China's health challenges
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.38943.408021.80 (Published 17 August 2006) Cite this as: BMJ 2006;333:365
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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
Competing interests: No competing interests
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
Competing interests: No competing interests