China released its National Mental Health Working Plan (2015–2020) in June 2015. Addressing the undersupply of mental healthcare is the major task set in the plan. According to research published in the Lancet, a leading medical journal, the one-month prevalence rate of any mental disorder for adults in China was about 17.5% from 2001 to 2005 (Phillips et al., 2009). This rate indicates that over 170 million adults are suffering from at least a type of mental disorder in China. Of these patients with mental disorder, over 158 million adults have never received any treatment. It is also estimated that the number of people with serious mental diseases in China is 16 million. The registered number of people with serious mental diseases was about 4.3 million in 2014.
Given the large number of people with mental diseases, mental health is a major public health issue in China for three reasons. First, huge economic and social costs are imposed on other members in the community, including family members and colleagues in the workplace. Family and community members need to take care of people with mental disorders by providing effort and spending resources. It was reported in 2014 that among all diseases, mental disease outranked the rest in terms of disease burden in China (Beijing Youth Daily, 2014). Second, suicide is a major public health issue. Mental disorders such as depression and schizophrenia are leading reasons for suicide (World Health Organization, 2001). Third, mental disorders are associated with criminal activities. Psychiatric patients are more likely to be linked to use of weapons and violent behavior.
Development of Mental Healthcare in China
Before 1949, there were only five psychiatric hospitals staffed by around 60 psychiatrists, an arrangement mostly initiated by western missionaries. Since the 1950s, various types of psychiatric institutions have been built including day and night hospitals, community follow-up programs, home care services, etc. In 1985, the number of mental healthcare institutions was 320 with 64,000 beds (Qian, 2012).
Since the 2000s, after massive economic and social changes, the prevalence of mental diseases has rapidly increased.
In recent years, the capacity to provide mental healthcare services has increased. The number of institutions further increased to 1,650 by 2015. The number of beds was over 260,000 in 2013 and the growth rate in the number of beds was about 9.5% between 2007 and 2013 (Ministry Of Health, various years). The number of psychiatrists was more than 20,000 and psychiatrists per 100,000 people reached 1.49 (National Health and Family Planning Commission, 2015).
However, the demand for mental healthcare has increased even faster. The utilization of mental healthcare was low in the pre-reform era as mental health was believed to be mainly a product of a capitalist society. In many cases, people with mental disorders usually did not realize the existence of mental diseases. Their visits to the doctor were usually a misinterpretation of mental disorder as physical pain. However, since the 2000s, after massive economic and social changes, the prevalence of mental diseases has rapidly increased. The incidence of mental disease has increased from 27 per 1,000 in the 1950s to 175 per 1,000 in the 2000s (China Daily, 2012).
Undersupply is a Big Issue
The major issue now is the undersupply of mental healthcare. In 2013, there were 1.9 beds per 10,000 people for mental healthcare in China, compared with the global average of 4.4 beds per 10,000 people. From a recent talk published by Xinhua, the number of nurses working in psychiatric hospitals in China is 1.91 per 100,000 people while the global average is 12.97 per 100,000 people.
In addition, the bed utilization rate increased from 73.6% in 2000 to 96.5% in 2013. This high utilization rate suggests an increasing shortage of mental healthcare services. In 2013, the number of inpatients was over 1.6 million. The number of mental patients admitted to hospitals had increased by 13.2% annually between 2007 and 2013, significantly higher than the growth rate of hospital beds (Ministry Of Health, various years). The growth rate of outpatients for mental healthcare services increased at a similar rate of 12.2% annually between 2007 and 2013, which significantly outpaced the 8% growth rate for overall outpatient services. The volume of outpatient visits for mental healthcare services reached 34 million in 2013. With greater awareness of the importance of mental health, the utilization of mental healthcare services is likely to increase in the future.
The undersupply of mental healthcare for some vulnerable social groups remains outstanding. The mental health problems of low income groups are particularly undertreated. According to an article published in the scientific journal PLOS One in 2015, the major reason that relatives gave for restraining people with mental diseases in their home was “financial difficulties” (96%) (Guan et al., 2015). The other vulnerable group is young people. It is estimated that at least 30 million people under 17 years old have been diagnosed with mental disorders in China. Over 200 million migrant workers in China constitute another vulnerable group. Migrant workers, who are away from their family and have a heavy workload, are susceptible to mental disorders. A recent self perception survey shows that over 40% of migrant workers have shown symptoms of mental disorder in Guangzhou.
Policies for Increasing Supply
China’s first national mental health law was enacted by the National People’s Congress in 2012, with the law taking effect on May 1, 2013. According to this law, both the central and local governments will increase their fiscal inputs to support mental healthcare. All counties or cities are to provide community level mental healthcare services. Preventative efforts should be set as a priority and most services will be provided from the community level.
Now, China has reached the threshold level for expenditure requirement for mental healthcare recommended by WHO (i.e. 2% of total health expenditure). The share of mental healthcare expenditure in total health expenditure is reported to be about 2.35% in China (Xinhua News Agency, 2015). However, the expenditure share in China is still lower than the world median for mental health expenditure as a share of total health expenditure, 2.82% (World Health Organization, 2011).
The total number of privately owned psychiatric hospitals increased from 90 in 2010 to 214 in 2014.
The recently released National Mental Health Working Plan (2015–2020) highlighted community level care as the future direction of mental healthcare. In particular, the infrastructure of county level psychiatric hospitals as well as community level clinics for mental healthcare will be upgraded. By 2020, 80% of people with severe mental illness will have access to continuing medical treatment. Also, the number of psychiatrists will be doubled to over 40,000 by 2020 (National Health and Family Planning Commission, 2015).
Apart from increasing government inputs, the other solution to increase supply of mental healthcare proposed by the Working Plan is to encourage the entry of the private sector. The growth of the private sector in mental healthcare has been very fast in recent years. The total number of privately owned psychiatric hospitals increased from 90 in 2010 to 214 in 2014. It was estimated by the consultant company Frost & Sullivan that the total revenue of privately owned psychiatric hospitals will increase from RMB 5.1 billion in 2014 to RMB 13.6 billion in 2019, with an over 20% annual growth rate.
A recent outstanding case of a privately owned psychiatric hospital is the Kangning hospital group. Kangning hospital group manages nine hospitals, all of which are located in Zhejiang province. It is now ranked as No. 2 in terms of market share of psychiatric hospitals in China. Kangning hospital group accounts for 5.8% of market share, just next to the Shanghai Mental Health Center (whose market share is 6%). In 2014, the total number of beds in the Kangning hospital group was 2,210 and the amount of net profits in 2014 reached over RMB 51 million. In November 2015, Kangning hospital group’s Hong Kong IPO raised about $80 million for its further expansion (Southern Weekend, 2015). It suggests the high confidence of investors in the future growth of this sector.
However, there are some issues for the development of the private sector. First, doctors of private hospitals are restricted in gaining professional recognition in terms of granting of professional rank, research projects and participating in academic activities, etc. Second, the status of social insurance designated hospital is important for private hospitals. However, private hospitals face restrictions in obtaining such designation. Third, regional health resource plans, which are formulated by the local health authority, sometimes impose restrictions on new entrants in the health service sector.
To increase the supply of mental healthcare, both government inputs and the entry of the private sector are important. The government should commit to the goals set in the National Plan for upgrading both the physical infrastructure and other capacity to deliver mental healthcare services. Supplying services to vulnerable groups should be prioritized in particular. For the development of the private sector, some complementary policies including relaxing strict regulations and addressing insurance designation bias against private hospitals should be considered.
Guan, L., et al. (2015). Unlocking patients with mental disorders who were in restraints at home: A national follow-up study of China’s new public mental health initiatives. PLoS ONE, 10(4), e0121425. doi: 10.1371/journal.pone.0121425.
Ministry of Health (Various Years). China Health Statistical Yearbook. Beijing: Peking Union Medical College Press.
National Health and Family Planning Commission (2015). National Mental Health Working Plan.
Phillips, M., et al. (2009). Prevalence, treatment, and associated disability of mental disorders in four provinces in China during 2001-05: an epidemiological survey. Lancet, 373, 2041-2053.
Qian, J. (2012). Mental health care in China: providing services for under-treated patients. The Journal of Mental Health Policy and Economics, 15(4), 179-186.
World Health Organization (2001). The World Health Report 2001: Mental Health: New Understanding, New Hope.
World Health Organization (2011). Mental Health Atlas.