“The unfolding drama of Anil Potti — a Duke researcher who posed as a Rhodes Scholar and appears to have invented key statistical analyses in a study of how breast cancer responds to chemotherapy — has sent ripples of angst through the cancer community. Potti’s antics prompted editors of The Lancet Oncology to issue an “expression of concern” — a Britishism that might be better expressed as “Holy Shit!” — about the validity of a 2007 paper in their journal by Potti and others.

So why write a blog on retractions?

First, science takes justifiable pride in the fact that it is self-correcting — most of the time. Usually, that just means more or better data, not fraud or mistakes that would require a retraction. But when a retraction is necessary, how long does that self-correction take? The Wakefield retraction, for example, was issued 12 years after the original study, and six years after serious questions had been raised publicly by journalist Andrew Deer. Retractions are therefore a window into the scientific process.”

Why is this important? Because of opinions such as this from the friendly folks at Asia Healthcare Blog. This was in reaction to recent US press and media honing in on a new type transferable antibiotic resistance in gram-negative organisms. NDM-1 (New Delhi Metallo-beta-lactamase 1) is named after the city that was visited by the patient in whom the first organism carrying this enzyme was isolated.

“Sorry Indian MPs, claims like this are not made lightly by scientists or one of the most highly respected medical journals in the world. And, if for some strange reason the Lancet decided it was going to publish study findings based on maliciously distorted information just so that the UK could somehow claim political superiority over all of India, then this is something that should be challenged through study and not through parliament.

The most important thing in a world 7 billion strong is too be vigilant against the threat of global pandemic. Instead of worrying about their reputation and the medical tourism industry, Indian physicians, public health experts, and government leaders should focus on double checking the findings of the study.

GIVE ME MY ANTIBIOTICS!

India has a lot to lose from a marred medical tourism reputation, having heavily invested both government and private dollars into the development of its medical tourism industry. The worst thing that could happen is for profit and pride to be put ahead of health. We’ve had this happen once already this decade in China, and that culminated in the frightening summer of SARS. And, if the reporting of Swine Flu numbers is anything to go on, then Indian hospitals and governments aren’t exactly on top of the ball when it comes to keeping other countries abreast of their health problems.”

Damjan Denoble, Editor, Asia Healthcare blog

and from Reuters Health Information (incidentally Ivan Oransky of Retraction Watch is the Executive Editor at Reuters Health – very interesting indeed):

New superbugs could spread around the world after reaching Britain from India – in part because of medical tourism – and scientists say there are almost no drugs to treat them.

With international travel in search of cheaper healthcare increasing, particularly for procedures such as cosmetic surgery, lead author Dr. Timothy Walsh from Britain’s Cardiff University said he feared the new superbug could soon spread across the globe.

“Because of medical tourism and international travel in general, resistance to these types of bacteria has the potential to spread around the world very, very quickly. And there is nothing in the (drug development) pipeline to tackle it.”

In a study published online August 11th in The Lancet Infectious Diseases, Dr. Walsh’s team found that NDM-1 is becoming more common in Bangladesh, India, and Pakistan and is also being imported back to Britain in patients returning after treatment.

“India also provides cosmetic surgery for other Europeans and Americans, and it is likely NDM-1 will spread worldwide,” the scientists wrote in the study.

Part of your view appears to me to be a tad naive Damjan. The Lancet it seems would be well-advised to review their quality control processes. A supposed Rhodes Scholar? A Duke researcher? Isn’t that your Alma Mater Damjan (kidding of course)? 12 years for the Wilkinson retraction? The Wilkinson retraction was regarding the issue of autism being linked to MMR vaccine which turned out to be b-ll sh-t (please read Medicine, media and accountability: What’s the hazard ratio of that?).

Will this episode also blow up in the Lancet face? Why is it necessary to potentially malign a country, a city, a possible growth industry? Why all the hoopla? Lets call HIV, “African monkey/ Gay man disease”, or H1N1, Spanish flu, or salmonella, McChicken bacteria? Now, I know this last sentence is not politically correct so let me preempt any complaints by saying I don’t really suggest that we should seriously demean a McDonald’s McChicken, though I’m a burger-man myself.

What is this new “Superbug”?

From the original study which was high in science and low in hoopla factor:

Yong D et al. Antimicrob Agents Chemother 2009. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2786356/

The growing increase in the rates of antibiotic resistance is a major cause for concern in both nonfermenting bacilli and isolates of the Enterobacteriaceae family. β-Lactams have been the mainstay of treatment for serious infections, and the most active of these are the carbapenems, which are advocated for use for the treatment of infections caused by extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae, particularly Escherichia coli and Klebsiella pneumonia (21). However, carbapenemases are increasingly being reported; and the most prevalent of these would appear to be KPC, which has recently been characterized in the United States, Israel, Turkey, China, India, the United Kingdom, and Nordic countries.-

-Herein, we report on the genetic and biochemical characterization of a new subgroup of MBL, designated NDM-1, originating from New Delhi, India. We also report on its novel genetic context and describe a new erythromycin resistance gene, designated ereC.

And the conclusions (selected sentences) from this study:

The broad resistance carried on these plasmids is a further worrying development for India, which already has high levels of antibiotic resistance.

Strain 05-506 clearly arose in India, but there are few data arising from India to suggest how widespread it is. We are currently undertaking studies in several Indian cities to examine these points. Interestingly, there appears to be the possible transfer of blaNDM-1 in vivo either from K. pneumoniae to E. coli or vice versa, but more interestingly, the plasmids carrying blaNDM-1 in the two species are of different sizes. This evidence would suggest that there is rearrangement in vivo which could result from either duplication and insertion, e.g., transposition or rolling circle replication from the smaller plasmid, or deletion from the larger plasmid (33, 34). The plasmid carrying blaNDM-1 also carries blaCMY-4 and the complex class 1 integron carrying several antibiotic resistance-conferring genes (33), and it has also shown itself to naturally have a broad host range. When the plasmid was transferred to E. coli J53, the E. coli strain containing pNDM-1 was resistant to all antibiotics except colistin and ciprofloxacin and was shown by blotting and PCR to carry blaCMY-4, the ISCR region, and blaNDM-1. Therefore, the rapid dissemination of this plasmid among clinical bacteria would be a nightmare scenario.

In a country where there is little control on antibiotic prescriptions, the rapid dissemination of such a plasmid is alarming.

Ouch. Chalk one up for the Lancet and Damjan. India (and the world) had better wake up quick or there clearly is potential for a nasty bacterial brew to disseminate via our “The World is Flat” achievement. As an expat living in Singapore with ready and frequent access to India, I must say I exploit the ready off-the-street availability of zithromax and other premium antibiotics at a fraction of the cost in Singapore. Relatives bring a few courses of cipro, augmentum, zithromax, every time we go back and forth and I’m certain I’m not the only one. I think it’s time the WHO and India work on policy and procedures to take drugs which are only available by prescription elsewhere and limit access through the traditional channel- prescriptions by certified physicians. Yes, I know there are a billion people in poverty who cannot afford doctors visits and prescriptions, but the alternative is to let Darwin’s evolution work it’s magic on the human race (kill off millions) until WE develop resistance to those bacterial strains.

Tej Deol, M.D.

Despite relatively low healthcare spending, Hong Kong rates well in comparisons of basic health indicators, such as life expectancy.

Spending on healthcare (which tends to be resistant to economic downturns) ticked up to an estimated 6.2% of GDP in 2009, based on WHO definitions. This is still low compared with healthcare spending of 16.3% of GDP in the US, 10.6% in Germany and 7% in Japan.

The structure of healthcare expenditure has been changing. In the early 1990s the bulk of expenditure was accounted for by the private sector. However, in recent years public-sector expenditure has become more significant, and it now accounts for well over one-half of all health spending—a proportion that will continue to rise.

Spending

Healthcare spending in Hong Kong is being pushed up by the same factors that are affecting most developed economies: an ageing population, the emergence of innovative and expensive medical technologies, new sources of demand and rising consumer expectations.

In fiscal year 2008/09 (April-March) total public spending on healthcare stood at an estimated HK$36.8bn (US$4.7bn). The ratio of public health spending to total government spending is usually fairly high, but recent government efforts to cushion households against inflation and other economic problems have pushed up other kinds of public spending, with the result that health expenditure as a proportion of total spending fell to 11% in 2008/09.

The Economist Intelligence Unit expects total healthcare spending to increase from an estimated US$13.2bn in 2009 to US$16.6bn in 2014. This will be driven in part by expanding public health investment. But consumer health spending will also grow, from around US$5.6bn in 2009 to US$7.8bn in 2014, driven by rising disposable incomes.

At present, healthcare in government hospitals is not free but is heavily subsidised, and costs can be waived for those receiving comprehensive social security assistance. The disadvantage of this is that waiting lists can be long. Public subsidies cover around 95% of care costs: virtually all in-patient care costs are covered, but there is a slightly lower proportion of coverage for outpatient care. Hong Kong’s private hospitals handled only 20.4% of in-patient admissions in 2007, but the vast majority of outpatient consultations are provided by private doctors. The level of private medical insurance cover is extremely low in Hong Kong. Given the above figures, it seems probable that public healthcare provision is priced low enough (and is of a good enough standard) to curb the expansion of private-sector provision.

Several options to supplement existing funding have been proposed, including social health insurance (probably funded by a tax on the working population or employers); increasing out-of-pocket payments at the point of delivery; mandatory individual health savings accounts; voluntary private insurance;mandatory healthcare insurance; and so-called “private healthcare reserves” that seek to incorporate elements of private healthcare accounts and regulated medical insurance plans.

Policy

The Hospital Authority (HA) is now moving to outsource more of its services to the private sector, amid a general drive to reduce waiting times, shorten the average duration of hospital stays after surgery, place greater emphasis on patient empowerment and reduce demand for HA services.

Hong Kong’s ratio of an estimated 1.5 doctors per 1,000 people in 2009 is below that in Germany (3.8 per 1,000), the US (3.3) and Japan (2.2). Hong Kong had an estimated five hospital beds per 1,000 people in 2009, a level that has been broadly stable in recent years. The HA runs 48 specialist outpatient clinics and 74 general outpatient clinics. Around 4,760 doctors—roughly 40% of the 11,961 doctors registered in Hong Kong—are employed by the HA. Most other doctors are general practitioners in the private sector.

Growth in demand for healthcare services is estimated at 3-4% a year. This has resulted in the need to promote home and community care by building up the family-medicine services offered by the HA, and also by managing demand through the provision of primary care that can reduce avoidable hospitalisation for the elderly and the socially disadvantaged.

The government is keen to see further development of the medical services sector. By attracting paying mainland-Chinese clients to Hong Kong for medical treatment, this would in effect provide a subsidy to the local healthcare sector. Hong Kong has recently proved more politically stable than rival healthcare tourism destinations such as Thailand and Sri Lanka, but in the long term its advantage may lie in niche sectors, such as traditional Chinese medicine.

Diseases

In the past few decades Hong Kong’s population has aged and grown wealthier, and chronic diseases, cancers, and their associated disabilities have emerged as the leading causes of morbidity and mortality

Cancer was the leading cause of death in 2008, claiming 12,390 lives, followed by heart disease (6,737), pneumonia (5,399) and cerebrovascular diseases (3,751), according to government figures. Infectious diseases are also a significant threat: in 2008 there were 5,730 cases of tuberculosis, of which 237 were fatal.

In 2003 Hong Kong’s healthcare system was tested by an outbreak of the highly contagious severe acute respiratory syndrome (SARS) virus. The outbreak was eventually brought under control, but not before it had infected 1,755 people and killed 298. In the wake of SARS, official enquiries identified shortcomings in the organisation of the healthcare system for the control of communicable diseases. A Centre for Health Protection with responsibility for the prevention and control of communicable diseases was subsequently set up.

The territory’s experience with swine flu in 2009 paints a mixed picture of progress on preventing the spread of dangerous diseases. There have been few fatalities from swine flu, but the disease spread rapidly in Hong Kong, despite initial tough measures to attempt to halt its progress, including quarantine (the measures were criticised in some quarters as an over-reaction). The territory’s experience so far suggests that it is too early to assume that a future serious epidemic could be controlled effectively.

Recent increases in health expenditure have been a result of rising incomes, the growing incidence of prosperity-related chronic illnesses, such as heart disease, and the rapid ageing of the population.

In 2009 healthcare spending per head in Taiwan was estimated at US$1,074, and total healthcare spending accounted for around 6.6% of GDP. According to the health department, the proportion of Taiwan’s national income spent on healthcare has been rising consistently in recent years. Spending on pharmaceuticals is high, at around US$220 per person per year. Healthcare expenditure dropped in both US dollar and local-currency terms in 2009 thanks to the global recession, but is expected to rise steadily in the forecast period as the population ages and incomes rise.

Spending

Although medical coverage is almost universal under the mandatory National Health Insurance (NHI) system, it faces constant financing challenges

Nearly all of the hospitals in Taiwan have a contract with the NHI programme and are reimbursed on a fee-for-service basis. The NHI offers a comprehensive package of benefits, including outpatient and inpatient care, preventive care, dental services, Chinese medicine services and prescription drugs. The system is financed through a payroll premium that is paid by companies and employees and government subsidies. Co-payments are required for outpatient and inpatient care. These include fixed fees for outpatient visits and between 10% and 30% of hospital costs, depending on the length of stay. Certain categories of patient are exempt from these charges.

The finances of the NHI are poor, and overall contribution rates are not high enough to provide the quality of coverage that many in the population would like to receive. Since its inception, the Bureau of National Health Insurance (BNHI) has introduced a number of measures to boost revenue and cut costs. These include the introduction of a co-payment system in 1999. In 2006 and 2007 the BNHI lowered the prices of thousands of reimbursable drugs.

The finances of the system will eventually need to be reformed. More fundamental change is essential as the rapidly ageing population leads to a steady increase in demand for drugs and medical care. The public sector accounts for around two-thirds of healthcare expenditure, largely through the NHI system. Spending on the NHI programme reached close to 4% of GDP in 2007. Most private-sector spending goes towards outpatient facilities, although inpatient services and pharmaceutical costs, both Western and Chinese, are also important elements.

Policy

With citizens enjoying good healthcare, Taiwan appears to be increasingly keen to capitalise on local medical skills by encouraging health tourism from elsewhere in the region.

Taiwan had 23,874 medical care institutions in 2008. The largest number of these provided Western medicine (9,910), followed by dentistry (6,031), pharmacies (4,180) and Chinese medicine (2,888). Most hospitals, and an even greater proportion of clinics, are privately owned, and many are small. In 2006 there were 547 hospitals, of which 96% practiced Western medicine. In recent years there has been a gradual fall in the number of hospitals, but the surviving institutions have grown significantly in size. In 2006 there were 131,152 hospital beds, although the number of beds in private hospitals was approximately twice the amount as in public hospitals. Taiwan residents make frequent visits to the doctor, as those in the NHI face no financial penalties or additional costs for excessive use of the system.

Healthcare availability in Taiwan is generally good: there were an estimated 1.5 doctors per 1,000 people in 2009, compared with 1.7 in South Korea.

To curb costs, the government has put pressure on drug prices and declared in 2005 that the insurance system would no longer cover expenses for non-prescription drugs, such as cold and cough medicines. The government has also used reimbursement schemes and licensing regulations to protect local drug manufacturers. Counterfeit drugs are estimated to account for up to 20% of the market, according to unofficial industry estimates. A lax attitude towards uncovering and prosecuting those who make and retail counterfeit products has undermined the threat of legal counter-measures, and sentences for producing counterfeit drugs are particularly light.

In a bid to attract more healthcare tourists, in late 2006 the Council for Economic Planning and Development (CEPD) announced a plan worth NT$10.5bn (US$328m) to develop local medical services, particularly in areas such as health checks, laser eyesight correction, plastic surgery, dentistry and traditional Chinese medicine. Taiwan is a latecomer to this area (Thailand and Singapore already have successful health tourism sectors), but it seems keen to succeed. CEPD officials have suggested that Taiwan could establish hospitals in Vietnam or even Mongolia to export medical skills.

Less than a year after it approved the creation of the Taiwan Food and Drug Administration (TFDA), the Taiwan government has said that the agency will be formally inaugurated on January 1st 2010. The announcement of this date was made at a meeting of a governmental committee on strategies to develop the biotechnology sector, underscoring the main motivation for this initiative.

The aim is to bring regulatory procedures governing the pharmaceutical and biotech sectors in line with those in major regional markets such as China, South Korea and Japan in order to improve export prospects. Crucially, the TFDA will also aim to make Taiwan a more attractive investment prospect for multinational pharma and bio-pharma players.

Diseases

According to the health department, the main causes of death in 2006 (latest available data) were cancer (accounting for 28.1% of all deaths), strokes (9.3% of total deaths), heart disease (9.1%) and diabetes (7.2%).

The people of Taiwan are among the healthiest in Asia. In 2009 estimated average life expectancy on the island was 75.1 years for men and 81.0 years for women. The equivalent figures for men and women in South Korea are similar.

Outbreaks of diseases such as severe acute respiratory syndrome (SARS) and avian influenza (bird flu) have put added, albeit temporary, upward pressure on healthcare spending. In addition, 33 people are estimated to have died from swine flu, or A(H1N1), in Taiwan, and the government is rolling out a nationwide vaccination programme.

While improving, healthcare provision in India is still characterised by huge inequalities.

India spent an estimated 5% of GDP on healthcare in 2009. This is more than neighbouring Pakistan (which spent 2.4% of GDP on healthcare), and China (4.7%), but far less than the G7 average of around 12%. Annual healthcare spending per head is estimated at just US$55 in 2009, compared with US$172 in China. The Economist Intelligence Unit expects spending to more than double by 2014, to about US$143bn, although sustained economic growth in that period means that spending as a percentage of GDP will remain stable.

India has the second-largest population in the world, after China. Life expectancy has been improving, to an estimated 69.9 years in 2009 (67.5 years for males and 72.6 years for females), up from 57 years in 1990 and 37 years in the early 1950s. The infant mortality rate is high, at an estimated 30.1 deaths per 1,000 births in 2009, although this has dropped from around 80 per 1,000 at the start of the 1990s and 150 per 1,000 in the 1950s.

Spending

The private sector will be driving much of the growth in healthcare spending.

Widespread poverty and a lack of investment have prevented a strong domestic healthcare market from taking shape in India. However, building from such a low base and with a strong economic and policy environment, the outlook for growth is promising. Increases in personal income, government healthcare outlays and private domestic investment, combined with longer life expectancy, should lead to average annual growth in healthcare spending (in rupee terms) of around 14% in the forecast period.

Over 80% of healthcare spending in India, including that on pharmaceuticals, is out-of-pocket. Only one-tenth of the population has health insurance, and spending on healthcare is a major cause of indebtedness. Formerly, only state-owned companies were allowed to offer health insurance. However, the market was opened up to private participants in 2000, and in 2007 the government removed the limit on premiums.

The private sector accounts for more than three-quarters of total health expenditure, an extremely high proportion by international standards. The government is keen to encourage this trend; the National Health Policy 2002, which is still in effect, envisages an overall increase in health spending to 6% of GDP by 2010. However, only one-third of this increase would consist of public health investment.

Policy

The government is trying to address India’s severe shortages of healthcare infrastructure.

India has a rudimentary network of public hospitals and clinics, but most healthcare services are provided by the private sector, mainly through independent practitioners. Public hospitals are rare outside large cities, and standards of quality are variable. India is desperately short of doctors, with only 645,825, or 0.6 per 1,000 people, in 2004, according to the WHO. According to the government’s 2008/09 Economic Survey, there was a shortage of 4,833 primary health centres and 2,525 community health centres in 2008. In November 2009 the prime minister, Manmohan Singh, described the shortage as “one of the biggest impediments to strengthening of the public health delivery system and scaling up access to health care”.

The National Health Policy 2002 stresses the importance of developing primary care and public health measures, and supports a greater role for the private sector in widening the extent and coverage of care. Ongoing public health programmes include immunisation programmes, a tuberculosis control programme and an AIDS control programme. The government’s 11th five-year plan (2007/08-2011/12) focuses on improving the health indicators of marginalised groups, particularly women and girls. Among the plan’s explicit goals are reducing the infant mortality rate to 28 per 1,000 live births, halving the rate of malnutrition among children aged 0-3 and halving the rate of anaemia among women and girls.

The policy noted that there was particular scope for private-sector expansion in the urban primary care and tertiary-care sectors, and encouraged the growth of private health insurance. Although hospitals have traditionally been the domain of the state or private trusts and charities, the new-found prosperity of many Indian households is spurring demand for high-quality medical care, transforming the healthcare-delivery sector into a profitable industry. Continued lack of investment in state-owned hospitals and the increasing incidence of so-called lifestyle diseases (such as heart disease, cancer and diabetes) that is accompanying rising incomes will ensure that this trend intensifies. However, hospitals will face two significant challenges as they formulate plans to expand: the high cost of land in urban areas and a growing shortage of nursing staff.

Although most hospitals are overcrowded and understaffed, a number of world-class facilities have sprung up in the past two decades in India’s biggest cities, catering almost entirely to the rich. So well-equipped and well-staffed are these hospitals that India has become a leading destination for medical tourism. The current global economic slowdown appears to be swelling the ranks of medical tourists even more quickly, as rapidly rising unemployment in developed economies increases the incentive for individuals to look for cost-saving options.

Diseases

Malnourishment is a serious problem, reflecting widespread poverty, as are communicable diseases. Levels of infant and adult mortality and morbidity vary widely across states, partly reflecting the differing levels of resources available to state governments.

The National AIDS Control Organisation estimates that over 2.5m people were infected with HIV/AIDS in 2007, a figure that is backed by the Joint UN Programme on HIV/AIDS (UNAIDS). On a global basis India is second only to South Africa in terms of the number of people living with the disease, and still faces great challenges in tackling the virus. Moreover, only 7% of those people have access to treatment. Treatment will become more expensive in 2010-14 as multinational pharmaceutical companies receive patents in India for their AIDS drugs.

Rapid urbanisation is presenting further challenges. Pest-borne and infectious diseases will remain a problem, and the World Bank agreed in February 2009 to provide US$521m to India to control malaria, polio and kala azar (“black fever”, a parasitic disease). Health services will also have to cope with an increase in the chronic and lifestyle-related conditions that are associated with rising incomes and greater longevity.

As China has developed, healthcare spending has risen, leading to an improvement in health indicators. A massive reform programme is now under way.

As with most other economic indicators, healthcare spending in China has risen rapidly, increasing from US$1.7bn in 1980 to US$208bn in 2008. Nevertheless, spending on healthcare remains low by international standards, at an estimated 4.7% of GDP in 2009, despite the sharp rise recorded in recent years. Most OECD countries spend around 8% of GDP on healthcare. The increase in expenditure on healthcare in recent years will continue in 2010-14. This will be partly because of a further rise in incomes (economies tend to spend a larger proportion of income on healthcare as standards of living improve). However, the rise in spending will largely be driven by the government’s healthcare reform agenda, which aims to roll out a basic package of care for the population by the end of the year and universal access to a full range of healthcare services by 2020.

Increased health expenditure has been accompanied by an improvement in health indicators. Between 1982 and 2008 average life expectancy rose from 67.9 years to 73.2 years, while the infant mortality rate fell from 34.7 per 1,000 births in 1982 to 21.2 in 2008. But China’s population is ageing rapidly: the UN expects the proportion of the population aged over 65 to rise from 6.1% in 1995 to 9.3% in 2015, and projects that it will then more than double in the subsequent 20 years, to more than 19% in 2035. This process will increase demand for healthcare.

Spending

Ordinary citizens pay for much of their own healthcare out-of-pocket, particularly in rural areas.

By 2014 the Economist Intelligence Unit expects healthcare spending to have risen to Rmb2.8bn (US$487bn), 63% higher than the level in 2010 in local currency terms. In terms of per-head spending in US dollars, expenditure will have more than doubled from its 2009 level, to reach US$357.

In urban areas, responsibility for financing healthcare has shifted from the government and state-owned enterprises to individuals as the economic reforms of the 1980s have led to more people working outside the state sector. Although it has risen in the past couple of years, in 2005 the proportion of total healthcare expenditure accounted for by the government stood at just 18% (while 30% of the total was accounted for by companies, either state-owned or private). This compares with 87% of total healthcare spending coming from the government in the UK, 82% in Japan and 53% in South Korea.

In 2000 China’s health ministry estimated that 87% of rural patients paid the full cost of medical treatment themselves, with 60% of hospitalised patients leaving early because of their inability to continue to pay. Although rural provision has improved through the introduction of a Co-operative Medical Service in 2003, the system remains deeply flawed, and provision is a long way from being universal. Officials say that 200m Chinese have no insurance.

Policy

China’s reforms intend to expand insurance coverage, improve healthcare infrastructure and bring efficiencies to drug-supply.

To tackle these problems, the government unveiled a series of reform plans in November 2008 in a report entitled Healthy China 2020.

Its main tenets include:

• Developing the national health insurance system. The aim is to reduce the level of out-of-pocket spending and to provide sustainable funding for medical institutions. The ultimate goal is the provision of universal access to healthcare, funded through national health insurance, by 2020. This will be rolled out in stages, with the first priority being coverage for severe disease.
• Improving and expanding the public healthcare infrastructure. This includes the building of 2,000 county hospitals and 29,000 town hospitals. Another 5,000 town hospitals, 3,700 community health centres and 11,000 community health stations will be renovated and improved. China will train 1.4m village doctors and 160,000 community doctors.
• A strengthening of overall public healthcare through the establishment of a national health database, free medical examinations to under-3s and over-65s, and improved pre-natal care. The plans also outlined a host of other measures, from tackling tuberculosis and HIV, to unveiling a hepatitis B vaccine programme, and improving water and sanitation systems.
• Creating a national drug-supply system. The government’s main priority is to control centrally the production and supply of essential medicines. A list of essential drugs will be drawn up, the manufacture, distribution and pricing of which will be controlled by the government.

A major objective of the reforms is to prevent government-owned hospitals from relying on payments exacted from patients for tests, medicine and other treatments. Reports in the state-run press say that more than 90% of hospitals’ income comes from charges (which are often poorly regulated and excessive) for providing services and medicine. Weaning hospitals and doctors off these sources of funds will be a difficult task.

The government plans to publish a list of essential medicines. In the next three years government-run medical facilities will be required to give preference to the drugs on the list, and profits made on them by healthcare providers will be phased out. Providers will receive subsidies to compensate for their losses. Another big obstacle to reform could be a lack of enthusiasm among local governments. Of the planned Rmb850bn in spending, officials say that only 40% will come from the central government. Provincial and lower-level authorities may be reluctant to divert resources to areas that do not produce immediate benefits in terms of boosting employment and GDP growth.

Diseases

China faces serious health challenges, most notably from HIV/AIDS and smoking.

The WHO and the Joint UN Programme on HIV/AIDS (UNAIDS) estimate that there are around 650,000 people with AIDS in China. There is growing awareness of the health risks associated with smoking, in a country where 60% of adult males and 4% of females are regular smokers. The WHO has estimated that smoking kills 1.2m Chinese a year, and there is now a growing resolve on the part of the government to act more forcefully against smoking.

China saw a rapid rise in the number of cases of swine flu (A/H1N1) in the last two months of 2009. By the end of 2009 the health ministry reported that the number of cases of the diseases had risen to 120,940, with 659 deaths. However, the health ministry also reported that that almost 50m had received a vaccination.