatedly with all her strength on my chest. Some were taking off their shoes and slapping me with them. I could hear many voices asking: 'You want freedom, eh?'" The report states he later had his wounds stitched without anesthesia, before being beaten on these wounds by hospital staff.  

Wassim's is not an isolated incident. In May, Reuters documented the case of a protester who had lost sensation in his legs who requested to see a doctor in jail. He told the news agency: "The doctor hit my knees with his legs, and asked: 'There, is it better now?' and then he slapped me". Most pervasively, reports suggest that even when doctors have not been involved in direct abuse, they have falsified the causes of injuries and released information about patients to the Syrian regime's security forces. The result is a public distrust of hospitals, and a clear incentive for injured protestors to avoid the healthcare system. 

The medical torture of political dissidents holds a privileged place because it can be perversely justified. The torture of dissidents may be seen as an act of loyalty to the state. Doctors acting on behalf of the state, such as military doctors, have what is called "dual loyalty" - loyalty to both their patient and a third party.

In addressing the issue of dual loyalty, Physicians for Human Rights has proposed guidelines that physicians not be present when torture takes place, and calls on them to report all human rights violations, especially when they interfere with their loyalty to patients. Like the medical professionals from the US recently implicated in the torture and abuse of prisoners at Guantánamo Bay and Iraq, some Syrian doctors may have valued their contribution to the security of the state more than their adherence to the norms of their profession. 

But, in their pursuit of perceived enemies of the state, have these physicians become enemies of the profession? Doctors involved in torture should be pursued as enemies of medicine: their crimes documented, their professional credentials revoked, and their ability to practice internationally thwarted.

Identifying and disqualifying doctors involved in torture

While it is exceedingly unlikely that Bashar al-Assad, an ophthalmologist, will go back to correcting cataracts in London - where he trained - if his regime is overthrown, other physicians culpable in his regime's torture will seek to continue clinical practice abroad.

Even with continued instability, it is likely that physicians and other elites will seek to emigrate. Could doctors involved in abuse head to Europe, North America or neighbouring Arab countries and continue to operate? How will they be identified? Critically, the majority of Syrian physicians that have not been complicit with abuses must be distinguished from those who have. 

Unfortunately, the medical profession has no method for identifying or punishing doctors complicit in torture. We rely on human rights organisations to provide sporadic documentation of medical torture.

With limited access and competing priorities - such as being able to provide medical care while working in countries where torture occurs - these organisations have a narrow scope for documenting the occurrence of torture. In an excellent Lancet article, Len Rubenstein and Melanie Bittle argue that the World Health Organization is best positioned to play a leading role in documenting attacks on medical functions in conflict, and this should include those attacks committed by physicians.

Among the suggestions put forth by Rubenstein and Bittle are a UN Security Council resolution providing a mandate for the WHO to pursue investigations, and the use of mobile devices for securely and quickly transmitting information about abuse. By documenting medical complicity in torture, we give physicians under incredible pressures incentive to oppose orders from their superiors and the state.

The greatest challenge, however, is enforcement, and the punishment of physicians complicit in torture. No international body retains information on professional qualifications. Like most other professions, medicine has proclaimed a need to be self-regulating, yet it has no system in place to disqualify or sanction physicians on a global level (national licensing bodies exist in most countries, but there is little to no international coordination). To this day, investigations continue of Rwandan doctors now practising in Europe and Africa, accused of involvement in the 1994 genocide.

Of course, their crimes were far more widespread than those in Syria today, as doctors oversaw the killing of hundreds of patients and staff in their hospitals, but the challenge of enforcement is nearly identical. Even if medical complicity in torture does not warrant imprisonment, it ought to warrant professional disqualification - and as of yet, no institution or process is in place to disqualify a physician from practising internationally. 

Honouring the heroism of Syrian doctors

Attacks on the healthcare system are common - perhaps inevitable - in modern war, but doctors don't always become complicit. In Bahrain, the Salmaniya medical centre was raided, and its doctors beaten and jailed for treating protesters. In Libya, Misurata hospital came under fire, deterring the sick from seeking care and endangering staff and patients.

Despicable as these attacks are, they have come to be expected as a feature of conflict. Attacks on the healthcare system have been documented in almost all recent conflicts including in Afghanistan, Kosovo, Nepal, Iraq, and the occupied Palestinian territories. In most cases, doctors have acted admirably, and sometimes heroically: seeing the sick in their homes, in secretive and makeshift clinics, risking their lives to provide care. Under oppressive regimes, doctors may be risking their lives just by refusing to be complicit in torture. 

In Syria, a group known as the "Damascus Doctors" has been organising on Facebook to provide hidden clinics in areas of protest, as reported by CNN. These doctors are upholding a tradition of professionalism and protest that existed since at least 1980, when more than 100 healthcare professionals were arrested for striking to demand the lifting of Syria's state of emergency, in place since 1963 (as of 1990, at least 90 of them remained missing). These doctors, like many others who have opposed the regime, were subjected to gruesome physical and psychological torture. 

The overwhelming majority of Syrian physicians have likely been acting heroically. It is in their honour that we should pursue aggressive international efforts to document and disqualify those physicians complicit in torture. This will require emboldened international institutions, cooperation among national licensing bodies, and the courage of doctors, journalists, activists and human rights organisations in documenting and reporting medical torture.