The Collapse of the Rural Health System

The everyday reality of rural China is a terrain left
largely unexplored, bearing in mind its immense size and diversity. The impact
of Deng Xiaoping’s reforms is known above all by its positive effects: the
development of agricultural production and of industry, the creation of wealth
among the “ten-thousand-yuan-a-month peasants”, etc. Charlotte Cailliez,
who is a doctoral student at the School for Advances Studies in Social Sciences
(Paris), is carrying out research into a less cheerful subject: the present state
of the rural health system. The following article, the first fruit of her work,
is based on field studies carried out in the poorer regions of China. In order
to protect certain people’s anonymity, several place names have been changed.

Charlotte Cailliez

These days the gleaming, prosperous façade of China’s
townscapes is beginning to crack, and the looming social crisis is the focus of
attention. But, behind the thick curtain of propaganda and indifference, a little-known
drama is unfolding: the pauperisation and social decline of the countryside. At
the foot of the glass tower blocks that the Chinese persist in erecting, who are
those miserable folk dragging enormous loads about like the coolies of former
times, or those sweet-potato sellers half frozen in the icy winter, or those tousle-headed
children huddled in the nooks and crannies of the stations? From what Fourth World
do they come? They come from the country.

The rural decollectivisation that ushered in the reform
era has certainly won massive support from the peasants and brought about a formidable
release of energy. Production has manifestly taken off, rising by an average of
6.2% between 1979 and 1988, compared with 2.7% between 1953 and 1978 (1). The
rapid development of township enterprises (xiangzhen qiye) has played an
important role in the rising living standards of Chinese peasants. These enterprises’
share of rural production overall has gone up from 31% in 1980 to 47% in 1986.
They are also the biggest source of local government revenue: in 1987 they brought
in three times more than land taxes (2). Unfortunately their distribution is very
unequal; and their impact is significant only in the eastern part of the country.
Thus the poorer peasants in the centre and the West see their situation getting
worse: they are excluded from the growing prosperity elsewhere, and feel they
have been left to their fate. With decollectivisation, the state withdrew from
the rural world in two ways. The social services, in particular health and education,
which it had guaranteed through the medium of the people’s communes, were
swept away along with them; and it handed over to local government the financial
responsibility for social activities. The poorer regions are no longer in a position
to provide their citizens with even minimal public services. What was gained in
flexibility was lost in capacity for co-ordination or redistribution. So, in much
of the Chinese countryside, the state has only too often been transformed from
provider of services into predator: the peasants, stripped of their most basic
rights, are now overwhelmed by taxes. Throughout China’s interior, it is
they who have lost out in the reforms. The rural health system has not escaped
the upheaval. It is under-financed, and must now find its own sources of income.
It has begun charging fees, while disregarding any aspects of its task that do
not bring in cash. The system is decaying in rural China, with the exception of
coastal regions, and in the most impoverished areas it is only a memory.

Preventive care and treatment for all

Before the Revolution, China was a desert in health terms,
and its population was racked by disease. Average life expectancy was 35 years.
In less than three decades the communists set up a cohesive health system covering
the great majority of rural people. It was a structural achievement modelled on
the government’s political organisation, with its ramifications extending
to the heart of the smallest village. This organisation has remained unchanged
to the present day. The Ministry of Public Health takes overall responsibility
for the entire health system. Each level of government has a public health bureau
that answers to the relevant administration and to the health bureau at the next
level above. The health network in rural China is called the “three-level
system”. It starts with the county, which carries out national policies,
manages a number of institutions, such as general hospitals, anti-epidemic clinics
and training centres, and oversees the lower levels. Next come the health centres
in the people’s communes (and subsequently in the districts: this is the
lowest level at which qualified doctors are to be found. The bottom level is the
village doctor: he or she collects health data, organises vaccinations and provides
basic health care. Thus each level oversees the one below, and refers upwards
any patients whose care exceeds its competence. The most basic characteristic
of this system was its capacity to give the whole population access to primary
health care, and to efficient services of preventive health care and health education.
It became a model for the third world, and one applauded by the international
organisations (3). This system was effectively rounded off during the Cultural
Revolution, a sublimation for the pastoral utopia. Mao stepped up the building
of rural hospitals, and brought in free health care through rural medical co-operatives
managed by the communes; and above all he deployed the famous corps of “barefoot
doctors”… for better or for worse. For the better, of course, was the
generous policy of health care for all, the romantic image that so stirred the
West. For the worse, were the half-trained doctors whose political purity stood
in for their competence, along with the general dearth of medicines and equipment.
Even so, by the dawn of the economic reforms, the great epidemics and endemic
health scourges had been eliminated thanks to mass campaigns to improve sanitary
conditions, and to regular vaccination drives. Deaths in childbirth and the infant
mortality rate became statistics that could now be acknowledged; and life expectancy
advanced from 35 years in 1949 to 69 years by the end of the 1970s.

The failure of the reforms

Optimum conditions seemed to have been met, for the advent
of the reforms and growth in double figures to bring about a real advance in health
terms. The opposite has happened. The prevalence rates for infectious diseases
such as hepatitis and tuberculosis, which had been falling steadily, have been
rising since the mid-1980s; so has the infant mortality rate, which public health
specialists consider to be a basic indicator. It was officially put at 34.7 per
thousand in 1981 and 37 per thousand in 1992 (4), but is at present estimated
by UNICEF at 52 per thousand. A considerable gap has opened between the developed
regions and the rest of the country, as indicated by an infant mortality rate
that is four times higher in the poorer regions. Under the collective system,
90% of the rural population were involved in medical co-operatives, a kind of
basic insurance that, for a fixed premium, guaranteed the reimbursement of peasants’
medical expenses. With decollectivisation, the county governments were unwilling
to take on the responsibility, and now they cover less than 10% of rural people.
In the same way, during the 1980s, China introduced health reforms based on patients’
charges, decentralisation and privatisation. The state reformed the fiscal system,
and then had to face up to a huge drop in its revenues: the national exchequer’s
share in the total tax revenue is down from 64% in 1980 to 48% in 1991 (5). In
1987, the provinces reduced their health subsidies by 18%, and the ministry’s
already small contribution to financing the village doctors fell by 45% in real
terms between 1979 and 1987 (6). It is city dwellers who benefit the most from
health expenditure (7): while peasants are no longer insured, the costs relating
to government insurance for urban workers have risen by 30% a year on average,
and around 60% of public health spending is devoted to 15% of the population.
Whereas Mao based the health system on the country, and trumpeted the virtues
of the barefoot doctors, the rural areas of today—where three quarters of
the population live—get the meanest share. The health allocation for rural
areas came to 21% of the total health budget in 1978, and 10% in 1991 (8). This
anarchic privatisation, tacked onto an extremely hierarchical and politicised
system, has reduced to zero its coherence and efficiency. It is profoundly inconsistent
with the nature of the system, and has led to a series of catastrophes, including
the loss of access to health care, the growth of inequality, under-financing,
the deterioration of buildings and equipment dating back to the 1960s, the total
neglect of preventive care… The state has in effect withdrawn health care
from rural China. Its contribution being now subsidiary, hospital directors are
required to make their concerns profitable. The resulting rationalisation of management
certainly adds up to progress of a kind, but the sacrifice of preventive care
in favour of more profitable curative treatments is seriously harmful. Consultancy
fees are still fixed by the state at a very low level, and profits are made mainly
from the sale of medicines, which can be sold with a profit margin of about 15%.
Over-prescribing has become a big problem, along with the almost systematic use
of injections, and the abuse of antibiotics and cortisones. Clearly this financial
autonomy has seriously undermined the capacity for administrations and health
bureaux to regulate medical practices. A village doctor with three months’
training can prescribe any medicine—of course not including hard drugs. During
the 1960s and 1970s, the rural health services were extremely politicised. Health
workers were not only delivering a public service, they were also the political
leaders of the public health campaigns. Members of the communes all took part
in these activities to show their obedience to the Party, and because they were
paid for it in work-points. Since the introduction of household production contracts
(baochan daohu), it is no longer possible to mobilise people without
paying them. So there are almost no mass campaigns any more, and work on making
the environment healthier is largely being neglected. Three quarters of the funding
for health services comes at present from patients, and the old system of control
has not been replaced by any other forms of regulation, such as professional bodies
or formal systems enabling public health to be monitored. The health system no
longer functions as a public service: it is entirely subject to economic constraints.
That being the case, infectious diseases are becoming more widespread, and epidemics
more common. Tuberculosis and neonatal tetanus, the vaccinations for which are
in theory both free and compulsory, kill more than 200,000 children a year. Hepatitis,
tuberculosis and AIDS are spreading uncontrollably, for lack of preventive care,
affordable treatment and health education. At the time of the great floods of
1994, cholera killed more than 1,500 people across the affected provinces. Also
at that time, the health authorities announced an increase of 49.2% in epidemics
of haemorrhagic disorders and a 47.9% increase in the incidence of encephalitis.
Still according to ministry figures, China has 20,000 sufferers from leprosy,
and 4,000 new cases are diagnosed every year (9).

Growing inequality

In conformity with China’s pattern of development,
health differences have opened up between regions and within them. The most worrying
consequence is that the poorest people have lost their access to treatment. For
a family earning 500 yuan per year, hospital treatment costs on average the equivalent
of 30% of a year’s income. And that assumes that it can come up with the
deposit, which varies from 1,500 to 3,000 yuan depending on the county. In a poor
county, 48% of those referred to hospital simply stay away; in one such county,
out of 151 deaths only four people had had contact with a health worker during
the period immediately preceding their deaths (10). Only 4% of health expenditure
in 1993 went on the poorest quarter of the rural population (11). As a general
rule, of the three levels that make up the health care system in the countryside,
the county hospital is accessible only to the rich peasants. Indeed, to generate
more income, the hospitals focus their investments on sophisticated equipment,
and costs have rocketed up. In practice their services are intended for urban
dwellers with social security. According to a survey, one admission to the county
hospital costs the equivalent of 57% of the average person’s annual income
in Shibing, in Guizhou province, and 95% in Shunyi, in Shaanxi. The admission
charge went up by 40% in real terms between 1990 and 1992 (12). Clinics in the
communes are worst off: their equipment is worn out and their buildings often
dilapidated and dangerous. They have trouble paying the wages, and cannot afford
maintenance insurance. Many have gone bust: 14% closed down between 1980 and 1988
(13). In Jiangxi province, an extended survey carried out in nine districts
(14), indicates that all these buildings date back to the 1960s and 1970s
and are in a bad state: about a third of them are used as lodgings for the staff.
Their incomes are drawn largely from the sale of medicines—and medicines
account also for the bulk of their expenditure: 70%. By contrast, the funding
devoted to staff training and building maintenance accounts for 0.15% and 1.8%
respectively. Interviews with doctors show that 80% of them want to leave, mainly
because of the low pay: their basic salary of about 100 yuan a month is less than
what the local peasants make, and less too than the salaries of the village doctors.
As for the village clinics, they are the key element in rural health care, in
the matter of preventive care and responsibility for treating everyday illnesses.
Here too, the situation is serious. Many villages can no longer afford to pay
their health workers, who now earn a living by reselling medicines and moonlighting.
They have become private practitioners. Formerly they were paid in work-points
by their units and by the communes, and they took care of people’s health
education, the collection of epidemiological data, water supply, carriers of disease,
vaccination campaigns and the welfare of mothers and infants. These health workers
played an essential part in the struggle to control the spread of disease, a role
that is now considerably reduced for lack of public funding. In the poorer regions,
most practitioners cannot scrape a living from their medical activity; and, in
the villages surveyed in Jiangxi, the doctors make more than half their money
by working on the land. Under-financed, half-trained, their morale broken, many
of them have quite simply given up. They numbered 5.5 million in 1978, and 1.7
million in 1988 (15).

Case study: Guangxi province, Changrong county, Dayun
district

Guangxi is a coastal province, but most of its people live
in mountain areas. It is an autonomous region where the Zhuang are in the majority,
but which includes also Miao, Yao and Dong communities. Trade, industry and foreign
investments are concentrated around the great urban centres and in the rural areas
of the East and South, which benefit from proximity to Guangdong’s economic
development. Elsewhere, in the North and the West, its people are destitute. At
the “first level”, the Health Bureau of the xian, the statistics
are encouraging, and the organisation chart is intact. But examining the two other
levels will confirm the vacuousness of such statistics. The anti-epidemic clinic
and the centre for mother and infant welfare also stray from their mission to
ensure their own survival, and offer specialised services on a fee-paying basis.
As for the general hospital, which is well-equipped, it is beyond the financial
reach of most of the villagers, in a zone classified as poor (16). Nearly all
the district clinics are in a disastrous state, yet each of them is responsible
for a population of about 20,000 people. Of the five that were visited, two are
completely dilapidated: holes in the roof, leaks and cracks. Most of the equipment
dates back to the 1960s: all of it is rough, ruptured, rusty. At the Changrong
hospital, the delivery of each baby is high-risk, because the roof is about to
collapse. Nearby, there is an operating table that has seen better days: it has
not been used for years. Old surgical instruments are stored in a cupboard. There
is no one left who knows how to use them. These places have to generate their
own funding. The health authorities make a contribution solely to disease prevention,
by providing free vaccines and certain medicines such as chloroquine to guard
against malaria. Local government pays about 80% of the wages bill: staff earn
from 200 to 280 yuan a month, paid very irregularly and from four to six months
in arrears. The doctors, about ten to a hospital, have in general had three years’
training at the local medical school, itself in ruins after repeated flooding,
and facing closure.

No one heeds the WHO recommendations for treating common
diseases, such as diarrhoea, respiratory infections, fevers, tuberculosis…
For a simple cough, multiple antibiotics are prescribed, along with a gastric
treatment to combat the side-effects of the antibiotics, and vitamins… Invariably
the patient will be put on a drip. As for collecting epidemiological data, no
one is doing it; one may wonder where the Ministry of Public Health gets its statistics.
Patients are few in relation to the population; it is clear that these hospitals
have lost their credibility. In general, the peasants wait until the very last
moment to seek medical help: often they arrive in hospital in a serious condition;
the doctors are then unable to cope; and, for lack of money, it is rarely possible
to refer the patients to the county hospital. A drama thus becomes an everyday
occurrence. We should note that most patients are middle-aged men; priority of
treatment is given to those who can work; and children represent only 15% of patients.
Dayun district, where we stayed, is the last at the end of the valley:
the track stops there. A little further, behind the mountains, is the unknown,
the outside world… another province. At the time of my first visit, in May
1997, the track was no longer passable, because the beginnings of the rainy season
had already swamped it. So after leaving the county headquarters behind, to a
five-hour journey along an uneven road was now added a short stage by boat. The
commune is made up of five larger villages, the administrative centres for a total
of 35 villages scattered in the mountains. According to the national poverty criteria,
74.3% of the families there are below the poverty threshold (less than 500 yuan
a year), of whom 21.2% are below the threshold of extreme poverty (less than 300
yuan a year) (17).

These incomes are derived from the cultivation of rice,
manioc, and sweet potatoes, and from timber. Fields are terraced against the mountainside.
Only one harvest a year is possible, and the entire population runs short of grain.
Not one village family manages to bridge the gap; 70% of them face destitution
for three or four months every year; and the remaining 30% go short for one or
two months. Half the population is illiterate. The commune has 361 employees,
which adds up to a yearly wages bill of 960,000 yuan. In May, they had not been
paid since January. In Dayun hospital, one is immediately struck by the lack of
activity: in the big entrance hall, that is often used for consultations, and
sometimes for a disco in the evenings, sick people are rarely seen. The women
do their embroidery; the children play… When a sick person turns up, an elaborate
discussion begins; there is time before the next patient will be seen. So then
everyone takes a hand in polishing up the diagnosis, translating from Mandarin
into the Miao dialect and vice versa and, according to the patient’s financial
means, working out a prescription that will bring in a little cash for the hospital.
Overall, the hospital gets 60% of its budget from the government, and must eke
out the rest through its own devices. On the other hand, the staff cultivate their
own vegetable gardens and keep chickens and pigs to feed themselves. A consultation
plus treatment comes to 30 yuan on average; an admission to hospital, 300 yuan.
Before, there was a government allowance enabling the very poor to have access
to health care. That is all gone. As everywhere, the recourse to injectable drugs
is systematic. Local doctors acknowledge the uselessness of some drips, but justify
them by the patients’ expectation. They do not seek, or no longer seek, to
offer health education. Many patients begin a course of injections that they cannot
complete for lack of money. Why do they not prescribe a complete oral treatment,
less expensive, but having the advantage of making people better, and regaining
their confidence? The response is at best doubtful. Taking account of the hospital’s
debts (30,000 yuan) and of unpaid salaries, the staff are quite simply afraid
of being out of work… And even though they can make do with little, the director
tells us, they still need to eat. A score of people are admitted to hospital every
month, and many cannot pay. Some patients do a moonlight flit; others leave hospital
prematurely, with a little advice to keep them going. From 15 to 20 people are
sent on every year to the county hospital; among them only five to ten would stay
any time there. The reasons for this low rate are, of course, financial, and they
are compounded by the difficulty of travelling to the county headquarters (ten
hours’ journey, of which six are along a track that is not always passable).
On the preventive side, vaccinations are free at the hospital, but the village
doctors, who are not paid for this work, ask families to make a contribution of
five mao. Some of them estimate that, since charges were introduced, the cover
extends to less than half the population.

In the villages

To reach the surrounding villages, it takes between two
and six hours’ walk through the mountains. Along the steep paths winding
through forests and small paddy-fields, suitably escorted by the party secretary
and the director of the hospital, we can see some peasants working, but also many
children in the fields, carrying yokes, or trotting behind little herds of cows.
It is usually women and girls who have the task of fetching water. From the village
of Yalu, for example, it takes two hours’ walk every day to reach the spring
during the good season, and six to eight hours during the dry season with a 30-kilo
load. When we arrive in the village, all the children come running up; there are
lots of them; their feet are bare, and dirty. In the village of Jixing, the school
head declares (in the presence of the party secretary of the district) that the
school attendance rate is about 70%. But the same teacher admits later—without
quoting any figures—that the rate is far lower, because school fees of about
120 yuan a term have to be paid in full by the pupils’ families. According
to the hospital director, many young people can no longer speak Chinese, despite
the availability of schools in every administrative centre. The rate of economic
emigration is estimated by the local authorities at 15 to 20%. Young people are
leaving in groups, entrusting their fate to one of their number, the one who speaks
Mandarin. The village doctor in Jixing, who holds surgery in his own home, has
for all equipment a few syringes and a stethoscope; but his dispensary is well
stocked. In his own opinion, his main problem is his lack of knowledge. He had
seven months’ training, and admits that he is unable to relieve the ordinary
symptoms that he comes across. He buys the drugs himself, and finds it hard to
recoup his costs. Three other doctors that we came across in the district said
their medical activities were costing them money. In Yalu, which is the administrative
centre for three other villages, the poverty is more glaring. The doctor holds
surgery in a dirty-looking corner. His equipment, syringes and needles, is in
a mess. In his doctor’s bag, which must date back to the Cultural Revolution,
there is neither a thermometer nor a stethoscope… just a few syringes full
of antibiotics, mostly past their use-by-date. The training of these doctors,
often disjointed, lasts from a few months to a year. It is conducted in the district
or by correspondence. Their clinical training, at the bedside, is very limited;
and they acquire no skill in questioning patients, or examining them, or sounding
their chests. They do not keep records, other than of their patients’ debts.
Some of them are scarcely literate, and so there would be little point in extending
their training. Even though they manage to treat diarrhoea and respiratory infections,
they cannot deal with other common childhood illnesses such as parasitosis, anaemia
and chronic malnutrition. The situation in Dayun is a paradigm for the failure
of the health system in the poorer regions. All the problems that we have described
are found there taken to the extreme; and it is evident that the source of the
problem is economic. How to provide health care for villagers whose means are
so limited? How to improve sanitary conditions where there is no adequate supply
of water? How to revitalise the system of three levels without a road?

Disease and poverty: extracts from a social survey

Cancelling the dream of universal health care is playing
an active part in robbing the most vulnerable people of their security. According
to the Ministry of Public Health, from 20 to 30% of poor rural households are
affected by serious illness; and, because of illness, half of the poorer peasants
are reduced to indigence (18). In these regions, about 60 children out of every
thousand die of malnutrition (19). Many villages no longer have any medical support,
or have never had it. A non-governmental organisation, Amity Foundation, has surveyed
320 poor countys in six provinces of China (Gansu, Qinghai, Sichuan, Yunnan, Guizhou,
and Guangxi) and identified 15,407 villages without any medical presence. In Shaannan,
a deprived area in Shaanxi, in the valley of Erbagou, the head of a village with
200 inhabitants replied willingly to our questions: on this infertile land, there
is unending scarcity. Crops come down to potatoes, maize, beans: no fruit, or
rice. During the off-season he works as a porter at the xian: and earns
two yuan a day. There is no doctor in the village. People look after themselves
using plants, or they resort to asking the witch-doctor. The children are vaccinated
by peripatetic teams. All births are at home. The main cause of infant mortality
is diarrhoea, because water is not boiled for lack of fuel and all the population
is infested with parasites. In case of serious illness, a choice has to be made:
wait for death, or go deeply into debt. The village head had taken his doctor
to the county hospital for treatment, ten years before, and was just finishing
the payments. On the other hand, family planning is a very present concern; the
propaganda slogans are everywhere; and the advice workers pass through the village
every month. Fines are severe for unauthorised births, and people are encouraged
to inform on their neighbours. The village head found two baby girls outside his
door one day in the cold of winter; they would certainly have died. He brought
them in; and, ever since, he is plagued by the family planning advisers, who are
demanding that he should pay two fines. Yet the villagers are not provided with
any means of contraception, and baby daughters and handicapped babies are frequently
abandoned. Some of the men leave for the town during the winter-season, but work
is rare in the Shaanxi towns, where many workers in state enterprises have already
been laid off, and the would-be immigrants are regularly sent home by force. Women
also abandon the country to work in services, in catering or prostitution. They
do not come back. In Shaanbei, to the north of Baoji, the living is no easier.
It is an ungrateful soil, known as loess: hard as a rock during the winter months,
but transformed into a torrent of mud by the slightest rainfall. In these wretched
villages, it is obvious that certain ills are endemic: people’s limbs are
deformed by fluorosis, and there is Kashin Beck, goitre, dwarfism, idiocy etc.
Of China’s 592 poor counties where the census has been taken, 574 are seriously
affected by endemic conditions; the prevalence rate reaches 96.6% (20). In the
most deprived regions, the insoluble problems of the agricultural economy are
compounded by a total neglect of people’s health and social conditions. Disease
leading to poverty leading to disease—this is the vicious circle that, as
in feudal times, decimates the population and breaks up families. The census officially
records that China has 200,000 children in the streets, mainly waifs from the
country whose families have broken up. They are the symbol for the anguish of
the poorest country areas. There could be several million of them, children who
have ended up in the main stations of provincial capitals, without legal recourse,
without legal existence.

The political answers

In December 1996, a big national conference on health was
held in Peking, bringing together all the directors and deputy directors of the
provincial health bureaux. Before the conference, the official line on public
health still clung to the notion of the greatness of the Chinese health system,
an inspiration to health politics around the world. The basic problems were sometimes
touched upon, but in an almost anecdotal way, within a context of general optimism.
At this conference, a radical change of tone was struck. The analysis of the problems
by the central government, and in particular by Li Peng, was astonishing in its
lucidity. The alarm was sounded. This breakthrough is part of an attempt by the
centre to reassume responsibility for the provinces. The conference focused unambiguously
upon the problems of rural life; the proposed solutions were well thought through,
aiming to restore a high standard of health care, along with more equal access
to it (21). The main decisions were as follows:

– to bring the health budget’s share of the national
budget from its present 2% up to 5%;

– to develop the medical co-operatives;

– to pay village doctors at least as much as the local
administrators;

– to improve preventive health care and public hygiene.

But, as far back as 1988, the Ministry of Public Health
adopted a series of measures to improve rural health, measures that did not prevent
the inexorable worsening of the situation in the poorer regions. The obstacles
are eminently political. When one reads the official version, one can see that
Peking does not itself decide to put such and such a measure into practice; it
“exhorts”, “requests”, or “requires” local administrations
to find the financial resources to apply it. The difficulty is twofold. On the
one hand, Peking has lost its power of coercion over the provinces, because they
control their own finances; on the other, the poorer regions, having no income
other than from agriculture, have not the means to apply such costly measures,
even if they had the will.

Jiujiu haizi! Save the children!”
(22)

China’s rural health system had founded its success
on two great principles: preventive care, and universal access to treatment; the
reforms have swallowed them up. The spectre of a monstrous epidemic is coming
closer with every day that passes. While Shanghai’s infant mortality rate
is lower than New York’s, tens of thousands of country children die from
lack of treatment, for bronchitis, or diarrhoea, or an abscess. It is the “absence
of the state” that is at the root of the problem: the lack of any public
funding or control. Even though the state remains the principal force in China’s
economic dynamic, its responsibilities are now divided up, dissipated, managed
by a host of different bureaucratic bodies. Until the state summons up the will
to reform its health system in depth, to reform also the precise mechanisms of
finance and control, the success of whatever policies Peking may choose must remain
uncertain.

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