Why COVID-19 claims of China are hard to believe and difficult to follow

Over the years China has made an image of playing with data and information for its vested interests. Therefore, it’s concealing and sharing of information on COVID-19 outbreak, both, are looked at with suspicion by almost all the countries throughout the world. However, the Chinese model of COVID-19 response is almost impossible to follow even for its believers.

If the available data are believed, the People’s Republic of China (China) has done exceptional work in combating and controlling the COVID-19. 

China peaked COVID-19 with 15,152 cases on February 13 but on the very next day, it registered only 4,050 cases and within seven days China was below 1,000 cases per day. The sudden rise in cases is not surprising but a sudden fall is extraordinary. Hereafter, China quickly flattened the curve and on March 11, the day WHO declared COVID-19 a pandemic, China registered only 31 cases. For the first time, it reported zero case and zero death on May 29, thereafter the daily number of cases in China are below 50 except on June 14 (58 cases) and June 23 (52 cases) which were due to the second wave of the COVID-19 outbreak in Beijing.

“China’s bold approach to contain the rapid spread of this new respiratory pathogen has changed the course of a rapidly escalating and deadly epidemic,” reads the report of the Joint Mission consisting of 25 national and international experts from China, Germany, Japan, Korea, Nigeria, Russia, Singapore, the United States of America and the World Health Organization (WHO) that conducted 9 days’ investigation into China’s COVID-19 response from 16-24 February 2020. The joint team appreciated the strict measures due to which ‘public life was very reduced’ but it helped to control the spread of COVID-19. “The Joint Mission estimates that this truly all-of Government and all-of-society approach that has been taken in China has averted or at least delayed hundreds of thousands of COVID-19 cases in the country,” it added. The committee has enlisted some strict lockdown measures such as compulsory masking, restriction on people to come out of homes, ban on traffic and transport, social distancing, but not enough details on how these measures were implemented. It is also silent on alleged violations of human rights and the right to privacy which are main concerns in several countries in combating the pandemic. However, it recommended China ‘to further enhance the systematic and real-time sharing of epidemiologic data, clinical results, and experience to inform the global response’.

What was the strategy for a successful show by China to control COVID-19? President Xi Jinping gives credit for this success to the Communist Party of China Central Committee (CPC Central Committee) and China’s Socialist System. “China achieved great strategic outcomes in the fight against the disease, and the achievements demonstrated the outstanding advantages of the CPC's leadership and China's socialist system,” said Xi Jinping in a conference of the top seven multidisciplinary public healthcare experts of China on June 2. These experts highlighted several loopholes in the healthcare system of China in handling pandemics to which Jinping ‘instructed related departments to resolve the problems they raised’. This confession from the top indicates that all is not well in the Chinese healthcare system and it is yet to develop an integrated, holistic, and pandemic resilient healthcare management information system.

China’s Healthcare Management Information System

What kind of healthcare information system and pandemic response system China had just before the outbreak of COVID-19 in Wuhan? As China is very selective in providing information into the public domain, we focused on information available with third parties.

The IHR Capacity Progress 2019 of WHO has given full marks to several developed countries on the 13 IHR capacities needed to detect, assess, notify, report, and respond to public health risk and acute events of domestic and international concern but the most of them were hit hard by the COVID-19 pandemic. This could be better understood with a comparative analysis of ‘e-SPAR State Party Annual Report-2019’ which forms the basis of WHO’s Global Health Observatory:

• China has been given full marks in coordination with WHO, Zoonotic Events and Human-Animal Interface, Food Safety, Laboratory, Health Surveillance, Human Resource, and Points of Entry (ports, airports, and territorial borders) for infectious disease management in the country. Besides, it has been given 80% marks in Risk Communication and National Health Emergency Framework, and 90% marks in Health Service Provision. As per WHO, all these capacities are crucial for a pandemic resilient healthcare information system.
• In terms of Risk Communication, South Korea and China have been given 80% marks each while the US achieved 100%. Out of 13 capacities, South Korea has been given full marks in 11 capacities while the US achieved 100% in nine capacities.
• South Korea achieved 80% marks for coordination with WHO (IHR Coordination and National IHR focal points) while China and the USA were given 100%. Interestingly, China is accused of concealing the information on the COVID-19 outbreak while the USA has alienated itself from the WHO.
• In terms of ‘Zoonotic Events and Animal-Human Interface’, the USA with 80% marks has been ranked lower than China (100%).
• In ‘Points of Entry’ management and Health Surveillance, China, South Korea, and the USA have been ranked equally and given 100% marks. However, there is a huge difference in the actual performance of these three countries in combating COVID-19.

The e-SPAR grading of China, however, does not match with the Global Health Index 2019 which has ranked it on 51^st position among 195 countries with 48.2 out of 100 points. In this index, China has been graded average on several parameters and given less than 50 points while the USA was ranked on the top. In this Index, France was ranked 11^th, Japan 21^st, Brazil 22^nd, and Italy on 31^st. Almost all the high ranking countries are hit hard in the ensuing COVID-19 pandemic.

China’s Country Cooperation Strategy (CCS) 2016-20 submitted to WHO does not reveal much on its health management information system and existing pandemic response system. However, some reports and research papers published in the pre-COVID-19 period give a glimpse of China’s healthcare management information system which could be understood as under:

National Health Commission (NHC)

China NHC is the umbrella body of the healthcare system in China which besides coordinating with national-level healthcare and research institutions also acts as the center of public health policy formulation. Previously known as the National Healthcare and Family Planning Commission (NHFPC), the organization was renamed in March 2018 and is headed by a minister.  

China has a four-level public healthcare system – national, provincial, municipal/community, and county. Though it has allowed private ‘for profit’ hospitals, the healthcare system in China is primarily controlled by the public sector in which healthcare centers/ hospitals at municipal and county-level act as the main source of health data collection. In 2018, China had 12,000 public hospitals, 21,000 private hospitals (excluding township and community hospitals), of which about 20,050 were non-profit and 12,600 were for-profit hospitals. In addition, the People’s Army has its own hospitals and healthcare system. The NHC directly governs 44 national hospitals and is also linked with similar kinds of systems at the provincial, municipality, and county levels.

China Center for Disease Control and Prevention (China CDC)

Like the USA’s CDC, the China CDC also provides technical and knowledge support for disease control and prevention. However, it’s not a standalone center in China but the country has CDCs at the provincial, community, and local levels. China CDC is reportedly managed by professionals and coordinates with different research centers in public healthcare such as Public Health Emergency Center, Public Health Surveillance and Information Services, Policy Research and Health Communication, Management of Health Hotline (Health Hotline 12320), Infectious Disease Control and Prevention and Public Health Surveillance and Services, etc.  

China’s Infectious Disease Information System (IDIS) is apparently a dedicated center of China that requires each COVID-19 case to be reported electronically by the responsible doctor as soon as a case has been diagnosed. It includes cases that are reported as asymptomatic and data are claimed to be updated in real-time.

Digitization of Health Records

China launched a scheme for the digitization of its healthcare system in 2010 which was upgraded and renamed in 2013 as ‘4631-2 Project’ aimed at complete digitization and integration of health records. The project is integration of four (4) levels of health systems, i.e. national, provincial, community/municipal and county, six (6) applications (public health, medical service, medical guarantee, drug administration, family plan, and integrated management) and three (3) information databases – Demographic Information Database (DID), Electronic Medical Record Database (EMRD) and Electronic Health Record Database (EHRD). The third and final phase of the project was aimed at applying big data technologies, artificial intelligence, and internet-plus that included advanced applications such as predictive modeling, clinical decision support, disease or safety surveillance, public health, and research.

Two evaluation studies of the project – Implementation of National Health Informatization in China: Survey About Status Quo and Data integration of electronic medical record under administrative decentralization of medical insurance and healthcare in China – published in 2019 reveal the followings loopholes in this ongoing project:

• Electronic Medical Record (EMR) or Electronic Health Record (EHR) of patients is the primary source of healthcare data collection. However, there exist three different formats for EMR data collection – hospital, Medical Insurance Information System (MIIS), and Regional Health Information Platform (RHIP).
• The EMR formats vary significantly from one group of hospitals to another and also within the hospitals of the same affiliating agency/group. Thus the EMR system in China is usually not integrated or interoperable. Patients often must bring with them a printed health record if they require to visit doctors in any other hospital.
• Hospitals have their vested interests and engaged in corrupt practices in maintaining different formats of EMR as this helps in increasing their revenue by repeating diagnostic tests, prescribing alternative medicines, and compelling patients for unnecessary procurement. Furthermore, sharing EMR data may also reduce hospital revenue.
• As healthcare classification, standards and coding are not uniform in China, several hospitals produce their own disease codes, billing codes, drugs, herbs, and supplementary databases. A few provinces develop their own province-wide standards. China has its own drug classification standard. Besides, it’s policy to promote Chinese Traditional Medicine (CTM) has caused the formation of several drug standards at the provincial level. These loopholes are used by hospitals to get inflated healthcare bills approved by insurance agencies as almost 100 % of the Chinese citizens have health insurance coverage.
• In a survey in 2017, about 80-85% of healthcare data was unstructured which required more professional curating staff and technologies like natural language processing to automatically process the data. Besides, only 7 % of hospitals had more than 20 full time IT staff members while 76% of medical institutions (1520 out of 2,000) did not have any IT staff.

As China has almost complete healthcare insurance coverage, EMR data are primarily used by hospitals to get paid through healthcare insurance but they are of little use for patients. This is because if a patient changes the hospital, the receiving doctors will not be able to access his/her previous health records. Besides, there exists a rural-urban, provincial, and regional disparity in the public healthcare system in China that was not robust enough to combat successfully a highly contagious disease outbreak like COVID-19.

China’s COVID Response Plan in Wuhan

The joint team of WHO gives credited to ‘stringent’ and ‘labor-intensive’ measures for the success of China’s response plan against the outbreak of COVID-19. But the report could not reveal much on the coercive nature of actions during the lockdown. However, experts in the WHO panel accepted that there was not much to learn from China as those stringent measures were not feasible in other parts of the world.

China deserves the credit for providing the world the genetic structure and diagnostic protocols of COVID-19 but its pandemic response system raised eyebrows from the days COVID-19 was unknown pneumonia. It has been facing allegations of suppressing information including the elimination of coronavirus whistleblowers including Dr. Li Wenliang who was later declared a ‘martyr’.

The experts also doubt the number of COVID-19 cases and deaths in the country as NHC provided seven different versions of definition for COVID-19 to WHO. In the initial days, only severe cases of pneumonia were reported. According to experts, if the later versions of definition are applied the number of COVID-19 cases in China will be about three times high. Besides, several media reports of international journalists revealed strict directions to healthcare professionals not to feed COVID-19 data into the system.

As the disease outbreak was very close to the Chinese New Year which is observed between January 10 to February 18, referred to as the world’s largest human migration, the chances of spreading the virus were very high. However, despite the measures adopted by China the people who traveled back to their workplaces in Italy, Iran, and other European countries spread the virus there. 

The ‘White Paper’ published by China provides a glimpse of strict measures it may have used and the kind of national resources it had mobilized to combat the virus. Followings are the key aspects of China’s COVID-19 response plan:

• Hubei Provincial Hospital of Integrated Chinese and Western Medicine on December 27 reported pneumonia of unknown cause to Wuhan CDC. The Wuhan City government set up a team of experts for investigation. Subsequently, China NHC, China CDC, and other health institutions were pressed into service for epidemiological, diagnosis, and other scientific researches.
• Chinese President Xi Jinping, on January 7, in his capacity as the General Secretary of the CPC Central Committee, presided over a meeting of the Standing Committee of the Political Bureau of the CPC Central Committee and issued instructions on the prevention and control of a possible epidemic of the pneumonia of unknown cause in Wuhan. Thereafter, he supervised the entire pandemic response plans of China on a daily basis. Within a month (January 7 to February 7) he summoned four meetings of CPC Central Committee and mobilized entire political cadres up to the village level to work as volunteers with the government system.
• On January 20, NHC confirmed disease is spreading ‘between humans’. Jinping on January 22 ordered immediate imposition of tight restrictions on the movement of people and channels of exit in the entire Hubei province including the city of Wuhan. The complete lockdown was implemented in Wuhan within hours since January 23.
• On January 27, Jinping issued an instruction to his party workers ‘calling on all CPC organizations and members to bear in mind the supremacy of the people’s interests and Parity’s founding mission, strengthen confidence and solidarity, take a science-based approach and targeted measures, and lead the people in implementing the decisions made by the central Party leadership’.
• The CPC has more than 4.6 million primary-level organizations. According to the CPC Central Committee, over 39 million CPC members fought the virus at the front line, and more than 13 million CPC members volunteered their services out of which nearly 400 died due to COVID-19.
• As China has a single-party system, there is no opposition to criticize or challenge the government's decisions and directions. Furthermore, Jinping is a permanent president and enjoyed the status of PRC founder Mao due to which his words are law of the land.
• Emergency command mechanisms headed jointly by CPC workers and government officials were established in provinces, cities, and counties across the country, forming a top-down system with the unified command, frontline guidance, and coordination between departments and among provinces. The government termed it ‘people’s war on the virus’ and applied ‘non-medical means’ to block transmission.
• About 4,000 healthcare workers of the People’s Liberation Army (PLA) and Air Force helicopters were also deployed in Wuhan. The number of government employees, police security forces, and PLA personnel are not given.
• Strict door to door surveillance through temperature check-up, masking, and lockdowns were implemented with the help of community workers and volunteers in Wuhan as well as entire China. The huge human resource helped the government system to enforce 24x7 lockdown and force the people packed inside their homes.
• About 40,000 construction workers and several thousand sets of machinery and equipment were mobilized to set up two hospitals - 1,000-bed Huoshenshan Hospital was completed in just 10 days and that of the 1,600-bed Leishenshan Hospital in just 12 days. Besides, several temporary treatment centers were set up and operationalized.
• The cities and provinces contributed to fulfilling the shortage of healthcare workers, PPE kits, masks, diagnostic kits, and other resources in Wuhan and Hubei province.
• Though WHO was against traditional medicines, China claims to have widely used a combination of Traditional Chinese Medicine (TCM) and Western Medicine for pre-emptive prevention, differentiated medication, and multi-targeted intervention, and at every step of COVID-19 treatment and control. Chinese herbal formulae and drugs were administered to 92 percent of all confirmed cases. In Hubei Province, more than 90 percent of confirmed cases received TCM treatment that proved effective, claims China.

Conclusion and Agenda for Discussion 

The healthcare information system in China was not efficient enough to handle the pandemic which compelled it to follow a highly labor-intensive approach by deploying party workers, community workers, villagers, laborers, healthcare workers, government officials, army, and air force altogether. Besides, the white paper did not mention the cost of mobilizing such as a huge human rescore for combating COVID-19. Decisions of Jinping are beyond questions in China but if the model is followed in other countries, the decision making authorities may attract allegations of corruption, misuse of bureaucracy for political gains, and converting the public offices into party offices of the ruling party. 

The authoritarian political system of China which is referred to as the ‘socialist’ system by Jinping may help him to enforce such drastic stringent measures as there exist almost no independent institution to review/scrutinize the decision of the President. There may have been violations of human rights in mobilizing party workers, community workers, laborers, and also in enforcing 24x7 strict vigil to pack people inside doors but the world will perhaps never know this.

Jinping’s call for a ‘strong public health system’ in June indicates that the country has finally realized the importance of a holistic and integrated Healthcare Management Information System (HMIS) and making a focused effort in that direction. It seems the use of technology was gradually emphasized in China’s fight against COVID-19. Being a ‘socialist system’, it was no difficulty for China to monitor real-time geospatial locations of its citizens for contact tracing. There is hardly any issue of the right to privacy before the State.

The mobiles were reportedly marked as red, yellow, and green on the basis of the health status of the subscribers, and movements were tracked to prohibit the infected persons. China also claims to have utilized big data, artificial intelligence, 5G technology, telemedicine, etc. It seems with the passage of time, technological innovations helped China’s fight against COVID-19 which was more effectively used to control the second wave of COVID-19 in Beijing. However, the Chinese strategy to improve performance by covering-up the COVID-19 pandemic reportedly continues even after the Wuhan crisis.

The experiences of China underline the need for a robust HMIS to develop a COVID-19 pandemic resilient public healthcare system and also for unforeseen disease outbreaks and natural disasters in the future.

VisionRI's Centre of Excellence on Emerging Development Perspectives (COE-EDP) aims to keep track of the transition trajectory of global development and works towards conceptualization, development, and mainstreaming of innovative developmental approaches, frameworks, and practices.