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    From Barefoot Doctors to Nationalized Health Care

    The marketization of China’s medical system has created a disparity between rural and urban areas, contributing to rising treatment costs.

    My father became a barefoot doctor in 1969. As part of China’s Cultural Revolution from 1966 to 1976, millions of urban youth were sent to the countryside to work and live with the rural populations.

    Barefoot doctors are medical practitioners from the countryside who have limited medical training. Beyond a rudimentary understanding of traditional Chinese medicine, my father had no formal medical education prior to his relocation.

    He received basic instruction at a county-level medical school. Since there were no proper facilities, he had to practice on his own dog to learn how to anesthetize, and the poor beast lost its life after an accidental overdose.

    And yet he always recalls his life as a barefoot doctor positively. The job meant he didn’t have to work in heavy labor like many other urban youth who came to the countryside, and it also won him respect and rewards from the people he helped, usually in the form of food. When he visited a patient at home, the family normally served him a meal to show their gratitude.

    His experience is reminiscent of the approach to health care in Maoist China. Doctors like my father filled the huge gap left by the absence of well-trained doctors and provided China’s rural areas with basic medical coverage. This system improved Chinese people’s health at low cost. The Nobel laureate Amartya Sen regards the difference in basic health care coverage as a key variable in explaining how China outperformed India in economic development in the late 20th century.

    However, after opening up to the world and reforming its economy, China’s public health system has undergone two dramatic changes. First, health care is no longer free: Patients now have to pay a large percentage of the medical costs. Second, the state has provided subsidies to hospitals while still allowing them to make a profit on the side.

    The underlying logic behind these changes was market-oriented: More money flowing into the system meant better services. This transformed the rural health system. Many barefoot doctors bought up village clinics and became private practitioners.

    But most of the new resources were centralized in cities, and the number of medical professionals in the countryside greatly decreased. There was soon a huge disparity between medical treatment in urban and rural areas.

    To those living in the countryside, the change has been substantial. Whereas barefoot doctors typically visited patients at home, people are now forced to travel to crowded and severely understaffed hospitals. Rising medical costs, which are generally much more affordable to urban dwellers than rural residents, have further exacerbated the situation. Marketization of the industry has also caused many doctors to “overtreat” their patients by prescribing unnecessary medication to make extra money on the side. All of these factors have contributed to a growing rift in doctor-patient relationships.

    There’s no doubt that free medical care lowers the efficiency of the system and wastes resources, but treating public health as a powerful economic sector is also misleading. In 2002, the weakness of China’s public health system came under international scrutiny during the SARS outbreak. Beijing, which was supposed to have the strongest medical facilities in the country, was caught unprepared and became the center of the outbreak.

    Suddenly, public health issues became political. During the early stages of the SARS epidemic, the Chinese government concealed information that caused a severe socio-political crisis and dealt a heavy blow to the country’s efforts in improving its international image as a responsible global power. The lessons learned during the crisis caused China to begin working on amending its public health system.

    Consequently, the government started investing in projects to make health care more accessible and affordable. A network of community hospitals designed to satisfy basic medical needs was quickly established nationwide, including rural areas. All general practitioners in these hospitals had to be certified.

    These community hospitals were fully subsidized by the government and forbidden to have their own coffers, thus eliminating the interest-driven phenomenon of doctors overtreating their patients. The New Rural Cooperative Medical Scheme offered health coverage to rural populations, and a medical insurance system for serious diseases was also established, providing a sort of safety net to the public.

    However, even with the increased government investment and oversight in the past decade, medical costs have been on the rise. According to a study conducted by the Chinese Academy of Social Sciences, from 2008 to 2012 total health care costs shouldered by patients in China increased from 587.6 billion yuan (roughly $88 billion) to 965.5 billion yuan.

    Furthermore, distrust and tension between doctors and patients have not abated, in many instances even escalating to violence. Doctors remain overburdened, and their long hours and minimal salaries will have long-term effects on the industry, since poor working conditions will likely discourage students from entering the field of medicine.

    Against this backdrop, China held a national health conference in August. A week later, the Central Politburo of the Communist Party of China (CPC) released a blueprint called “Healthy China 2030.” In terms of system reform, the aim is to continue building an equally accessible health system and work toward creating more favorable working conditions for doctors. To ensure the plan’s implementation, health system reform measures now include regular checks by higher government organs into local operations.

    However, it remains to be seen whether or not the blueprint will effect real change. For instance, it proposes to establish a “health impact evaluation system” for construction projects but neglects to specifically mention which metrics will be used to evaluate the so-called health impacts.

    Burdened by a huge population and facing a transforming social economy, China’s public health system is undergoing great changes, with new setbacks emerging constantly. It is likely that China’s health care system will become more rights-based, consistent with the CPC’s people-centered development ideals. However, there are still many problems in the decision-making and implementation process that need to be worked out.

    (Header image: A barefoot doctor walks to a patient’s home, Nanchang, Jiangxi province, March 11, 2016. VCG)