BOOK REVIEWS

The Collapse of the Rural Health System

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.