China Education System

Primary Education

In China, primary school education is compulsory and it lasts 6

years. Children start schools at age six (seven in some areas).
The language of instruction is Mandarin Chinese with the
exception of the primary schools that mainly admit ethnic
minority students. A typical school year is comprised of two
semesters and runs from the month of September to July. Students
attend classes five days a week and primary school education
currently includes nine compulsory courses, which include
Chinese, Mathematics, Social Studies, Nature, Physical
Education, Ideology and Morality, Music, Fine Art, and Labor
Studies. Foreign Language is normally offered as an elective
course. In order to graduate, all students are required to pass
graduation examinations in the subjects of Chinese and
Mathematics. The examinations are normally designed and
administered by schools with guidance from local educational
authorities. Students move on to 3-year junior (lower) secondary
schools after graduating from primary schools.

Middle Education

Junior (lower) secondary education lasts three years following

the completion of primary school. In order for students to
obtain a certificate of graduation, students are required to
pass graduation examinations and meet minimum physical education
standards. The graduation examinations are designed and
administered by individual schools according to guidelines set
by the provincial educational bureaus or by local educational
authorities. Students are typically examined in the following
subjects for graduation: Chinese, Mathematics, Chemistry,
Physics, Foreign Language, and Politics. Completion of junior
(lower) secondary education also marks the end of a 9-year (6+3)
compulsory education program.

Secondary Education

After the completion of junior (lower) secondary school,

students can choose to enter either general (academic) senior
secondary school or vocational senior secondary school. General
(academic) senior secondary school lasts 3 years and vocational
senior secondary school lasts 3 or 4 years. Senior secondary
school is known as and vocational senior secondary school is
known as in China. Students wishing to continue their study in
the general (academic) track must pass the entrance examinations
for general senior secondary schools, which is also known as
China. Designed and administered by provincial educational
authorities, the entrance examination includes the same subjects
as the junior secondary graduation examination. At the end of
their final school year, graduates of senior secondary schools
seeking admission to post-secondary education are required to
take the National Higher Education Entrance Examination, also
called National College Entrance Examination (NCEE), commonly
known as in China.

Vocational Education

Vocational education programs are offered at both the secondary

and post-secondary levels. Vocational senior secondary schools
provide subject and occupation specific education and training.
Vocational senior secondary education is highly employment
oriented and graduates normally enter the workforce. However, it
does offer some access to further education, particularly in the
technical/vocational specialties. Since the year 2000, the
Ministry of Education (MOE) has allowed graduates of vocational
secondary schools to take the NCEE and be admitted into higher
education programs.

Higher technical/vocational education is available at the level,

which require two or three years of full-time post-secondary
study. It is possible for graduates of higher vocational
education programs at the zhuanke level to obtain a "benke 本科"
degree (Bachelor’s degree) certificate through an upgrading
program, but in a limited number of fields. Vocational higher
education institutions are currently administered at the
provincial level.

Tertiary Education

Higher education is provided by institutions of various types

including general and technical universities, specialized
institutions, professional universities, military institutions,
medical schools and colleges, independent colleges, and adult
higher education institutions of various types. Entry to
university depends primarily on how well the students perform in
the entrance examinations. Students with outstanding academic
performance in their secondary schools can also possibly be
granted an exemption from the entrance examination and be
recommended directly to the university of their choice through a
method called (baosong 保送). In addition, some private
institutions are exempted from the NCEE (gaokao) and accept all
students who can afford the tuition fees. Prestigious
universities (key institutions) maintain higher admission
standards, and therefore require higher NCEE (gaokao) scores
than other institutions. Entry to higher education in China is
highly competitive.
THE CHINESE HEALTHCARE SYSTEM: HOW IT WORKS AND FUTURE TRENDS

E D O A R D O M A R I A N O F R I 1 3 NOVEMBRE 2015 0

GENERAL INTRODUCTION
Health care spending in China is increasing rapidly. According
to a Deloitte report released in 2015, the country’s annual
expenditure is projected to grow at an average rate of 11.8
percent a year in 2014-2018, reaching $892 billion by 2018.
Spending will be driven primarily by consumers’ rapidly
increasing incomes and the government’s public health care
reforms.

Despite these positive numbers, China’s health care spending, at

an estimated 5.4 percent of gross domestic product (GDP) in
2013, is still much lower as compared to OECD countries. The
country also has a large health care demand gap due to an aging
population, growing urbanization, proliferating lifestyle
diseases, rapidly increasing consumer wealth, and the
advancement of universal health care insurance. While all of
these elements are driving overall health care market expansion,
continued development cannot proceed without heavy investment by
and strong support from the Chinese government.

China is a vast country with uneven economic development. Rural

and urban residents are categorized separately according to the
household registration system (hukou), and the government
financing systems is different for the two categories of
citizens.

After the economic reforms started in 1978 China experienced

rapid economic growth in the past two decades, benefiting many
sectors of the economy. However, the economic success was not
mirrored in the healthcare system. The transition from a
centrally planned economy to a market‐oriented economy has caused
problems in the public health arena.

There have been several debates regarding China’s healthcare

reforms in recent years. Critics, composed primarily of
individuals from outside the Ministry of Health, have labeled
the past reforms as failures, attributing it to the excessive
dependence upon market mechanisms in the healthcare sector. Yet
supporters, composed of individuals from within the Ministry of
Health, have asserted that past reforms were relatively
successful, pointing to the fact that the problems associated
with the shortage of health services and drugs during the period
of the planned economy have largely been resolved.

In response to the emerging problems in its healthcare system,

China has made numerous attempts to rebuild universal coverage
system since the late 1990s. The health insurance system
collapsed in the late 1970s, and a great number of residents
left uninsured. Through decades of effort, the Chinese
government has developed three systems, in both urban and rural
areas, which provide coverage for more than 90% of the
population. The condition was especially troublesome in rural
areas, revealing sharp rural‐urban disparities in health
insurance coverage and related healthcare services and costs.

Starting from the late 1990s, the government established three

new health insurance systems. During the launch of each new
health insurance scheme, the government also proposed other
measures to provide more healthcare resources to the targeted
population. In 2009, the government started a new round of
healthcare reform. In the new round of reform, the major goal
was to provide universal coverage to all residents, and to
target on disadvantage population to improve the healthcare
service for them and reduce disparities.

According to a statement by the State Council, the goal of

universal coverage is to provide safe, effective, convenient,
and affordable basic medical services to all urban and rural
residents. One of the most important components of universal
coverage is health insurance. Before this goal of universal
coverage was officially introduced in 2009 with the Chinese
government’s announcement of the blueprint for health system
reform, health insurance reforms in both urban and rural areas
had resulted in greater health insurance coverage. Three major
health insurance schemes were established. The Urban Employees
Basic Medical Insurance (UEBMI) was launched in urban areas in
1998, and the Urban Residents Basic Medical Insurance was
launched in 2007. In rural areas, the New Rural Cooperative
Medical Insurance (NRCM) was established in 2003. Below follows
a brief introduction to each scheme.
  The Basic Medical Insurance for Urban Employees

In 1998 was set the Urban Employees’ Basic Medical Insurance

System. This was the first step in re‐establishing the health
insurance system in urban areas. The Urban Employees Basic
Medical Insurance (UEBMI) is compulsory based on employment. It
provides basic medical insurance coverage for urban employees in
both the public and private sectors. Local governments, mainly
at the municipal level, set the level of deductibles,
copayments, and reimbursement caps according to local economic
levels. The UEBMI is financed by premiums from both employers
and employees. In their decision, the State Council suggested
that the employers’ contribution be 6% of the employee’s salary
and the employees’ percentage be 2%. The revenue collected from
premiums is distributed evenly into two independent accounts:
the medical Savings Account (MSA) and the Social Pooling Account
(SPA). All employees’ contributions and

about 30% of employers’ contributions go into the MSA, and the

remainder of the employers’ contributions goes to SPA. The two
accounts are managed separately and pay for different services:
the MSA covers outpatient and emergency services and drug
expenses, and the SPA covers inpatient services.

 The Basic Medical Insurance for Urban Residents

In 2007, the State Council issued guidelines to launch the Urban

Residents Basic Medical Insurance (URBMI). According to the
guidelines, the URBMI covers primary and secondary school
students who are not covered by the UEBMI (including students in
professional senior high schools, vocational middle schools, and
technical schools), young children, and other unemployed urban
residents on a voluntary basis.

The main purpose of the guidelines is to provide coverage for

urban residents without formal employment with the intention of
eliminating impoverishment resulting from chronic or fatal
diseases, which can lead to catastrophic medical expenditures.
The URBMI was piloted in 79 cities. In 2010, this insurance
scheme was expanded nationwide and gradually extended to all
unemployed urban residents. The financing of this insurance
program mainly comes from participants’ premiums. The government
also provides a smaller amount of subsidies, compared to the
premium contributions. The premium of the policy is determined
by the local government, according to the local economic level,
the medical care expense level, and the participants’ household
income level. There are extra government subsidies for low‐income

families, disabled students, and young children.

 The New Rural Cooperative Medical Insurance

In recent years, especially since the SARS outbreak in 2003,

healthcare reform, primarily in the rural regions of China, has
received unprecedented attention from the central government.
While a rural health insurance system had existed in China prior
to its economic reforms, it floundered during the early 1980s
primarily because of the collapse of the rural collective
economy. As a result, some 90% of the rural population was left
without any type of health insurance coverage. In 2003, the
State Council issued the decision to further enhance the rural
health care system, aimed at re-establishing the new rural
cooperative medical insurance (NRCM). The NRCM scheme covered
the rural residents on a voluntary basis in order to avoid
impoverishment caused by catastrophic expenses from infectious
and endemic diseases.

The NRCM was piloted in 2003 in selected counties. In 2010, the

NRCM covered more than 90% of all rural residents. The NRCM was
funded by premiums from both the insured and by subsidies from
the local and central governments. This was the first time that
Beijing had allocated funds from the central government budget
to support a rural health insurance plan. The NRCM provides
partial coverage for all kinds of medical expenses, excluding
some outpatient expenses and drug expenses. The reimbursement
caps vary by local economic development levels. The initiation
and expansion of the NRCM diminished the disparities in health
insurance coverage; however, it is still unknown whether the
expansion helped reduce disparities in other healthcare areas,
such as healthcare utilization and cost.

A brief overview of the three main insurance schemes is provided

in the table below, taken from RAND’s report on “China’s Health
Insurance Reform and Disparities in Healthcare Utilization and
Costs”