How Will Health Care Design in China Be Impacted by Social and Health Policies, and Demographic and Population Health Trends?

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What is the Aim

Much has been written about China’s health care system and the strides it has made in public health, but less attention has been paid to the physical environments this progress has made within. There is a lack of coherent information regarding China’s health policies and demographic trends as they relate to the design of health care environments. Health care design is inextricably linked to the achievement of government targets in public health and should be taken as seriously as improvements in education, funding and human resources.

This report aims to provide key areas of focus for the planning and design of health care facilities in China to ensure that facilities designed and built in the coming years can cope with existing and future challenges as well as actively contribute to the achievement of government health goals.

What We Did

Data and information from publicly available government policy documents and national health statistics, reports and data from international non-government organisations, and journal articles regarding contemporary conditions in China’s health care system were compiled and analysed.

Data and information were collated to form a clear story of China’s current health care market and population health as well as aims for them in the coming years in relation to the design of health care facilities in the country. Although the government publishes annual statistics, it is not always clear how the figures have been reached and the years for comparison are not always consistent. Meanwhile, some publications provided more detail regarding how the statistics were calculated than others. This meant that the author used as many documents as possible to gather trend data on various health statistics.

What We Found

Four key impact areas emerged from the study:

The Urban-Rural Divide
The urban-rural divide in China’s health care is one of the biggest problems the nation’s policymakers face. It can be seen most keenly in the differences in infant mortality rates. While infant mortality is decreasing rapidly across the country, in 2017 the rate for rural areas was still almost double that of urban.

National Health and Safety Commission of the People’s Republic of China, 2017 Department for Environment, Food & Rural Affairs, 2017

By 2030 it is predicted that there will be an additional 61 cities with populations of one million or more in China. Narrowing the gap between urban and rural health is a key target of current Chinese health policy. As China’s population swells and urbanizes in the coming decades, health care environments must be ready to accommodate these changes. Planners should focus on flexibility, for example, modular systems could be implemented to enable maximum future elasticity in urban centres.

In addition, a method of elevating the quality of rural primary health facilities could be developing a standardised unit that can be replicated across the nation. Through unity, a higher level of quality control and equality of provision could be achieved. The targeted improvement of the quality of the built environment of rural primary health facilities will be a prerequisite for reducing the urban-rural divide.

Health Insurance and Current Health Policy
In 1998 China began a social medical insurance system to cover the basic medical needs of workers. This has since expanded to achieve more than 95% (basic) coverage of the total population in 2014 (Chen & Xu, 2016).

An impact of increasing levels of medical insurance coverage and strengthening primary health care to engage people to make better decisions about their health and health-seeking behaviours, will be a reduction in hospitalizations and emergency care use as well as improved outcomes and patient satisfaction (China Joint Study Partnership, 2016). With current health policy and government targets aiming to improve primary health care and address imbalances in the insurance system to encourage people to use primary care, the current strain on ED and outpatient hospital space may well be reduced. Therefore, while some health care environments (Primary & Community Health) need to increase in capacity and improve in quality of design, other areas (Emergency and Hospital Outpatients) should reduce in required capacity in line with these moves aimed at reducing the hospital-centric nature of China’s health care system. It is therefore a risk to only build larger facilities to accommodate current challenges of volume. Flexibility in programme and spatial requirements should be incorporated for when these challenges shift and subside.

The State Council Information Office of the People’s Republic of China, 2017

The One Child Policy and Demographics
The infamous family planning policy limiting how many children a couple were permitted to have was introduced in 1979 in an effort to prevent the crisis in population size that was predicted in the following century. The most noticeable impact of the Policy, and the most threatening to the health care system, is that of the increasing proportion of the elderly population. The impacts of the One Child Policy mean that China’s Old Age Dependency ratio is projected to more than triple between 2015-2050 (United Nations, 2017) putting an unprecedented burden on the children and grandchildren of the elderly.

With no mature elderly care market to ‘fix’, and a culture that prioritizes ageing at home under the care of family members, China needs to carefully consider how to best provide the medical, social and emotional care for its ageing population. China has an opportunity to create new typologies, in design, function and operation models, unique to its needs.

Extracted from data contained in the United Nations, 2017. World Population Prospects: The 2017 Revision, Volume II: Demographic Profiles

The End of the One Child Policy Relating to the Care of Women and Children
The recent changes to family planning policy in China is a significant change and impacts family dynamics, and attitudes to the treatment of pregnant women and children. In China the rate of intervention during delivery has been especially high. In 2014 Chinese reports on the national average caesarean rate ranged from 38% – 58% while the UK’s caesarean section rate was 26%. The reasons for China’s high caesarean rates are complex and include demand side drivers such as women requesting the procedure as they feel it is safer or they fear vaginal delivery, and supply side drivers such as financial incentives resulting in caesarean sections becoming an increasingly important source of revenue for hospitals (Liang, J., et al. 2018).

Hellerstein, S., Feldman, S., Duan, T., 2014

From each of these key impact areas two design recommendations or opportunities were extracted:

  • Urbanization requiring growth and flexibility in health care
  • A focus on health care environments improving rural health
  • Improving the patient-doctor interaction through waiting design
  • Impacts of prioritising primary health on facility requirements
  • Elderly population’s needs from design
  • Need for China specific elderly care typologies
  • Impact of LDR design on cesarean section rate targets
  • Paediatric design considering shifting family structures

The results are presented in the form of  a written report supported by graphs, tables and other graphics to visually represent data and conclusions.

What the Findings Mean

HKS is a global firm working all over the world, including in China’s health care market. It will be beneficial to designers and planners to understand problems and opportunities that exist in the health care market in 2019, and those that might develop over the next decades, to ensure that the facilities we design today continue to serve users’ needs and government objectives for years to come.

This knowledge, and further knowledge built from this report, will enable designers to directly contribute to the achievements of public health targets in China. 


Team Members:
Sophie Crocker

Health Fellowship