Li Xiufen, whose family tills rice fields high in the terraced-carved hills of southwest China, had to borrow $730 from other villagers when she needed stomach surgery two years ago — a debt that remains unpaid.
When her husband, Zhang Wenkai, 54, contracted meningitis last year, she begged him to go to the hospital, but he refused.
"We didn't have enough money for the hospital fees," says Li, 56. "So he died at home."
Li's loss highlights how China's market-oriented system in the past few decades has priced health care beyond the budget of many Chinese in rural areas. That is about to change.
The Chinese government announced a $124 billion, three-year overhaul of its health care system that calls for building a clinic in each of the country's 700,000 villages, expanding medical insurance and capping the cost of hundreds of prescription drugs.
The ambitious package, announced last month, will provide "safe, effective, convenient and affordable health services" to all of China's 1.3 billion people by 2020, the government said. And its impact will extend far beyond China's borders as a way to stimulate the economy and better handle a medical crisis, such as an outbreak of SARS, bird flu or the new strain of swine flu sweeping the globe.
The plan reverses years of unstitching the Maoist-era social safety net that used to send "barefoot doctors" across rural areas of China to provide free or nearly free basic care. People who now live in the countryside — the bulk of China's population — stash away savings to cover the cost of a doctor visit or hospital stay in case they get sick. The new health care system could free the Chinese to spend more on goods instead of saving for future medical care.
China's health care changes are aimed at making coverage affordable, not free. More than 200 million Chinese lack any health insurance, the government says, and the new plan could cover 90% of the population with some sort of basic medical insurance by 2011. The insurance coverage will reimburse a significant percentage of patient costs, but not all. In 2010, the government will increase its health insurance subsidy for farmers and unemployed urban residents from $11.73 to $17.59 a person.
Here in Yunnan province, close to the Vietnamese border, health coverage is threadbare at best. And the priority is growing food, not buying consumer goods.
The area is named Tiger Mouth for the view of mountains across a spectacular valley where over 1,200 years every inch has been carved into rice terraces. Tourists are drawn by the panoramic vistas of the land tilled by the local Hani ethnic group, among China's poorest people. They have little cash left after a hard year's planting.
The challenges facing China's health planners are as spectacular as the scenery. "Shanghai and Beijing are moving ahead very quickly" with the announced changes, says Sarah Barber, a health policy expert at the World Health Organization in Beijing. "But the poorer regions will struggle to come up with the funds" to cover their share. The central government will pay 40% of the promised $124 billion program, while local governments must come up with the rest.
Yunnan province — 1,300 miles southwest of Beijing — ranks among China's least-developed regions. Local authorities will invest $6.6 billion in health reform over the next three years, says health chief Chen Juemin, who is lobbying Beijing to make Yunnan a pilot project.
About 5,000 general practitioners will be trained, and hospitals built or renovated in all 129 counties. Chen warns that funds are very limited. "We want do things, but our money is very little — that's Yunnan's characteristic," he told reporters in early April.
Farmer Li has not yet heard these latest promises, nor has her local doctor, Ma Jingliang. With the mud of spring planting still on his trousers, Ma unlocks his simple clinic in Mengpin village on a recent afternoon.
"I wish I could be a full-time doctor," says Ma, 45, from the Yi ethnic group, who received basic medical training at regional hospitals but is not a qualified physician. "I'm often tired after a day's work, but I have to serve the people," he says. "I don't do it for the money!" he adds with a laughs
To open the clinic six hours a day, Ma earns $7.30 a month from the local health bureau and makes an additional $15 from drug sales, mostly to treat colds and pneumonia.
"He's a good doctor. He has culture and knowledge, and he'll give you an injection or drugs and let you pay later," says Shi Yuqing, 25, a Yi farmer tending rice fields. A basic, state-run rural insurance plan reached the region last year, but Ma says many patients owe him for a year or two, even on small sums such as $1.50.
Three miles away, in the township of Panjihua, physician Xiao Yunhong worries the new funding will get stalled at the county level and fail to trickle down to help his clinic.
"We are the frontline of health care and can stop people traveling to the cities for treatment, which is one of the government's main aims," he says.
To accomplish that, Xiao says he needs more and cheaper drugs — and better personnel. The county in 2006 assigned 18 staff to his clinic, "But there were only funds for six in an area of 18,000 people, and we lack expert knowledge," he admits.
Shopkeeper Li Xia wishes that expert help had been available in 1996, when her son was born in Xiao's clinic. Li's father, an exorcist who practiced the Hani's polytheistic religion across several villages, warned that he was born at the wrong time, Li says.
"I didn't believe him then, but now it seems he was right," she says. Tian Xiang was diagnosed with hydrocephalus, or "water on the brain," that caused physical and mental disabilities. His grandfather tried chanting rituals to drive out the bad spirits.
His mother has tried, without success, to seek more scientific treatment, and to get a disability allowance. "You have to pay through the back door to get any service here, but we lack the money. And the doctors in this province are not expert enough anyway," Li says.
Li Rui, however, is one lucky little boy.
Chinese Premier Wen Jiabao chanced upon the 2-year-old when visiting the Tianjin train station in February. His parents were returning home after exhausting their savings on Li's treatment for leukemia. Wen was able to get the youngster free care in Beijing that saved his life.
Most are not as fortunate. Since 2005, the Chinese Red Cross Foundation has helped just 10% of the 4,000 children with leukemia who applied for funding — out of 2 million children in China with the disease, according to the state-run Xinhua News Agency.
Some patients have taken matters into their own hands. Wei Qiang set up a do-it-yourself kidney dialysis clinic in the capital's outskirts.
"We did this to survive, as the price is too expensive in hospitals," says Wei, 34. Authorities closed the illegal facility last month, but Wei and nine other patients refused to leave for several weeks until media coverage forced their local governments to offer financial help.
"I'm a farmer. I don't understand the terms of the new medical reform, but I believe our country is changing for the better," Wei says.
Heart-rending cases are all too common, as "there is no safety net in China," says David Wood, a former senior manager at hospitals in California and Colorado, who runs the ChinaCare Group health consultant in Beijing.
"If you don't have money, you just don't get treatment," says Wood, citing estimates that 70% to 80% of health care dollars come out of the patients' pockets.
The new plan "is the most progressive, intense reform effort I've seen," Wood says. The Chinese system is focused on state hospitals that have more than 1,000 beds, but the quality of care "rapidly disappears the farther you go into the countryside. Due to the lack of GPs (general practitioners), most patients self-refer to the large, impersonal institutions that offer no continuity of care," Wood says. "Directing money to community health clinics is by far the most effective way of providing better care."
He also hopes the promised controls on the price of medicines and increased funding to hospitals will remove the incentive to overcharge and overprescribe. In a sign of the problem, Yunnan health officials last month launched a "price honesty" campaign at provincial hospitals and asked the public to help monitor and help stop overcharging.
The new government plan was drafted over three years and included a month of public debate, which "was unusually democratic," says Gordon Liu, a health economist and professor at Peking University's Guanghua School of Management, who was an adviser on the plan.
"This is helpful for China moving forward, economically, socially and politically," Liu says.
The government decided against the expense of a welfare health system similar to that in the United Kingdom and opted for a social insurance approach, mobilizing resources from government, society and individuals, Liu says.
"The system offers the choice of the USA, but the financing of France or Germany to try to persuade everyone to join," he says. "China is on the right track now, but on the delivery side, we face a major challenge."
An increase in spending?
The plan offers good news to spur the economy here and in other countries, Liu predicts.
"Once Chinese have better health security, due to the new insurance programs, they will not put aside so much money and use more of their savings on consumption," Liu says. "This will substantially benefit the Chinese and world economy."
In recent years, China has been at the heart of outbreaks of bird flu and SARS. Barber of WHO welcomes the promise of $2.20 per person to be spent on public health and communicable-disease control. "This commitment could have an impact on control of communicable diseases," she says.
The new plan bears the WHO footprint of universal access and a people-centered approach, says Barber, who welcomes the emphasis on expanding health insurance and making essential medicines more affordable, but wants more focus on the actual benefits package patients can expect.
Deploying qualified staff to rural clinics and paying them remains a huge challenge, she says.
Billionaire Liu Qun wants more room for private players. In March, the pharmaceutical tycoon launched a program of free check-ups, and cheaper drugs, for 1 million farmers in Wanzhou in Chongqing province.
"Some of the new policies are the same as I offered three years ago, but they don't go far enough," Liu says. "Medical resources remain very poor in the villages, and there is great waste of resources from doctors overprescribing. The provincial authorities here don't give people like me enough support. To solve China's health problems, we should be more like Western countries and allow market models, companies and non-governmental groups such as charities to make their contribution."
Shopkeeper Li Xia, whose son, now 13, has hydrocephalus, welcomes help from any source. Li and her husband, Tian Yingwu, have heard of a hospital that specializes in treating this illness in Changsha, almost 700 miles away, but fear they won't be able to afford it even though they run a small business. "Every parent wants their child to be healthy. I hope the health care reforms mean everyone is equal, and we can get fair treatment," she says. "But I doubt they will reach us here."