Wednesday, April 16, 2014
Closing rural healthcare gap tough challenge
Global Times | November 09, 2011 22:06
By Global Times
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Li Dun (李楯)

Editor's Note:
Reforms have been introduced into China's healthcare system in the past few years, extending medical insurance to the majority of rural residents. But medical experts still warn of a discrepancy between the countryside and the cities. Can this gap be closed? What can the government do to ensure parity of healthcare for all? Global Times (GT) reporter Chen Chenchen talked to Huang Yanzhong (Huang), senior fellow for global health at the US Council on Foreign Relations, and Li Dun (Li), professor of law and public policy at Contemporary China Research Center of Tsinghua University, on these issues.

GT: How do you see the severity of China's health problem?

Huang: A look at the average life expectancy and the disease burden in China reveals a worrisome picture. Between 1981 and 2009, average life expectancy in China rose by only about five years, from roughly 68 years to 73 years, according to China's official statistics. In countries with similar life expectancy levels in 1981 but slower economic growth thereafter, like South Korea, Malaysia, Mexico and Colombia, by 2009 the life expectancy had increased by seven to 14 years.

China also battles with a legion of microbial and viral threats, including HIV/AIDS, tuberculosis and rabies, like many less developed countries do.

Meanwhile, chronic non-communicable diseases like diabetics, which are typical of developed countries, are taking even more intractable forms in China. And the suicide rate is more than twice that in the US.

GT: Some hold that the public health crisis, especially in rural China caused by poor medical services or environmental problems, may have a negative effect on social stability. How do you see the state of rural healthcare since 1949?


Huang Yanzhong (黄严忠)


Huang: In the 1950s, China built a three-tiered healthcare system in rural areas consisting of county hospitals, commune healthcare centers, and village clinics. During the Cultural Revolution (1966-76), the Ministry of Health (MOH) was marginalized from the policy process. With less bureaucratic obstruction, policy became better coordinated.

An unprecedented number of health personnel were sent to the countryside. Some farmers were given informal medical training, and these "barefoot doctors" would then treat common illnesses and promote preventive healthcare. So-called cooperative medical care, a community-based health insurance scheme, spread rapidly.

However, the ensuing economic reforms dramatically changed this landscape. The system's urban bias has returned. Due to a shift in the government's agenda regarding economic development, public health was relegated to the back burner.

Li: In the Mao era, rural cooperative medical care was a political, not a medical system. It was feasible mainly due to three reasons. First, urban doctors were forcibly expelled to rural areas. Some of the "educated youth" went to rural China with basic medical skills, including acupuncture. Finally, roving doctors, trained via the traditional master-apprentice medical training system, still existed.

Today the doctors and young people exiled from the cities long ago came back, and roving doctors without professional diplomas are illegal. These reasons, on top of a colossal migrant population, have led to the decline of medical services in rural China. In the Mao era, cooperative medical care covered nearly the entire rural population. But the rate had fallen to only 10 percent by 2003.

Since 2003, the government  has launched a pilot new rural cooperative medical care system. The new system, which serves as a basic healthcare security system for the rural population, was basically adopted across the nation by 2008.

At the moment, more than 96 percent have joined in the system, and the healthcare compensation standards are still rising. This somewhat alleviates rural people's burden in medical treatment.

GT: Will the dual rural-urban medical system be changed in the near future?

Li: I'm not optimistic. This is a stubborn legacy left by the planned economy. Zhang Mao, Party Secretary of the MOH, has publicly called for breaking down the dual system. However, practical implementation is still lacking.

Over the past three decades, a structure of stronger power, a weak market and little social participation has taken shape. Reform has switched a closed system to a market-oriented one. This is good. But China has also moved from a low-risk society to a high-risk one. The government should take the initiative in covering the cost of reform. However, the coverage is seriously delayed, especially in rural areas, leading to further problems.

GT: Reform of healthcare is high on the government agenda. The government's ability of mobilization during public health emergencies, like the A(H1N1) flu, is quite impressive. But why is healthcare reform stalemated?

Huang: In coping with disease outbreaks such as SARS or A(H1N1), a campaign-style approach helps overcome bureaucratic inertia and mobilize necessary resources in a short period of time. The same approach won't work for healthcare reform, especially public hospital reform.

Indeed, without fundamentally reforming the management and financing of public hospitals, simply pumping more money and resources into the public hospitals only sustains waste, corruption, and inefficiency.

Li: With healthcare reform, there are two problems among decision-makers. The first the division of interests among different government departments.

Healthcare security should be a part of social security. It should not be divided and secured by insurance.

The A(H1N1) flu was more like a farce. The WHO colluded with some medical giants, and exaggerated the severity of the flu. This happens in China too. The MOH should tell the public where all the emergency funds went.

The MOH, as well as experts with central think-tank also exaggerated the severity of AIDS in China. In 2010, they reported an estimated 10 million HIV-positive people. However, official data later showed that the number was much less, roughly 740,000.

Since the Deng era, we have repeatedly stressed peace, development and cooperation. However, rockets and aircraft carriers are apparently prioritized before people's lives.

No country has a perfect healthcare system. But China's situation is really different. We are neither a developed power, nor an average developing country at the moment.

We once had a planned economy and the deeply-rooted rural-urban dual system. The inertia is quite considerable, and we have to navigate a way out by ourselves.

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