The physician will not heal himself
'When a patient goes in to hospital, among the first things they're asked is "How much money have you got?" Treatment is decided according to what they can pay - and when the money runs out, they're shown the door.'
This grim picture was sketched more than once by sector specialists consulted in the course of preparing this article. It is framed by data showing that, in fully 70% of cases when Chinese people fall ill, they do not seek medical care.1
Spiralling costs, poor service and inappropriate treatment keep people away in droves - especially rural people, the overwhelming majority of whom pay out of pocket for all their medical expenses.It is a classic, vicious circle: suppressed demand increases pressure to maximise the profit earned from each patient, which invariably translates into yet more prescriptions for medically unnecessary procedures and, pre-eminently, drugs.
The human cost is incalculable, avoid-able suffering, of which a disproportionate share is born by females: girl children in poor families who are reluctant to invest in a trip to the doctor; women who skip antenatal care or who suffer reproductive tract infections that go undiagnosed and untreated for years; older women who endure pain rather than inflicting medical bills on the family, or are blinded by cata-racts whose removal, in China, costs twelve times the Asian average. 2
When major illness or accidents make a trip to the hospital unavoidable, the expense can cripple families for a generation. As many as a quarter of rural families have gone into debt in order to pay medical bills.3 The poorest, who are least able to borrow, are often obliged to sell whatever they have, deepening the pit of poverty. According to recent research, as much as 30% of poverty in China is directly attributable to medical bills.4
Families that can afford medical help for more minor ailments run the risk not only of exorbitant charges but also of mistreatment. Up to 30% of childhood deafness in urban China is caused by indiscriminate use of ototoxic antibiotics.5 Unsafe injection practices are believed to account for the very high prevalence of Hepatitis B: in 1999 it was estimated that 38% of children were infected by the time they reached four years of age.6
How could a system that was widely admired twenty years ago for its cost-effective delivery of primary health care become so dysfunctional?
'Excessive decentralisation of regulat-ory authority and funding', answers Dr. Ray Yip, who has spent ten years trying to arrest the decline, as a consultant on World Bank projects and, latterly, health adviser to Unicef.
Aggregated government spending on health, (although low, at just 0.8% of GDP in 19987), has not declined since the 1980s; in fact it has actually grown, slowly but steadily. But it has declined very substantially relative to total government revenue, which has increased strongly over the last decade. (Figures 1, 2). And, with health costs soaring, government spending has declined sharply as a proportion of the total amount China spends on health ('total health expenditure'). By 2001, government was supplying only about 5% of public hospitals' income, covering about 30% of their wage bills.8 The rest came from user charges.
This has sometimes been described as amounting to the privatisation of public health services. (There has indeed been a parallel growth of fully private health service providers, of which more later). But it is not simply the free play of competition and market forces that now drive health service providers' income generating behaviour. Rather, the present system combines the worst features of both the command and the market economies.
For, through its Prices Bureau, central government still sets the price that health service providers can charge for thousands of different medical procedures. The most basic feature of the charging structure is that - ironically, out of concern to guarantee equitable access to medical expertise - consultation fees are extremely low. In theory, it costs only around a few cents to see a highly qualified senior consultant at a big city hospital. Doctors must therefore make their money by other means.
These include diagnostic tests. City hospitals invest heavily in hi-tech equip-ment so that they can provide - frequently spurious - diagnostic services that pay, rather than relying on physicians' under-priced skills in clinical diagnosis. The city of Beijing is said to have more CT scanners than the whole of Great Britain. Competition between facilities undermines attempts to establish referral systems in which the most expensive equipment is shared between hospitals.
Money is also made by encouraging long hospital stays. Cataract surgery again provides an example: patients in many provinces remain in hospital for a week for an operation that other countries provide on an outpatient basis.9
But the single most important source of income for health service providers is the sale of drugs, and this has led to chronic over-prescribing. According to Yip, fully 60% of China's total health expenditure is used for buying drugs, compared to an international average of around 15%.
A US-trained physician, Yip says that he would feel comfortable prescribing a range of around 25 common drugs without consulting reference books; but that he has visited village clinics where 'barefoot doctors' with only rudimentary training stock more than 200 drugs in their dispensaries, half of them injectable. Although better trained, urban doctors are equally lavish in their prescribing habits. Many city hospitals code their prescriptions to make sure that outpatients buy the drugs at the hospital pharmacy rather than taking their business elsewhere. And, notes Yip, in many cities flyers bearing a telephone number and the words 'High prices for drugs' (高价收药) can be found posted in public places. This is an invitation to people who have medical insurance, and who therefore tend to come away from hospitals particularly laden down with medicines, to offload their surplus onto a flourishing black market.
Government has made sporadic attempts to cure the health system of these bad habits but, because it is now providing only a small proportion of their income, it is extremely hard for govern-ment to call the tune. Public hospitals are highly autonomous and increasingly unaccountable. So too are those run by other work units, notably the People's Liberation Army, which have long since opened their doors to all paying customers, and which are not even nominally under the jurisdiction of the public health authorities.
As a result, there has been a general breakdown in the system's willingness and capacity to deliver preventive care and public health programmes - because they don't generate income for the health service providers.
Among the casualties of the system's shifting priorities have been the public health and hygiene education campaigns - against rats, rubbish, waterborne diseases, malaria etc - that the 'barefoot doctor' system used to underpin.
Maternal and child health workers, rather than getting out into villages to screen infants and pregnant women, now remain in the township or county seat, waiting for paying customers. According to a 1999 Chinese Academy of Social Sciences study of 36 villages, maternal and child health services were reaching only 40% of the target population.10
Immunisation programmes are said to have held together somewhat better, in part because in many areas village health workers still receive a small subsidy for administering vaccines. The health ministry reports high, aggregated coverage of DPT, polio, BCG and measles vaccines (but the 36-village CASS survey just mentioned found a far from universal coverage rate of 80%). Although vaccines are theoretically free, fees for 'service', 'administration' and 'equipment' have been introduced in most areas (much as various fees have been universally introduced for nominally 'free' basic education). Naturally, this is a barrier to access for children from poor families. Investigations following a case of polio in Qinghai Province in 1999, just as the disease was about to be pronounced eradicated in China, revealed that as many as half of the children in the area had not been immunised.11 UN agencies report that actual prevalence of the diseases targeted by vaccines is '5-10 times higher in poor areas and populations'.12
Because it now provides only a small proportion of hospitals' income, government finds it extremely hard to call the tune.
Erosion of these specific services has been accompanied by the crumbling of supervision and referral systems. In theory, rural China has a 'three tier' health system, linking county, township and village facilities. Medical staff from the higher facilities are supposed to supervise, support and train colleagues at lower levels. But there is no financial incentive to do this. Indeed, higher level facilities are directly competing for customers with their juniors. Why would they take time out from profitable activities to hone the skills of their competitors (unless, say, an international programme paid them to do so)? In practice, there has been increasing concentration of equipment and skilled staff at higher levels that are able to take on the more profitable cases of illness.
The rural public health system is thus less a 'system' than a constellation of nominally public facilities competing for private customers. In this at least it resembles the health market in big cities.
For all but the most minor complaints, for which they might buy medicines over the counter, urban people tend to go straight to outpatient departments in the country's 16,781 urban hospitals. Govern-ment policymakers have, since the late '90s, recognised the need for services to be more community based, but progress towards this is hampered by the hospitals' vested interest in retaining their market share.
A GBP 10 million (USD 16 million) Urban Health and Poverty project, funded by the UK Department for International Development, has since 2000 been trying to promote networks of family doctors and nurses, working out of community health centres and referring to hospitals only cases that require specialist or inpatient care, in the cities of Shenyang, Chengdu and, latterly, Xining and Yansha. (The project is also piloting medical financial assistance for the poor in these cities). This initiative was to be under-pinned by regional plannings processes in which local health authorities would assess the health needs in their areas and coordinate health services accordingly. Central government guidelines issued in 1999 required all local authorities to undergo such a planning process. But, says Qiao Jianrong (乔建荣) of DfID, 'Regional planning is a good concept, but nobody is really implementing it.' Many areas have embarked on assessment and planning exercises, but they have limited capacity to impose reforms upon basically autonomous service providers.
More than 48,000 township hospitals offer the rural population the first level of service after the village barefoot doctor. In the poorest counties, these 'hospitals' sometimes comprise no more than a one or two-room clinic with a couple of beds. Proportionate to the size of the pop-ulation they theoretically serve, township level facilities are seriously under-used, especially for inpatient services. Patients who can afford to pay very often skip this tier altogether and go for treatment directly to county town or even big city hospitals.
In addition to the profit-seeking behaviour of health service staff and managers, at least three, mutually rein-forcing factors undermine the quality and availability of rural health services.
Firstly, what public funding is available comes predominantly from local govern-ments. The poorest (and least healthy) townships and counties are invariably already indebted and able to afford least. Even if they can follow central guidelines as to the proportion of local budgets to be allocated to health - and, most likely, many cannot - the available pie is too small at the outset. China's national health accounts do not give a breakdown of local government spending on health, but they do distinguish between urban and rural per capita total health expenditure in different regions (Figure 4). The disparities are immense, ranging in 1998 from CNY 2,314 (USD 279) per capita in urban areas of Zhejiang to CNY 61 (USD 7) in rural Guizhou.13
Secondly, notoriously, around 90% of China's rural population has no health insurance. Villagers in the rural collectives of the Maoist years were covered by cooperative medical systems but, with the decollectivisation of agriculture, most rural people opted out of these, causing the schemes to collapse in most areas. Lack of trust in the management of the schemes is reported to have been a critical factor in their demise - and has proved a major constraint in recent and ongoing efforts to revive this kind of system. Meanwhile, with rural people 'paying as they go' for all medical care, they stay away from the doctor if at all possible or if they do not have the cash to go; and this reduces the income of rural facilities. The problem is aggravated by rocketing health care costs, as ever more medical procedures are ordered, to increase profits and cover growing wage bills for serving and retired health staff. A Ministry of Health survey of 15,000 hospitals showed that inpatient costs per admission rose from around CNY 400 (USD 48) in 1990 to just above CNY 3,000 (USD 361) in 2000.14
Thirdly, rural facilities suffer from chronic overstaffing. Local governments still have a duty to provide jobs for certain of their citizens, such as retired soldiers and returning vocational school graduates who cannot find jobs elsewhere. Accord-ing to Ray Yip, local officials often assign these people to the public health system as a way of discharging their obligations without adding to their own budgetary burden - because health facilities are seen as able to generate the income to cover wages. Township facilities, says Yip, are often so bloated with staff that there are no more than two patients per day per employee. The bulk of each employee's daily wage must therefore be covered from the profit on treating just two patients, creating an irresistible temptation to add to the number of spurious proced-ures and medicines prescribed.
Given the threat to rural services that this combination of factors clearly pre-sented, why has government been so slow to act? Rapidly rising rural incomes and rapidly falling poverty counts in the early 1980s may have encouraged complacency, reinforced by apparently steady progress, until the mid 1990s, in health indicators such as life expectancy, childhood and maternal mortality rates15 - even though these almost certainly reflected improved diet, water supply, etc, rather than the adequacy of medical services. The reform-era zeitgeist of commercialisation, com-bined with the enduring romance of the 'modern' no doubt also encouraged a belief that city hospitals with hi-tech equipment equalled a more 'developed' health system than the shabby old 'barefoot' days. Health authorities, repeat-ing the mantra that China is 'still a dev-eloping country', tended to see problems in terms of the need for more and better hospitals, and the latest kind of equipment. This, at any rate, was the kind of support they sought from international donors; and a drive to rebuild and extend township health facilities was begun with the eighth Five Year Plan in 1991.
Health authorities believed that new hospitals and hi-tech equipment equalled a more 'developed' system than the shabby old 'barefoot' days.
But by the mid '90s the evidence of systemic dysfunction and decay was be-coming unmistakable. From 1994, the World Bank, which had already provided numerous health-sector loans began to collaborate with the Ministry of Public Health on a detailed study of health system financing. The results were published in a 1997 report, Financing Health Care: Issues and Options for China. This unusually frank and direct document discussed in detail all of the systemic failings so far sketched in this article.
Yet the last five years have seen little change in the basic trends. In most ways, the situation has since become worse rather than better. In contrast to its relatively energetic efforts in poverty alleviation and attempts to weave basic social security safety nets, government seems to have a blind spot when it comes to health care. The Ministry of Public Health is widely acknowledged to be not only under-resourced, but also politically weak (compared, say, to the State Family Planning Commission).
Moreover, government inaction can-not be explained simply in terms of urban bias, since health system decline no longer exclusively affects the rural population. Only around half of city dwellers are now covered by a reformed, contributory basic medical insurance scheme introduced over the last two years in response to soaring medical costs. This has higher thresholds and lower ceilings for pay-outs than the previous state system. The many workers in the informal and private sector who do not pay into to the scheme, and the growing body of urban unemployed and migrants in urban areas, lack the basic health security that must be an important constituent of the goal of xiaokang ( 小康) - 'being better off in an all round way'.
Lack of control now probably para-lyses policy as much as lack of will. Health service providers have become so set in their ways that change will be extremely hard to achieve. James Killingsworth, a health economist with the WHO mission in Beijing, believes that central govern-ment will have to put more money into the system, but is reluctant to do so because 'it may just be a black hole'.
Nevertheless, October 2002 saw a top level 'Decision' to kick-start new financing mechanisms for rural health care.16 Like many Chinese policy statements, the 'Decision' is long on generalities and short on specifics; but it proposed a new cooperative medical system (CMS), pledg-ing central funding of CNY 10 (USD 1.2) per capita of the rural population, to be matched by a further CNY 10 per capita from local governments and voluntary contributions of CNY 10 from individuals who choose to join the scheme. It also pledged unspecified funds for Medical Financial Assistance (MFA) packages for the poorest. The Ministry of Civil Affairs has been allocated CNY 300 million (USD 36 million) to start pilot MFA projects, and has begun experiments in several provinces.
Both CMS and MFA schemes have also been components of a World Bank and DfID financed Basic Health Services ('Health VIII') project that, starting in 1998, set out to address some of the problems discussed in the Financing Health Care report of the previous year. At first sight, then, this looks like a success story for international aid: donors collaborate with the government to assess existing policy and services, then develop pilot work to address some of the main problems, with key lessons finally taken up and enshrined in national policy.
But it was not quite that simple. The government has in fact frequently nodded towards the revival of cooperative medical services - notably, in a January 1997 'Decision on Health Reform and Develop-ment' that also called for improved drug management and stricter controls on health facility staff, although these fiats have not been implemented. Preparation of the Health VIII project (so called because it is the Bank's eighth health sector project in China) began as early as 1995, although as it was finalised it was indeed seen as an attempt to 'test the health reform strategy' laid out in the 1997 'Decision'.17 But whilst the project was credited with modest success in its mid-term review in 2001, it has also demon-strated the intractability of some of the financing and services issues - and the CMS component has been one of the least successful.
As originally agreed, half of the USD 70 million loan was to be used for upgrading and equipping rural health facilities in 71 poor counties of seven provinces (Anhui, Chongqing, Gansu, Guizhou, Henan, Shanxi and Qinghai). Most of the rest would fund improve-ments (basically through training) of supervision, referral, clinical protocols and case management. Counties could also choose one of three 'priority health interventions' - maternal and child health, immunisation or tuberculosis control - for further, special support. An additional component would aim to strengthen health planning and management. The World Bank had wanted a larger proportion of funds devoted to 'software', but the State Planning Commission resisted this, and ruled out using the loans for CMS and MFA schemes.18 In the end it was agreed that these would be financed by the Chinese counterpart funding of USD 37 million. Half of that would come from central government, 10% from the provinces, 20% from prefectures and 20% from county and township governments. This hefty contribution from local govern-ment, on top of the loan repayments they would have to make, meant that some of the poorest counties in selected provinces did not participate in the project.
As the project began, some financing constraints were eased by 'blending' of funds from the UK Department for Inter-national Development. In 1999, it made a GBP 15 million (USD 24 million) grant for a 'Health VIII support project', to provide more technical assistance at cen-tral and provincial levels, but also to focus on two pilot counties in Chongqing and three in Gansu, allowing for more intensive experimentation. (DfID has recently contributed a further GBP 6 million, adding another 5 pilot counties).
A mid term review conducted in 2001 showed some progress towards the project objectives, but only very modest improve-ment in the uptake of services. By most criteria, counties receiving DfID intensive care were doing significantly better than the rest - although, given the large number of counties involved, project experiences have varied considerably.
All of the project counties had form-ulated health resource plans. This was not a detailed exercise in the rationalisation and allocation of health resources. That, says Liu Yunguo (???), Deputy Director of the health ministry's Foreign Loans Office, 'is a very difficult task for health authorities, so we [just] asked them to describe the different functions for county, township and village health services'. Some township facilities were merged or closed as a result of this process; but aggregate staff levels rose rather than fell.
All project counties have designed health information management systems (reporting, keeping patient records, etc, especially for immunisation and maternal and child health services); but it remains too early to say whether these will continue to function as intended.
Use of township health facilities actually fell during the first two years of the 'Health VIII' project - though not by as much as elsewhere.
Some progress has been made in supervision and referral says Dr. Liu; but 'supervision' has so far happened through training events arranged by the project, rather than becoming institutionalised on a sustainable basis. Liu also points out that while it is relatively easy to persuade lower level medical workers to refer upwards cases that are too complicated for them to deal with, it is much harder to persuade county or township facilities to relinquish patients who can be dealt with by community paramedics.
According to the review, 45% of project township facilities had adopted clinical protocols, while 67% of township facilities and 49% of village health centres were using essential drugs lists.
But if this implies better services, they are not being more widely used. The review report noted a 2.3% drop from 1998-2000 in outpatient and emergency visits to township facilities in project counties - with the slender consolation that this was less than the nationwide 6.1% drop. (In the DfID intensive care counties, however, visits increased by 7.7% from 1999 to 2000).
Initial results in the 'priority health interventions' showed some improvement, but room for plenty more. Forty eight of the project counties chose maternal and child health as a priority intervention. One objective of the programme was to increase the proportion of children born in institutions. In 1998, in 41 of these counties more than half of all births happened at home. By 2000, the number of counties where most children were born at home was cut to 35. Only 11 counties out of the total 71 could boast, by 2000, an 80% or better rate of antenatal and postnatal checks (compared to five and seven counties respectively in 1998).
Increased use of these services is partly ascribed to the medical financial assistance that the project aims to provide for the poorest 5% of the population. (By the mid term review it had reached only 2.2%). This provides subsidised, as opposed to free, services. In 2000, more than half a million people were registered as eligible for assistance, and 20.2% of them had claimed it, though pay-outs were less than lavish, averaging a mere CNY 17.73 (USD 2.1). There were relatively few claims for inpatient treatment (presumably, the patients could not afford even a subsidised hospital bed), but claims for outpatient treatment were growing and 6% of those eligible had claimed for assistance with preventive services such as immunisation and ante-natal checks.
According to Liu Yunguo, the main problem with MFA implementation has been mobilising the local government funding for it. This is obviated in the DfID pilot counties, where project funds cover the costs and where, as a result, the reach is greater. In Qinghai, Liu notes, the government was enthusiastic and allocated poverty alleviation funding to support the scheme. On the whole, he says, it has proved a 'very good model'.
Cooperative medical schemes, aimed at people who can afford to pay a small premium in advance, have worked less well. Again, it is hard to secure local government funds to match the voluntary contributions of participants, even though the government contribution is no more than CNY 3-4 per capita (of which nearly half is, in theory, already pledged in funding for the project). But the scheme is also a hard sell to a generally sceptical rural population. There are, Liu points out, 'hundreds of different models', and some have worked better than others, but a common feature is the lack of a large enough base for sustainable risk pooling. The young and robust don't want to join (and many of them have migrated out of the area anyway), and those most keen to join are also those most likely to claim benefits, the elderly or chronically sick. As a result, funds often run out of before the end of the year, leaving claims that cannot be settled, or needing premiums to be raised retrospectively. Again, the counties DfID supports have fared best, because the project puts in CNY 10 per capita.
This leads Liu to conclude that CMS is 'really hard to implement on a voluntary basis. It has to be compulsory unless government pays most of the fees.'
The new CMS proposal, outlined in last October's central 'decision', does pledge government support - but, in light of the Health VIII experiences, it will not be easy to persuade local governments to pay their share.
James Killingsworth of WHO cautions that the new plan should not necessarily be seen as just a health insurance scheme: 'It could be used for infrastructure, capital investment, beefing up services as well.' He adds that 'The guidelines are so broad that there may be hundreds of different patterns in the way the funds are used', and argues that 'the main problem is fund management, how to make sure that the funds are used as intended, not just to cover what costs are pressing at the time.'
The least sanguine observers are con-cerned lest, without adequate fund man-agement, hospitals will simply redouble their prescribing energies until any extra money is used up. The most important step to prevent this, in Ray Yip's view, would be price reform, so that income is earned from charging for consultations rather than from the profits on procedures and medicines. But, he believes, this could only happen with re-centralised control of the public health system, to enable it to set and enforce appropriate standards.
Others emphasise the importance of bringing in intermediaries as purchasers of health services. Maurits van Pelt, a DfID adviser to the Health VIII project, sees the involvement of the Ministry of Civil Affairs in establishing new MFA pilots as 'very promising'. Although some doubt the Ministry's competence to purchase health services on behalf of those qual-ifying for assistance, van Pelt believes 'it would create a healthy dynamic to have another body involved in the bargaining.' Civil Affairs, he suggests, should recruit retired medics to develop their capacity as a watchdog, making sure that the MFA beneficiaries are supplied with appropriate services.
A future contender for management of CMS funds might be the Ministry of Labour and Social Security, which already manages basic medical insurance in urban areas and was recently rumoured to be set for a merger with Civil Affairs.
Some believe that services would be improved by expansion of the fully private health sector and the competition it would bring. Alongside the commercialisation of the public health system, a fully private sector has become established. This mainly comprises individual practitioners running small clinics, but includes a few cases where public facilities have been contracted out to private companies. Some townships have also turned their health facilities into shareholding enter-prises. In addition, international medical companies have established clinics and small hospitals in major cities, catering mainly to expatriates and charging international prices for the consultancy services of local Chinese doctors.
According to James Killingsworth, research has shown that in cases of relatively minor illness Chinese people view private practitioners positively for their competitive prices (easy to achieve as they are not paying swollen wage bills) and for the relative civility with which they treat patients (especially welcome in the case of, eg, STDs). But in cases of more serious illness people are more inclined to trust the public facilities.
At least two factors will certainly drive expansion of the private sector. Medical schools are producing 100,000 graduates per year, but public hospitals can absorb only 10,000 - so there is a steady supply of qualified doctors wishing to enter private practice. And WTO will open market access for international companies. Far from being hostile to this trend, the Communist Party gave it a green light in the October 2002 'Decision', which ord-ered local governments to 'Give equal treatment to private medical institutions that satisfy relevant conditions and grant them encouraging policies such as tax reduction or exemption.'
China's last two decades amply dem-onstrated that competition between health care providers does not in itself improve quality services. Experience elsewhere suggests that a functioning public sector is imperative for equitable access to services. At this stage in China the further embrace of market forces may well prove a dangerous distraction from taking health seriously as a public good.
A more urgent task than giving tax breaks to private investors is to improve the accountability of health care providers. Government appears to accept the prin-ciple that people should be protected from commercial cheats, and it should extend that principle to health service admin-istrators and doctors. For theirs is the worst kind of cheating, as it exploits our personal fears and suffering, and abuses the shamanistic authority even the most 'advanced' of us defer to in professional healers. This requires a triple dose of civil society, blending the three powerful forces of representation, information and litig-ation.
Firstly, local health authorities need health users' councils - made up of local citizens, not Party and government bur-eaucrats - to act as watchdogs. Township hospitals need management boards with health user representatives. Likewise CMS schemes.
Secondly, Chinese people need to be empowered by knowing much more about their bodies and their health. This is a battle that health care consumers in the West have fought quietly for the last three decades, and with significant success, against a medical establishment that never liked having its authority challenged. Information technologies greatly increase the prospects for accelerated change in China, if only at first among the urban elite.
Thirdly, people need redress when they are seriously harmed. And in fact they are beginning to seek it. A trickle of court cases have seen (pitiful) damages settle-ments for gross malpractice. If these grow, and there is every reason to suppose they will, they could have more impact on practitioners than state 'Decisions' and exhortations to higher standards.
Fanciful? Perhaps not. Government is struggling to get the health system in order and, after SARS, perhaps realising that failure to do so will drag China's economy down. It therefore has every reason to encourage 'public supervision' of service providers, in order to assure the quality and affordability of health services that the nation needs in order to thrive.
1Gao Jun, Rao Keqin, Tang Shenglan and Rachel Tolhurst (2001) Changing Access to Health Services in Urban China: Implications for Equity in Health Policy and Planning 16(3); quoted in UN Theme Group for Health (2003) China Health Situation Assessment (draft).
2For an overview of the impacts on women of China's health system failure, see Xiao Li goes to the doctor in our Spring, 2000 issue (Vol III No 1), Ailing Health System Hurts Women Most (on our website). The figure for relative price of cataract operation price was supplied by the specialist eye-care agency, Fred Hollows Foundation, as quoted in Making Sight Affordable, China Development Brief Vol. II No. 4 (also on our website).
3UN Theme Group for Health (2003) p. 35, quoting figures given at Ocotber 2002 National Conference on Rural Health.
4UN Theme Group for Health (2003) p. 64, quoting forthcoming work by Liu Yuanli and William Hsiao.
5Calloway, A (2000) Deaf Children in China Gallaudet University Press, p. 56
6UN Common Country Assessment Report on Health in China (Draft Version 12), xerox, November 1999
7China Health Economics Institute (2001) China National Health Accounts, Final Report p. 14 Figure 5.1
8UN Theme Group for Health (2003), p 57
9Fred Hollows Foundation, as quoted Unseeing and largely unseen., in China Development Brief Vol III No. 3, Autumn 2000.
10魏众 Wei Zhong<<中国农村的健康和养老保障>>(Guarantees for Health and Geriatric Care in China's Countryside ). CASS Economics Institute, 2003
11Qinghai polio case brings to light very low immunization rates in China Development Brief Vol III No. 1, Spring 2000
12UN Theme Group for Health (2003) p. 55
13China Health Economics Institute (2001) China National Health Accounts, Final Report p. 21
14Dr. Rao Keqin, Transitional Economy and Health Reform, quoted in UN Theme Group for Health (2003) p. 59
15Given China's reporting systems, the state's formal monopoly on statistical surveys and the consequent difficulty of obtaining reliable, independent data, these figures should in any case be regarded sceptically, although UN agencies quite routinely re-publish and tacitly endorse them.
16Decision of the Central Committee of the Chinese Communist Party and the State Council on Further Strengthening Rural Health Work, October 19 2002.
17Liu Yunguo and Gerald Bloom Designing a Rural Health Reform Project: The Negotiation of Change in China, p. 20 IDS Working Paper 150, IDS, January 2002.
18Liu Yunguo and Gerald Bloom, p. 12