International healthcare leadership challenges and China’s healthcare reforms​
Steering reform through uncharted waters [4]

International healthcare leadership challenges and China’s healthcare reforms

Promises and prospects for leading in the public interest

This article draws on the four global healthcare leadership challenges that exist in any healthcare system in any part of the world, and which drive the recent introduction of the University of Manchester's Masters of Science (MSc) International Healthcare Leadership programme which expands in March 2019 with the introduction of the programme in Shanghai. I want to explore these leadership challenges within the context of healthcare reform in China, which has been informed by discussions during my latest visit over the last three days in Shanghai.


This afternoon, our China centre Director Sherry Fu, Weiyan Chen, Course Counselor and Marketing Officer, and myself, were hosted by Christine Lee, the Associate General Manager of the United Family Healthcare hospital at Pudong when we discussed the promises and prospects of the current process of healthcare reform in China.



The four challenges that apply to any healthcare system include:

• Ensuring that everyone has access to different levels of healthcare in a timely, cost-effective and seamless manner (universal access and - according to the World Health Organisation - a fundamental human right).

• Giving prevention as much priority as treatment and recognising long term benefits.

• Delivering healthcare across a range of public/private and hybrid systems.

• Integrating care across diverse primary, secondary and tertiary providers.

The unprecedented reforms taking place in China provide significant opportunities, but many leadership challenges remain in taking this forward. There is a clear commitment to make a difference. The Vice Premier Li Keqiang described the government’s goal as that of establishing “a universal basic health-care system providing safe, effective, convenient, and low-cost health-care services by 2020.

Chinese Healthcare System Reforms

A changing market

The increase in spending on China’s healthcare system has experienced phenomenal growth. This has recently been evidenced by the recognition that the Chinese nurses’ workforce has greatly expanded in the 5 years up to the end of 2015, with the number of Chinese registered nurses reaching 3.2 million, with almost two-thirds holding higher associate degrees[1].

However, Cheng et. al. tell us that social and economic development, disease spectrum changes, accelerated ageing and a constantly improving quality of life have increased the urgent demand for quality, safety and cost-effective care. This has also paved the way for the flourish of evidence-based nursing in the Chinese healthcare system. At a broader level, spending is projected to grow from $357 billion in 2011 to $1 trillion in 2020 with increases evident from pharmaceuticals to medical products to consumer health [2].

Leadership remains the key mechanism for driving this forward. 

If we consider the four global leadership challenges from an external contextual analysis, there is a real commitment from the political and economic environment to match the continuation of economic improvements with changes in the social context as a result of significantly changing demographic trends. Drawing on mechanisms of reform, such as improvements in infrastructure, the rollout of universal insurance coverage and the encouragement of innovation, the prospects look promising. Having existed with a landscape dominated by large public hospitals managed by the Ministry of Health and local government, in 2012 the Chinese government announced ambitious plans to develop the private healthcare sector, in order to relieve the strains on the public healthcare system resulting from the rapid ageing of the population [3]. We saw an excellent example of this in Pudong this afternoon, but to what extent do the promises apply with public healthcare?

Collective leadership can create the conditions where evidence-based leadership (EBL) and evidence-based practice (EBP) can build on the experience of evidence-based medicine (EBM) in putting patients at the heart of what Chinese healthcare leaders do. The most common definition of Evidence-Based Practice (EBP) is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” (Sackett D, 1996) From a leadership perspective, we can build on this in promoting a style of leadership that uses the best evidence in decision making in supporting the public interest by integrating collective expertise and systematic research that impacts the public good.

It is not without risk. 

Multi-National Corporations (MNCs) may be ‘chewing at the bit’ to get a slice of this reform (as they are in other regions such as the Middle-East), but the reforms are equally aimed at reconciling low-cost universal health-care coverage with rewards for innovation. I make a distinction between ‘globalisation’ (in which MNCs will relocate to a new region but provide the services in an identical way as elsewhere across the globe) and ‘internationalisation’ (where the relocated services will be tailored to local contexts). In the case of China’s healthcare reforms, such MNCs will need to take full account of the reforms’ aims to encourage innovation by ‘local champions’; intentions to enter this changing market will need to consider the benefits of forming strategic alliances in creating market opportunities and targeting new customer segments through partnership within the region. The value chain will be ever more complex particularly as the government is seeking 20 to 30 percent price reductions on high-value consumables, so this is not a cash-rich opportunity.

What about the patient?

Changes are being made to the infrastructure, insurance coverage and the improvement of inequalities of access to health and fragmentation of healthcare services. Improvements to the infrastructure are required more in smaller cities and rural areas, which appears to be a key aim of the reforms, together with a smoothing out of the disparity between overcrowding in the larger hospitals in major cities and the underuse of facilities in smaller cities and smaller communities, where there is less confidence in the quality of healthcare. It is further acknowledged by the reforms that a significant challenge remains for reforming public hospitals, a legacy from the inherited healthcare landscape.

It is reported that ninety-five percent of the population is now covered by government insurance programmes, although coverage remains basic and many provinces do not provide outpatient coverage. Where this is provided, co-payments are still quite significant although an aim of the reform is to reduce co-payment and raise annual caps. In terms of government stewardship, this will inevitably increase both regulation and levels of intervention and render market penetration more problematic.

To reduce fragmentation, and tackle what has long been an imbalance, one of the major themes of the reform is to strengthen primary care, the gateway to the healthcare system. The intended introduction of community-based facilities such as community-health centres, within locally tiered networks and more locally based hospitals, currently less well funded than, and more fragmented from, secondary and tertiary care, will be essential together with improved referral systems between primary-secondary-tertiary healthcare. As the World Health Organisation advocate, prevention starts with primary care.

The leadership challenges

Given the significant changes being proposed across most elements of Chinese healthcare, education is paramount, and a key aim is to improve the quality of care through primary mechanisms with an intention to train general practitioners and allied health professionals. As we recognise in other international healthcare systems, a key priority is to encourage the development of healthcare leaders; clinicians and non-clinicians alike. This is particularly important in supporting the intended infrastructure reforms and, indeed, to ensure that prevention is given as much priority as treatment. Given that chronic long-term conditions are increasing exponentially, and, with the expected rise of the elderly population, prevention must be a key feature of the collective leadership that is required to ensure that the reforms achieve their ambitious outcomes and improved integration between primary, secondary and tertiary care will be critical to this.

The success of leadership should be as evidence-based as is the case with medicine. Clinicians have to follow rigorous re-accreditation of their skills given the fact that people’s lives rely on this. Those who lead healthcare organisations make decisions that can have an even more significant impact on people’s lives and yet their leadership does not require such re-accreditation nor, indeed, accreditation in the first instance. Critically, leadership of healthcare resources - whether this relates to the national stewardship of healthcare resources (irrespective of its public or private provision) or the decisions being made by grassroot leaders - should be values and ethics based and driven by the needs of the patient and the public. 

Putting the patient at the heart of what healthcare leaders do is the underpinning golden thread of our leadership development programme for International Healthcare Leadership, supported by three further threads emphasising a focus on international perspectives (for shared learning and practice), leading through networks (as healthcare networks become more complex) and in encouraging creativity and innovation (by creating the conditions for leaders to ‘think out of the box’ and do things differently). As the pressure on the stewardship of funding becomes more central to decision making and in steering the world’s largest healthcare system through its uncharted waters [4], collective leadership will be the key to its success.

References

 [1] Cheng, L., Broome, M. E., Feng, S., & Hu, Y. (2017). Factors influencing the implementation of evidence in Chinese nursing practice. Journal of clinical nursing, 26(23-24), 5103. doi:10.1111/jocn.14053

 [2] Le Deu, Franck, Parekh, Rajesh, Zhang, Fangning and Zhou, Gaobo (2012) Health care in China: Entering ‘uncharted waters’, https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/health-care-in-china-entering-uncharted-waters

 [3] Understanding China’s Emerging Private Healthcare Market , Asian Healthcare Titans 2016 , A report by The Economist Intelligence Unit, http://graphics.eiu.com/upload/topic-pages/China-Healthcare/Clearstate-China-Understanding-the-Emerging-Private-Hospital-Sector-(2015).pdf

[4] Li Keqiang made this remark during the China national conference on the deepening healthcare reforms as China’s vice-premier and leader of overall healthcare reform agenda (see Le Deu et.al above).



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