Tao Guoqi's right leg rarely leaves the ground. The construction labourer from Anhui drags it behind him as he walks, pivoting his hips to propel himself forward. His leg had been badly broken a few years ago when some bricks fell on it, he explained. It was 'pretty bad' but he could not afford hospital treatment, so some colleagues made a splint and bandaged him up. 'They didn't do a very good job,' he said. Brutal as his case may sound, Mr Tao is hardly the exception in China. According to a central government survey, more than two-thirds of rural residents who were referred to a hospital did not go because they could not afford the treatment. And now, Mr Tao and hundreds of millions like him, are worried about having to seek treatment for something far more serious. Even though the central government has announced that free care will be given to anyone showing symptoms of severe acute respiratory syndrome (Sars), they still doubt the quality of that care. Beijing's acting mayor, Wang Qishan, could hardly have put their minds at ease when he admitted at a press conference this week that the capital did not have enough qualified medical staff to deal with the Sars outbreak. Considering that the prosperous eastern cities receive the lion's share of public funding, that admission highlights how ill-equipped the poorer provinces are to deal with a health crisis. Indeed, the municipalities of Beijing and Shanghai, along with the provinces of Jiangsu and Zhejiang, account for more than a quarter of the country's total health expenditure - an anomaly which led the World Health Report 2000 to rank China 188 out of 191 countries in terms of fairness in funding the health sector. China's rural areas, which account for about 70 per cent of the population, receive just 20 per cent of the health-care budget. The results speak for themselves. While overall life expectancy has risen impressively, from 59 at the height of the Cultural Revolution in the mid-1960s, to 67 when Deng Xiaoping launched his reforms in the late 1970s, and to 72 now, child mortality rates show the gap between rural and urban standards. In the western province of Xinjiang, for instance, the figure is 68 deaths per thousand live births - 10 times higher than the rates in Beijing or Shanghai. Tibetan women are 46 times more likely to die during childbirth than Shanghainese women. If it were only money that was needed to fix the problem, there might be less to worry about in the Sars scare, analysts say. But the outbreak has highlighted several other inadequacies in the health system. These include its structure, whereby authority is fragmented and decentralised; the lack of training among its staff; and the basic prioritisation of its services. The job of fixing that system, which has fallen to Vice-Premier Wu Yi, could hardly be called enticing. Mostly, the inadequacies of China's health-care system are the result of the nation's rapid change from a socialist to a market-based economy. It was not so long ago that the Communist Party provided a full cradle-to-grave welfare system, under which practically everyone had access to basic health care. But with the changes that were adopted in the countryside from the late 1970s, after the collective system of farming was dismantled, that policy was - in the words of one western diplomat - 'thrown out the window'. Now, fewer than 10 per cent of the population have health-care cover. 'In some ways the health-care system is a microcosm of the whole country in that it is struggling to redefine itself,' the diplomat said. 'It calls itself socialist but behaves like a ruthless capitalist.' For evidence, he said, look right at the front of the system's front line: ambulances in Beijing will not accept a person who has suffered a heart attack until 10,000 yuan (HK$9,400) is handed over. Yet such ruthlessness is, on the face of it, understandable. Hospitals are no longer subsidised like they used to be. The government's direct share of total health-care spending has dropped from 36 per cent to just 15 per cent over the past two decades. Patients are now expected to foot nearly two-thirds of the total bill. Such a rapid transition has inevitably resulted in many hospitals being quasi-privatised: they have the responsibility to finance themselves, but they do not have the oversight of private shareholders. Thus, all too often they end up under the management of 'sharks', says Nick Young, from the China Development Brief magazine. And, he asks rhetorically, who ends up carrying the burden of raising funds? Those on the front line - doctors, who have to generate up to 60 per cent of their own salaries. Naturally, therefore, a system has developed that provides an incentive for medical staff to over-prescribe drugs and recommend dubious treatment, resulting in what the WHO refers to as 'inappropriate patterns of care and escalating costs'. Moreover, because hospitals are essentially competing against each other, there is no referral system, little co-ordination and large degrees of overlap. Since activities such as providing health information and offering preventive and curative treatment do not generate revenue, medical workers give them scant attention. Not all of this can be blamed on lack of funding, critics say. Even with enough money, China's health system would still be fragmented and decentralised. And decision-making would still be hampered by the blurred reporting lines between central and local authorities. Take the health ministry, where the formidable Ms Wu has assumed command. Just a fraction of China's 64,000 hospitals are actually administered by the ministry. Others fall under various other ministries, as well as local governments. Then there are those run by the People's Liberation Army and the police force, whose records are deemed national secrets. And yet more are managed by state-owned enterprises and private companies. Analysts say this makes Ms Wu's job extremely difficult. 'Each level of government - from provincial to county - is responsible for health care at that level, and thus the vertical line of communication and control is very weak,' said Liu Yuanli, from the Harvard School of Public Health. What this means is that a holistic approach to health care is sorely lacking, as curative care is separate from preventative care and public health care, Professor Liu said. A much more consolidated and better co-ordinated public health surveillance system is 'urgently needed' to combat major public health problems, he said. A source in the World Health Organisation agreed, saying: 'The regulatory functions in China's health system are nothing short of appalling.' The diplomat said: 'But heads rolled over the Sars cover-up. That was a first. It is a positive sign. Hopefully the fiasco will lead to a more accountable, transparent system.' Beyond such obvious restructuring, however, lie further challenges to overcome in the nature of the system. And most are, in fact, about money - or the lack thereof. Even to cater to the most basic needs of the people, the health system needed a massive injection of cash, the diplomat said. 'It is absurdly under-funded.' The WHO believes many people are not being given essential vaccines because of the focus on profits. Hepatitis B, for example, can be prevented with an inexpensive vaccine that is widely available. But as clinics and hospitals have no financial incentive to administer the vaccine they often simply do not offer the service. The result, the WHO estimates, is about 280,000 avoidable Hepatitis B deaths a year on the mainland a year. Lack of funding obviously translates into a lack of trained personnel. Better trained and more experienced staff gravitate towards the large urban centres where resources are pooled, leaving many rural hospitals with low-calibre staff. Many practising doctors in rural areas have only received a year or so of medical training. A nurse from a general hospital in Hebei said that so far this year they had been sued more than 10 times for negligence. 'The doctors sometimes make bad mistakes. But they are paid practically nothing. 'Nobody who was well qualified would consider coming here,' said the nurse, who asked not to be identified. 'But we are so, so busy. We just can't cope. The cadres say they will give us more funding but they don't have the money either.' Not all of the health-care system's challenges are internal, however. China's rapid industrial growth has brought with it an increased prevalence of certain diseases as a result of changes in diets and the living environment. 'China has the worst of two worlds in terms of disease burden,' says James Killingsworth of the WHO. Besides the strong presence of infectious and communicable diseases, such as tuberculosis, Aids and Sars, Dr Killingsworth says the changing face of the country has resulted in cancer, cardiovascular diseases and diabetes becoming more common - not to mention psychological disorders. 'This double burden will put a huge strain on the country's underdeveloped health-care system' in the years to come, the doctor says. Then there is the challenge that every East Asian country has faced as it develops: demographics. By the end of this decade, there will be 100 million people over 65 on the mainland; by the middle of the century that figure is expected to more than triple, and will include about 470,000 people over 100 years of age. Caring for this greying population will be an enormous burden on the health-care system. It will not be made any easier by the expectations of a rising middle class, either. 'In light of the move towards urbanisation and the fact the standard of education is increasing, people will be demanding a higher quality of health care,' Dr Killingsworth says. But the real question is, will they pay for the improved facilities? Particularly since China's accession to the WTO, there has been a debate in China as to what extent the government should privatise the health-care system. Advocates say a market-driven system is the only way to go, just as it has worked in every other sector of the economy that has been privatised. But people like China Development Brief's Mr Young worry about the country's growing income gap. Privatisation would mean that 'an underclass of maybe 200 million people would fall through the cracks,' he says. 'They would get third-rate treatment from the remains of the public system.' Dr Killingsworth says authorities seem to recognise the inherent flaws in the current system and are working to improve the model, particularly in the poorer regions. The government is trying to at least provide the rural poor with a very basic cover. A recently launched community-based health insurance will be financed by contributions of 10 yuan per person from the central government, to be matched by the local government. Professor Liu: 'This is a big step forward but it remains to be monitored and evaluated how the new policy will be implemented on the ground.' At the end of the day, analysts say, China is going to have to start devoting more resources to health care. At present, it accounts for about 5 per cent of total government expenditure. Other developing countries in the region spend about 8 per cent while developed economies spend between 10 and 14 per cent. Hong Kong comes in at 15.4 per cent. 'They basically need to put more money in and set up a system to effectively monitor and regulate how it is used,' the diplomat said. 'But the political tensions between all the factions, and the logistical implications of looking after such a huge number of people in such a vast area, will always mean this is a nightmare of a task,' he added. Still, others are hopeful that if there is a silver lining to be found in the current Sars outbreak, it is that the central government's priorities are going to be shifted for them by a growing middle class that has been woken by the inadequacies of the health-care system. 'It is inevitable that they will have to rethink their focus on quantitative growth,' says Jean-Pierre Cabestan, Hong Kong-based director of the French Centre for Research on Contemporary China. 'The quality of that growth has left much to be desired, and there is a strong constituency for change now, with greater emphasis needing to be placed on health care.' Mr Tao would certainly agree.
