PHA-Exch> Rural China: Missing the barefoot doctors

[Claudio Schuftan]

From: Vern Weitzel vern at coombs.anu.edu.au

http://www.economist.com/displaystory.cfm?story_id=9944734

>From The Economist print edition  (excerpts)

China's rural citizens are nostalgic for the past. They want a
public-health system that works. Mao's system of "barefoot doctors" for
country districts, set up in the1970s, may have been rudimentary, but at
least it was readily accessible and practically free. Public-health care
in rural China, is now in tatters. And the extent of rural discontent is at
last becoming known, as western journalists are slowly allowed to explore
the backward interior.

In recent years China's Communist Party has begun to pay attention to a deep
malaise in the countryside: the prohibitive cost of health care and
education for the rural poor, mounting debts at the lowest levels of
government, bloated bureaucracy and a growing wealth gap between rural and
urban areas. Riots have become common. Incomes may have been rising, but so
has dissatisfaction. In some parts of China, more than 60% of those in dire
poverty have been driven there by medical expenses. And for many rural
residents the higher levels of schooling are becoming unaffordable.

 The need, leaders often say, is to build a "new socialist countryside". At
a five-yearly congress due to begin on October 15th , the party will rewrite
its own charter to give pro-poor and pro-environment policies the same
sanctity as the philosophies of Mao, Deng Xiaoping and Jiang Zemin. But
among the rural poor there will be little celebration.

"If peasants become better off, the country is secure". On average, they are
becoming wealthier. For the past three years rural income per head has risen
by more than 6% annually in real terms. But the gap between rural and urban
incomes has continued to widen.

Rural China is still home to about 60% of the country's 1.3 billion people,
but agriculture's contribution to GDP has fallen from more than a quarter in
1990 to less than 12% today. Central-government spending on agriculture and
rural
welfare as a proportion of total spending has similarly fallen from 8-11% in
the 1990s to 7-8% for most of this decade.

Outlays on health care and education, as a proportion of total
spending, remain lower than they were a decade ago.

Farmers, except for tobacco-growers, have been exempted from tax on their
land or agricultural production.  Since 2003 a new medical-insurance system,
involving for the first time a financial commitment by the central
government, has been set up in at least 80% of rural counties in place of
the long-discarded barefoot-doctor scheme. At the same time, rural children
have begun to enjoy free education during their nine years of compulsory
schooling—although many
still have to pay for their textbooks.

The changes are a temporary salve, at best. In the case of the
medical-insurance scheme, the biggest beneficiaries are the richest
peasants. The poorest are just as likely to choose to die at home rather
than risk deeper impoverishment of their families by venturing into
hospital. The measures also do next to nothing for a huge section of the
rural population that has moved to the cities in recent years.
In 2004 the World Health Organisation (WHO) described the launch of the new
medical system during such a rapid population shift as "the equivalent of
launching a ship with a radically new design at the height of a typhoon".
The ship is not weathering well.

Hospitals are under pressure to push up charges. They are subsidised
by county government, but only enough to cover part of its staff's wages,
which are relatively generous. The rest of its money has to come from fees
and selling medicine. The government caps the prices of common medicines,
but doctors get round these by prescribing other medicines or ordering
unnecessary procedures, such as X-rays. Without changes in the way rural
hospitals are funded, poorer farmers will feel little benefit from the new
insurance scheme.

Some provinces are now bypassing both the prefectural- and
township-level governments in order to get funds more directly to rural
areas. But experiments with rural democracy—hailed by the party in the 1990s
as a great way to improve public supervision of how money is spent—have
proved too
challenging to the party's political grip.

Many Chinese experts say the burden of supporting basic health care and
education should be shifted to higher-level governments. That done,
prefecture and township governments could be massively trimmed or eliminated
altogether.
But neither widespread lay-offs in an already volatile countryside nor a
huge increase in central-government spending are palatable options for
China's leaders.

Nor are they rushing to address the needs of those millions of
country-dwellers who have moved in recent years to work in urban areas. Even
peasants who have been living for several years in cities are still
classified as rural residents, and as such are often excluded from urban
welfare schemes. Residents working in Beijing would have to go back to the
county for medical treatment if he wished to get reimbursement. Only a few
million migrant workers enjoy medical insurance provided by their urban
employers. From January 1st it will be compulsory for employers to offer it.
But since many migrants are employed informally, without contracts, this
will not
make much difference.
Such problems need urgent attention. Officials say that by 2020 about 60% of
the population will be living in cities or towns.
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