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EDITORIALS: Tao Liu China's health challenges BMJ 2006; 333: 365 [Full text]

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User fees and China's health challenges

Saroj A Jayasinghe   (19 August 2006)

China’s challenge - Rising Inequalities in Health and Wealth.

Sonal Singh   (21 August 2006)

User fees and China's health challenges 19 August 2006
Saroj A Jayasinghe, Locum Consultant Physician BHR Hospitals NHS Trust, RM7 0BE Send response to journal: Re: User fees and China's health challenges	The editorial by Liu does not give adequate consideration to the policy option of health services at zero-cost to user (1). The evidence from China confirms previous evidence that introducing user fees for health care reduces utilization of health care and thereby adds to human misery (2). For the elderly in China, medical cost (i.e. user fees) is the main cause for 40% of those not visiting a doctor, and for 75% of those not gaining admission to hospitals (2). Another argument against user fees is that it worsens health inequities (3). The financial gain from user fees is also insignificant, and in Africa income from user fees was less than 5%, although it was nearly 35% in China (3). The human costs of prolonged illness at old age and the increase in long-term to health costs from delayed treatment are further disadvantages. Even developed economies of Europe, have steadfastly maintained some facet of a zero-user-fees-policy. In many, the only out-of-pocket expense is a partial payment for drugs (3). Developing countries such as Sri Lanka and Cuba, are other examples where the governments have resisted charging user-fees for health. This policy, together with female education and extensive distribution of health services, has enabled good health (at least for the infants and mothers) at relatively low cost (4). The evidence from China is another example, which supports the dictum: “poorer countries should provide health care at zero cost to the users, until proven otherwise”. This should apply equally, at least to the poorer regions of China, and removal of user fees should be a priority, using well-established systematic methods (5). 1. Liu T. China's health challenges BMJ 2006 333: 365 2. Zhang T, Chen Y. Meeting the needs of elderly people in China. BMJ 2006 333: 363-364. 3. Creese A. User fees. BMJ 1997; 315: 202-203 4. Bhutta Z, Nundy S, Abbasi K. Is there hope for South Asia? BMJ 2004;328:777-778 5. Gilson L, McIntyre D. Removing user fees for primary care in Africa: the need for careful action. BMJ 2005; 331: 762-5. Competing interests: None declared
China’s challenge - Rising Inequalities in Health and Wealth. 21 August 2006
Sonal Singh, Dept of Medicine, Wake Forest University, Winston-Salem NC USA 27157 Send response to journal: Re: China’s challenge - Rising Inequalities in Health and Wealth.	We agree with the view that China has made rapid progress in in human development. The Life expectancy in China doubled from 35 to 71 years between 1949 to 2001.1 China’s Human Development Index (HDI), -a measure of life expectancy, education and income -has been steadily rising and it ranks 85th among countries with an HDI of 0.755 in 2003 .1 However, neither health nor wealth are equally distributed in China. According to the China’s Human Development report, China’s national Gini coefficient for income distribution, a measure of income inequality rose to 0.45 in 2002 from 0.3 in 1982.1Only 31 countries manifest higher income inequality than China. The average income of the highest income decile group is 11 times higher that of the lowest ones.1 There are widening disparities in health indicators between urban and rural areas. Life expectancy is 75.2 for urban residents and 69.6 for rural residents.1 The Human Development Index is 0.816 in urban areas vs. 0.685 in rural areas.1 Rural infant mortality rates at 34% and maternal mortality rates at 61.9 per 100,000 births, are nearly twice as high compared to that of urban areas (infant mortality rate is 14 %, and maternal mortality rate is 33.1 per 100,000 respectively). 1 The prevalence of children who are stunted (20 %) and children under-5 that are underweight (14%) is also higher in rural areas compared to urban areas (3% for both stunting and underweight). 1 There are only 2.4 medical personnel per 1,000 residents in rural areas, compared to 5.2 per 1,000 residents in urban areas.1 The collapse of the rural public health services was partly responsible for the delay and panic following the SARS epidemic. There are also widespread regional disparities in life expectancy and maternal mortality indicators, with the western regions faring the worst. The life expectancy for rural residents is less than 65 years in Tibet, Yunnan and Guizhou. 1Maternal mortality rates are also highest in the western regions.1 Among all provinces, the Tibet Autonomous Region (TAR) ranked lowest in terms of life expectancy- (65.81), literacy - (47% literacy) and Human Development Index (0.562).1 The TAR also has the lowest number of physicians and hospital beds in China.1 Only 15 % of the entire population of China can afford medical insurance.1 Several segments of the populations that are especially vulnerable to these inequalities include- the rural and urban poor, rural migrants in cities and landless farmers. Only 2% of rural migrant workers currently enjoy unemployment insurance.1Several coercive public health policies including that of forced abortions are prevalent.2 Some policy makers believe that China's pre-reform experience in rapidly expanding health care and basic education and ensuring egalitarian distribution of income, and its post-reform experience in pursuing intelligent economic policies would have expanded the gains in development if combined with wider public engagement and democratic participation. As Professor Amartya Sen argues in Development as Freedom, the abandonment of the entitlement to health care in China, which was carried out very smoothly through compliant politics, would have almost certainly received far greater resistance in more plural political systems .3 China’s ambitious aim of building a ” Xiaokang” society 1 in which people are not rich but have adequate food, clothing and basic necessities for a decent life will require addressing these widening disparities, prioritizing health opportunities for all , and acknowledging the inherent, instrumental and constructive 3 roles of freedom in achieving these goals. References 1. United Nations Development Program. China Human Development Report 2005, Oct 15 2005. Accessed Aug 17, 2006 at http://hdr.undp.org/docs/reports/national/CPR_China/China_2005_en.pdf 2. Watts J. Chinese officials accused of forcing abortions in Shandong. The Lancet 2005; 366; 1253 3. Amartya Sen. Development as Freedom. Oxford University Press, 1999 Competing interests: None declared