After Zero-Covid: Challenges Facing China’s Healthcare System

A Fangcang hospital (makeshift hospital) in Wuhan, Hubei, China, which was converted from Tazihu Sports Center for treating mild COVID-19 patients. There were 16 Fangcang hospitals in Wuhan, and each of them could accommodate hundreds of mild patients. Picture by 汮汐 from Wikipedia

By Xian Huang

China’s New COVID-19 Policy

The COVID-19 pandemic hit China first. However, from March 2020 to mid-2022, China contained the widespread transmission of COVID-19 and managed to handle this unprecedented public health crisis by the “zero-covid” strategy, that is, to eliminate the virus by massive lockdowns, testing, contact tracing, and quarantine. By mid-2022, China had officially claimed fewer than 6000 lives, far fewer than most populous countries in the world. This, the Chinese Communist Party (CCP) argues, is proof of the advantages of its leadership and socialist system. But the zero-Covid policy went into great strains as the highly transmissible Omicron variant was spreading in many parts of China in late 2022. Meanwhile, a remarkable stream of protests against zero-Covid arose among exhausted citizens and bankrupt businesses in big cities and on university campuses.

The party line began to change in late November with “zero-covid” suddenly disappearing from government documents and official speeches. Instead, the slogan “You’re in charge of your own health” has been promoted and repeated by state media. Nearly all public-health restrictions were gone in China by mid-December 2022, signalling that the zero-Covid era had come to the end. The abrupt dropping of zero-Covid puts China at risk of a massive surge of infections that overwhelms hospitals and could cause vast numbers of deaths.

Challenges Facing China’s Healthcare System

Of course, while I write this, Chinese health officials claim the country’s current wave of Covid infections is “coming to an end” with a sharp decline in the daily Covid death from 4,300 on January 4 to 896 on January 23. However, the impact of the pandemic is anything but transient, revealing at least two prominent shortcomings in China’s healthcare system: an inequality due to resource misallocation, and a lack of transparency.

China’s healthcare system is more inadequate and less accessible for ordinary citizens than for elites. Not only do health resources concentrate in big cities and rich regions, but also government health spending has long been largely allocated to tertiary hospitals rather than to primary care facilities that are more accessible for ordinary citizens. Consequently, distrust of local primary care providers is prevalent among the public.

Overcrowding in hospitals and shortage of hospital beds for COVID-19 patients in the early outbreaks in Wuhan, the first epicentre of the pandemic, were partially attributed to the long-lasting problem of resource misallocation in China’s healthcare system. It was only on January 24, 2020, that the Wuhan health authority began to implement a referral system to take advantage of the capacity of 205 primary care providers — with patients being referred to hospitals from primary care clinics. Although the rapidly-installed referral system did not eliminate medical resource shortages in Wuhan due to structural weaknesses in the primary care facilities such as lack of sufficient health workers, medical equipment, and diagnosis capacity, the initial outbreak in 2019 brought to the fore the important role that primary care centres could play in screening and monitoring for COVID-19 and maintaining routine care on other health conditions.

Regional Disparities

Sadly, the misallocation and under-investment problems in China’s healthcare system were never resolved, so the recent surge of Omicron infections hit China hard, especially the most rural and poorest parts of it. China can build a 1,000-bed hospital in six days and increase the average of ICU beds per 100,000 people from 4 to 12.8 within six weeks, but training Intensive Care Unit (ICU) medical professionals takes years. Ideally, there are three nurses working on one ICU bed; in practice, an ICU bed needs at least two nurses; in China, the average nurses per regular hospital bed is only .41.  Many public hospitals have fallen into financial crisis due to plummeting revenues and insufficient government subsidies for the mandated capacity expansion during the pandemic.

In addition, the geographic concentration of medical resources in big cities and rich regions undoubtedly augments health inaccessibility and inequalities for rural and poor citizens who tend to be older and have higher risk of severe illness. Social health insurance, the dominant method of health financing in China, favours urban state employees, providing insufficient financial protection to ordinary residents as it leaves most outpatient care and catastrophic diseases inadequately covered. Consequently, patients in rural or poor regions were reluctant to seek medical attention when COVID-19 symptoms are either mild or very serious.

To address this problem in the short run, upon the Wuhan lockdown on January 20th of 2020, the Chinese government announced that the expenses of COVID-19 treatment would be fully reimbursed by social health insurance or medical assistance. Since the government backed away from zero-Covid in December 2022, however, Covid testing and treatment have not been fully free for citizens anymore. Concerns about healthcare affordability resume as patients swarm into hospitals for healthcare Covid related or not.

Lack of Transparency

Transparency in China’s public health system is constantly concerning. From China’s early response to SARS and COVID-19 outbreaks to its retreat from daily release of accurate Covid data after dismantling zero-Covid, criticism over a lack of transparency and openness is widespread in domestic and international societies, impairing the government’s credibility and public trust. Given the information vacuum created by the state retreat amid the latest drastic surge of Covid cases, localities must come up with their own ways of obtaining Covid information, whether it includes hospital and ICU admissions or even COVID related deaths, to determine the size and severity of the surge.

Some rich localities go beyond administration data and undertake active Covid surveillance by routine blood tests in hospitals and antibody tests in communities, while poor localities use only online surveys to estimate current and cumulative infections. Regional disparities in information and healthcare provisions are thus enlarged by decentralization. While citizens, especially those vulnerable to severe illness and economic loss from Covid infections, are left uninformed and ignorant about the state of the pandemic, the CCP has moved on to proclaim its victory in guiding the country through the pandemic and bringing the economy back to life.

The shortcomings of China’s healthcare system are, at least partially, attributed to the “elitist” nature of its social welfare provisions that prioritizes the elites over the masses. Without fundamental change of its decentralized urban-rural-divide governance system and the current political regime that lacks genuine mechanisms for public participation and interest representation, health inequalities due to resource misallocation and lack of transparency will continue to prevail in China.

About the Author

Xian Huang is an Associate Professor of Political Science at Rutgers University. Her research has focused on the politics of social inequality and redistribution in China and East Asia. She is the author of the book: Social Protection under Authoritarianism: Health Politics and Policy in China (Oxford University Press, 2020).

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