China's Failing Health System

In

his thin cotton mask and makeshift welder's goggles, Dr. Li Li guards China's shifting front line against the severe acute respiratory syndrome (SARS) epidemic. The young doctor oversees a new fever ward at the medical clinic in Biange township in central China's largely rural Hebei province, and he's dangerously unprepared for an outbreak of the disease. A chronic funding shortage means his clinic lacks even enough surgical masks. Behind him, workers erect a flimsy Plexiglas shield across a hallway to create an isolation ward where one patient already lies feverish. Asked if his facility can cope with SARS, Dr. Li shakes his head. "All we have is our hands," he says. Even those go without basic protection against the virus that causes SARS. As the pathogen migrated from big cities to provinces like Hebei, the government sent Li boxes of latex gloves—all right-handed. He forces one onto his left hand and asks, "How am I supposed to work like this?"

It's a pressing question at a time when China's entire rural health-care system is under threat from SARS and is failing after decades of government neglect. While residents of the mainland's wealthier cities enjoy decent medical care, the network of doctors, clinics and hospitals serving the rural poor are simply unavailable to huge swaths of the population. Preventable scourges like tuberculosis and hepatitis B ravage the countryside, infant mortality is creeping upward after decades in decline—and now, with millions of migrant workers leaving their jobs in cities and streaming back to the hinterlands to escape SARS, it seems inevitable that some will infect villagers in places least able to cope with a medical crisis. If that happens, China and the world could lose a chance to eradicate a disease that has already killed 235 and infected 4,884 people in the mainland. "The state of the rural health-care system is like SARS," says Ray Yip, senior project officer at UNICEF in Beijing. "You can cover it up for a while but it will blow up in your face."

The government hasn't yet disclosed how many SARS cases in total have hit China's villages, where 800 million people live. But in Hebei alone, the number of reported cases shot up from 48 at the end of April to 157 on May 10. The World Health Organization (WHO) recently issued a travel advisory for Inner Mongolia and Tianjin, after their SARS caseloads rose to 284 and 149 respectively. Last week, Premier Wen Jiabao said there is currently "no large-scale epidemic emerging in the rural areas." Even so, he warned that dilapidated medical facilities, poor equipment and shoddy monitoring for epidemics were "hidden dangers for the spread of SARS" in the countryside.

Recognizing the danger, China announced last week it would provide free health care for SARS sufferers anywhere in the country, meanwhile setting aside $250 million to fight the disease. But it's unclear if those measures will be enough to stem the outbreak in outlying provinces, where the health-care system has been eroded by years of inadequate government funding, and where medicines are largely unaffordable to rural residents who each earn an average of $300 a year. Total medical spending for the 48 million people in the impoverished southern province of Guangxi, for instance, is just half that of Beijing's, with a population of 13 million. "Rural health care is the blister on China's medical system," says Cai Renwen, director of the National Health Economics Institute in Beijing. "You can lance it, but then you have to patch it with money," he says, "and the government hasn't been willing to spend."

Before economic reforms began to chip away at the communist system 20 years ago, medical treatment in the mainland—while often rudimentary—was widely available to its all citizens. China's famed "barefoot doctors," usually middle school graduates trained in first aid, hiked through hamlets offering prenatal examinations and setting broken limbs. The service, essentially free, helped to almost eradicate sexually transmitted diseases in China and nearly doubled the country's life expectancy from 35 to 65 between 1949 to the mid-1970s. But in the early 1980s, the mainland began shifting from communism to capitalism, and peasants had to dig into their own tattered pockets to pay for health care. At the same time, cash-strapped local governments cut subsidies to rural hospitals and clinics, essentially privatizing them. "Healthworkers started trying to maximize revenue instead of thinking things like, 'How many kids can I immunize this year?'" says Lisa Lee, a medical officer for the WHO in Beijing.

City dwellers remain better-off, mostly because six in 10 of them have some form of health insurance. Only 10% of rural residents do, and most of them are government employees or live in wealthy coastal areas, where many work in factories. More emblematic are people like Shi Yangxin. The 30-year-old peasant started coughing blood in December but tried to tough it out to save the cost of a hospital visit. He was diagnosed three weeks ago with tuberculosis. He sold his chickens and ducks to buy $20 worth of medicine. At his pine-board house on a hillside in Guangxi, he lays out five precious pill bottles and points out a Mao Zedong calendar with an "X" over each day he's taken the drugs, which are quickly running out. He's already drawn a $60 loan from the bank to pay for pills, seed and fertilizer, but is too weak to work his fields. With his parents, wife and five-year-old son to support, he has no idea how he can pay for another six-month supply of medicine. "I just don't have the money," he says.

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China's inability to stem tuberculosis cases like Shi's bodes ill for its SARS struggle. Like SARS, TB is a contagious respiratory disease whose spread can be contained through vigilant monitoring of its victims. Though TB has been all but eliminated in developed countries, it still afflicts 1.5 million mostly rural Chinese each year, an infection rate second only to India's. The World Bank recently concluded a decade-long project providing free TB treatment in 13 mainland provinces. It was a stunning success—incidence of the disease fell by 36%. But provincial governments ultimately treated the project as charity. They stiffed the program of a third of the matching funds they were supposed to contribute—in Heilongjiang province, "the special fund for tuberculosis control was allocated to infrastructure" by local officials, says a World Bank report. When the project ended in 2001 and the bank's money stopped flowing, the program collapsed in many areas and the number of TB cases began rising again, says Daniel Chin, a WHO adviser for the project. He complains of "a lack of attention to this problem by the Chinese government."

Beijing has tried to keep health-care costs in check in rural localities by capping the price of many procedures. For example, pumping the stomach of someone attempting suicide by eating fertilizer—a practice not infrequent among women in farming villages—costs $1. But governmental price controls mean local clinics have to raise funding by other means. Most adopt the strategy seen in the village of Nanzhao in Hebei. There, the local clinic contains a wooden desk, several threadbare chairs and a bookshelf lined with antibiotics, steroids and painkillers. In most countries, such potent medications can only be dispensed by qualified specialists, but for the clinic they represent a revenue stream to a former barefoot doctor with no medical degree. The sole way of covering expenses at a place like this is to "charge for medicine," says village chief Li Jinghua. So medical workers often prescribe them unnecessarily. According to UNICEF, 60% of China's health-care spending goes to drugs, compared with the worldwide average of 15%. Even in China's cities, where hospitals receive greater government support, UNICEF estimates that hospitals generate about half of the money needed to pay doctors' salaries through drug sales.

To make medical care more affordable in the countryside, the central government announced in October that it will create a cooperative medical program for rural areas. The program calls for every individual to contribute about $1 a year to a special fund, to be matched by the local government and by Beijing. The program won't be operational until 2010, but eventually peasants should be able to draw from it to cover their health expenses.

Yet even before it starts, few are optimistic it will work. In most areas the program will cover only about 30% of medical bills. By leaving the supply side of the health-care system unchanged, rural hospitals will still have to support themselves by selling medicine unnecessarily. A bigger concern is local corruption. Cai Renhua of the China Institute for Health Economics recently helped run an experimental cooperative program in 10 counties similar to the scheme planned by Beijing. He found that peasants gladly contributed to the fund—as long as professors from Beijing were the collectors. When local officials showed up, "the peasants assumed the money was going to their wine funds" and refused to pay, he says.

For desperately poor areas, the barefoot doctors of Chairman Mao's era might prove to be a more workable model. Gongdong township in Guangxi is a cluster of remote villages three hours' drive from the nearest paved road or flush toilet. Calcite in Gongdong's water causes kidney stones in residents and a lack of iodine in their diet makes goiters common. For the past six years, the French aid agency Médecins Sans Frontières (MSF) has trained the village doctors and midwives to treat minor injuries and illnesses with a basic stock of drugs, while referring serious cases to a township hospital. In addition, MSF introduced a payment scheme that seemed to work: it requires each village to classify locals according to whether they can pay for all, half or none of their medicine. Proceeds from drug sales help subsidize primary care for the poorest of the poor, while MSF pays the $9 monthly salaries of the village doctors.

The system eliminates the incentive for doctors to jack up medicine prices to cover their expenses. Yet the project costs MSF just 25¢ per person per year—a tiny investment that has brought basic health care to some 8,500 people. "We wanted to create a grassroots example of a practical program that works," says Yves Marchandy, who runs the program. But the project is scheduled to end in June. Local authorities don't plan to continue it because they don't have the budget. "The hospital authorities are overly focused on turning a profit," says Marchandy.

No new plan, of course, has taken SARS into account. It might be too late. Long accustomed to avoiding expensive medical care, peasants simply don't believe the government when it promises to treat them for free. With little cash or access to affordable conventional medicines, some have resorted to ancient remedies. Villagers living near the city of Xizhou, one of the poorest areas of SARS-hit Shanxi province, spent the night of May 6 lighting firecrackers to scare the disease away. Days later, the Worker's Daily criticized the practice, saying "the spread of superstition is another type of epidemic" that will "disturb and injure the people." What's really injuring rural people, though, is the lack of an adequate health system to care for them.