Serving the people?

China's health care system may be heading for a crisis

By Bruce Kennedy CNN Interactive

A hopeful future: Education and immunization campaigns have reduced child and maternal mortality rates in china

BEIJING (CNN) -- Not long after the founding of the People's Republic the world's imagination was captivated by China's "chijiao daifu" -- the barefoot doctors. Educated in setting broken bones, delivering babies, treating wounds and other basic medical needs, they brought health care to the lowest levels of society.

It was a time of socialist idealism. To the barefoot doctors and millions of Chinese, Mao Tse-tung's famous quotation, "Wei Ren Ming Fu" -- Serve the People -- was not just a slogan, but a way of life.

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For many Chinese the reforms of the past two decades have created a new way of life. Great strides have been made in reducing child and maternal mortality rates through national immunization programs and education campaigns. Agricultural advances mean that foods once considered luxuries are now plentiful. People are eating more and for the most part are healthier.

China is learning, however, that market socialism leaves some people behind, and that rising food consumption brings with it health issues long associated with industrialized countries, such as cardiovascular disease. According to some observers, China now faces a problem all-too-familiar in the West -- a health care system that needs immediate attention.

Barefoot doctors go private

A joint report, issued in late 1998 by the Australian Government and UNICEF -- the United Nations International Children's Emergency Fund -- warns the problem is especially acute among China's poor.

"The breakdown of basic health care service in the poor rural area is the direct result of [the] decentralization of public health funding," it says. "The largely market-based financing scheme clearly does not work in the poor area."

Dr. Ray Yip, a senior adviser on health and nutrition for UNICEF's Beijing office, says that while some parts of China are as advanced as Hong Kong or Singapore, other Chinese regions remain at poverty levels associated with nations such as Bangladesh.

"The barefoot doctors have become privatized," says Dr. Yip, who travels extensively throughout China for UNICEF. "To make a living they have to charge their patients."

Each year over 100 million infants worldwide need immunizing against six different diseases. China is among the developing countries that pays for its own vaccine bills.

That means many health care workers, especially those on the village level who do not qualify for county government subsidies, now have to regard the people they serve as revenue sources, not just as patients.

UNICEF has discovered alarming cases of village doctors with only a basic medical education forcing unnecessary medications and treatments on their patients so they can generate income.

"Village doctors, who are under-qualified, are giving injections and prescriptions when they shouldn't," says Dr. Yip.

Dr. Yip does believe, however, the majority of health workers are still being paid by their local governments -- in part or in full -- as well as receiving payments from their patients.

Good economy masks problems

The problems aren't just at the village level. The reliance on a market-based health system has led to a rapid deterioration of health care for nearly all Chinese, Dr. Yip says. Government health care insurance, for example, is under great financial stress -- including the threat of bankruptcy.

Sugarcoated pills are sometimes used in immunization drives. Mass vaccination programs have greatly reduced polio and other diseases.

"In the transformation from a pure, socialized medical system to a market-based system, they didn't take this into account," Dr. Yip says.

Escalating medical costs mean fewer people are going to doctors. That usually contributes to a rise in such infectious diseases as hepatitis, tuberculosis and sexually transmitted disorders. And when people spend less to save what they can for health care, the economy may be affected.

Dr. Yip believes that right now, because the economy is doing well, such health issues are not noticeable, particularly to the government. But that can change.

"In Russia, everyone knows mortality [levels] shot up as the economy went down. But the economy here is good, and that is creating a health buffer."

One of the rare places where the Chinese health care system is working is Tibet. It remains more socialized than the rest of the nation, and because the region is under close scrutiny from Beijing and the international community, it has received preferential treatment for its health care system from the government.

As he looks ahead to a potential crisis, Dr. Yip wonders about the past.

"China took for granted that they had a good, functioning health care system -- a system that people came from all over the world to study and admire," he says. "Ten years ago health workers could perform as if they had the public health in mind. But now, 20 years into a market system, only the hardcore [idealists] can afford to."

Bruce Kennedy was a Chinese history major at Bowdoin College in Maine. He worked for Visnews, the international television news agency, for five years before joining CNN in 1988. After a stint at CNN International, he began work at CNN Interactive. Kennedy has extensive experience in East Asian affairs, having studied and worked in the region.