Bernhard Schwartländer has been the World Health Organization (WHO) Representative in China since 2013. Prior to that, he held positions in organizations such as UNAIDS, the World Bank and the Global Fund to Fight AIDS, Tuberculosis and Malaria.
The German national has worked in China before: between 2007 and 2010, he was the UN Country Coordinator on AIDS in Beijing; and in the early 1990s, he came to the country to investigate sexually transmitted infections in the context of public health.
Over time, Schwartländer has seen China rapidly change. With the growing economy, many public health-related problems have been addressed, including access to health insurance and the transmission of infectious diseases. But vulnerable communities persist – especially in rural areas and the western interior. Despite China’s rising standard of living, there are still 70 million people who are stuck in poverty; 40 percent of them end up there because of health problems, Schwartländer said.
The WHO representative sees his role and that of international organizations in China changing. It used to be that WHO helped the country to provide health services, which is what the organization generally does in developing countries. But now, WHO’s work is centered around improving exchanges between China and other countries in research and medicine development, including helping the China Food and Drug Administration (CFDA) to achieve international standards; and in finding “out-of-the-box” solutions to various problems.
Financing has changed as well. With China’s economic growth, project funds from other countries have basically dried up.
“There’s not a single (government) donor that gives us money for projects in China because they all say, ‘China has enough money; we bring our money to Africa,’” Schwartländer said. “It was a huge change also in terms of the projects and what we do.”
The office now receives project money from new sources, including foundations such as Bill and Melinda Gates Foundation and Bloomberg Philanthropies, which are interested in improving China’s drug regulatory system, tobacco control and road safety.
As in other countries, WHO works closely with the Chinese government to support new laws, run pilot projects and – most daunting of all – implement the country’s comprehensive health reforms.
In the 2000s, China began a wide-reaching health reform. It was probably the biggest project of its kind in the world, first because of China’s size, and secondly because it was trying to bring “a fundamentally dysfunctional system into modern times,” Schwartländer said.
He recalled his first professional trip to China, in the early 1990s. “In my naïve mind I was always thinking that this is a good socialist health care system, where everybody had full access to health care,” he said. “But I very quickly recognized that in many ways this system is totally driven by money.”
Because doctors had extremely small salaries, a system was created in which they were putting markups on services and medicines in order to make a living and support the hospitals. In some cases, doctors would buy MRI or CT scan machines as investments, knowing that eventually they would turn a profit. The quality of health care depended on how much money the patients were willing, or able, to pay. In some cases, if the patients couldn’t afford the medicine, they were left to die.
That still happens today for some diseases that aren’t covered by insurance schemes, Schwartländer said.
“I think the health care system has significantly improved, and it’s now really a question of quality,” he said. “People are covered by basic insurance schemes. The problem today is that the scheme doesn’t cover enough. Many of the very expensive drugs, for cancer or (other diseases), are not really included (…) If you’re not covered for something that’s not part of the essential drug list, you still may get in the situation that you will not survive a very serious disease because you can’t afford access to the medicines and the treatments.”
Another challenge is the downfall of primary health clinics, or family doctors, the WHO representative said. Because primary-care doctors couldn’t add substantial markups to their services, both doctors and patients gravitated toward specialized hospitals. That explains why most Chinese hospitals are constantly overcrowded.
A system that relies almost entirely on specialized hospitals is much too expensive, Schwartländer said. So China is now working on building a “tiered system,” where people are placed in primary clinics or specialized hospitals and moved from one tier to another depending on their needs.
China’s International Role
As China’s economy has shifted, so has its position in the international arena for health care and research.
Other countries have stopped financing WHO projects in China that would be typical for developing countries. But instead organizations are showing interest in research and medical collaboration, as well as bringing the regulatory system up to international standards.
The Bill and Melinda Gates Foundation wants to help upgrade the Chinese regulatory system to boost innovation in the pharma sector, Schwartländer said. Similarly, Gavi, the Vaccine Alliance, supports a program through which Chinese-produced vaccines are “pre-qualified” by WHO, which ensures they’re produced at international standards.
“It’s a very different strategy, how we engage China as a partner,” Schwartländer said. “On one hand, where can we really help in their own development, but then how can we engage China as a very active and helpful partner globally in terms of innovation of health products: pre-qualified vaccines, pre-qualified drugs, which can be produced at high quality and much cheaper here.”
In its relations with the Chinese government, WHO brings in foreign experts for meetings with government officials; gives assistance for legal initiatives such as banning smoking in public places in Beijing, and soon possibly all over China; supports other projects such as the “Healthy Cities” program, which aims to engage mayors across China in building healthier environments; and offers feedback on various areas of diseases.
Currently, China could do better in managing hepatitis and tuberculosis, Schwartländer said. In the area of AIDS, which is his specialty, the WHO representative said the HIV crisis related to the black blood market in the 1990s has been fully contained. But there’s recently been an upsurge in the spread of HIV in urban gay communities. The issue would require a more open conversation about health risks among gays, and the strengthening of the NGO culture, he said.
In his years in China, Schwartländer says he’s learned it’s important to build his partners’ trust and offer feedback that includes possible solutions.
“I personally spend a lot of time, and I read a lot in social media to understand where things are going, and then what’s the wheel that I can turn to change something a little bit,” he said. “It’s small wheels that we have because I don’t have billions of dollars. But sometimes I need to find the small wheel that might make a big difference because you suddenly reach somebody with an idea who then can translate this into action.”