Improving the public health services that are available to all citizens should be pursued as one of main purposes of a strategy of large-scale urbanisation. However, in China, the improvement of health services is of much lower priority than efforts to build factories and transport infrastructure in order to generate and sustain the levels of economic growth that has come to define the country’s hyper-urbanisation. The resulting spatial structure of rapidly growing megacities in China, coupled with its institutional history, creates a distinct relationship between urban density and health care services within and between the core and peripheral areas of cities, including Shanghai.
What follows is an account of the spatial disparity of health care services in Shanghai. In the context of government-orchestrated decentralisation, I focus on how two salient features of demographic dynamics – ageing and migration – interact to create a set of challenges to the provision of spatially balanced and adequate health care to all Shanghai residents.
Due to the institutional legacy of urban-rural separation in China that favoured investment and services in cities, urban areas have better health facilities than rural ones. For the same reason, large cities have enjoyed better health care services than small cities and towns. In most Chinese cities, there is a greater concentration of health care facilities in the urban core than in the outskirts and administratively linked rural areas beyond. Take Shanghai, for example. Despite, or perhaps because of, a large population and high density at its centre, health service per capita is higher than in the suburban and rural areas. In Jing’an District, located in downtown Shanghai, there were 559 hospital beds and 317 physicians per square kilometre in 2006, 41 and 53 times higher respectively than Shanghai’s average. In the city centre, the number of hospital beds and physicians per 1,000 people was two to three times the average of the Shanghai municipality and five to six times its suburban areas. The urban core of Shanghai can thus considered ‘healthier’ than the outlying and rural areas within its municipal boundary, in relation to its greater availability of health services – one of the most important determinants of urban health.
Since the 1990s, Shanghai has experienced large-scale and accelerated suburbanisation and decentralisation, characterised by the construction of a number of new towns or satellite cities that are supposed to be environmentally friendly, international and rich with commercial and social services. This trend has both facilitated and reflected some spatial dispersal of central city population. The extension of railways and roads has induced more polycentric urban development, since people living in suburban cities can easily travel to work on public transportation or by the growing number of private cars. Between the fifth national Census taken in 2000 and the sixth Census recently completed in 2010, the population of Shanghai’s urban districts grew only slightly from 6.93 million to 6.99 million. Meanwhile, the population in the suburban districts rose by 70 per cent, from 10.72 million to 17.34 million. Suburban growth was more rapid in Minghang District and Pudong New Area, and most rapid in Songjiang District and Jiading District, where Songjiang New City and Jiading New City are located, whose populations have doubled in ten years.
This accelerated suburban population growth makes the already inferior health facilities and services in those areas even more deficient. It not only lowers the access of people living in these new suburban communities to heath care but also reduces the appeal of these places to central city residents who contemplate moving. This disparity is particularly problematic for the elderly population. While the average proportion of population aged 65 and above in Shanghai was around 10 per cent in 2010, it rises to 16–17 per cent in central urban districts such as Jing’an and Luwan, and drops to 6–7 per cent in suburban districts such as Jiading, Songjiang and Qingpu. The greater concentration of the older population in the central city can be expected, given their higher demand for health services, amongst other factors. However, it puts strain on old-age care facilities in the central city, where waiting times for nursing homes can reach several years. In contrast, there are often empty beds at nursing homes in the suburban and rural areas. Given the low standard and conditions of nursing homes in rural areas, the elderly in the central city are reluctant to move to those facilities. Therefore, building higher quality health facilities for the old in suburban new cities is an important step in encouraging them, and indeed all age groups, to move.
The continued growth of internal migrant populations in large coastal cities like Shanghai, especially in its outlying areas, poses another challenge to city healthcare, a key factor in the creation of sustainable urban communities. Due to China’s hukou system and its associated discrimination against migrants accessing public services, migrants do not have the same rights to medical care as local residents. As a result, and even though many migrants have lived in Shanghai for a long time, most of them do not have medical insurance and cannot afford to pay for the relatively high health service in Shanghai. The non-hukou migrant population who live more than half a year in Shanghai numbers almost nine million of the estimated 23 million people living permanently in the city. This means there is a huge population living and working in the city which is not able to access equal health care. This disparity creates a major source of potential social discontent and, over time, a less healthy workforce.
The inequality of public health services in the megacity of Shanghai has two sources. The first is the unequal geographic distribution of health care resources and facilities between the traditionally favored central city and the newly developed, but still less serviced, periphery. This disparity has been exasperated by the rapid relocation of central city population to the suburban areas. The solution should be to rebalance the spatial distribution of health care facilities, and to provide high quality health services in suburban areas, in proportion to population dynamics and shifting density aligned with better planning mechanisms. Second, inequality in health care is based on the unequal rights of different population groups, especially between local residents and migrants, and is also complicated by the issue of class. This raises an urgent need for municipal government to provide universal public health service to all people, especially for those migrants who have contributed a great deal to Shanghai’s prosperity. Only then can the opportunities of health as a driver for sustainable urban development be fully realised.
The author would like to acknowledge the comments and editorial support of Professor Xiangming Chen.