Going to see the doctor was too expensive for 54-year-old Chinese farmer Song Zhiyao, but the introduction of a rural cooperative medicine scheme in 2007 has greatly eased his financial burden.

A new public-health reform under review might give even more help to Song and millions of other Chinese citizens who have borne their own medical bills for as long as two decades.

Too much to pay

Song has lived in Xijiang Village, Kaili City, of southwest China's Guizhou Province for half a century, and misses the days of barefoot doctors before the 1980s.

"The villagers only paid a little money for the medical service at the doctor's small clinic, as the costs were basically covered by the state," he says. Although the young doctor could only handle injections or minor illnesses like coughs, Song was largely satisfied.

It was a time when China prided itself on a government sponsored medicine system, in which most Chinese enjoyed low-priced medical services.

But the climate changed in the 1980s when public health institutions were left to feed themselves because of lack of government funds. A guiding principle was that hospitals should and could be managed like enterprises according to economic rules, a novel idea for most Chinese. It was a starting point for hospitals to generate their own revenue by raising fees and aggressively selling drugs.

From that time, Song and his fellow villagers came to feel the burden of the costs of medicine. Living in a poverty-stricken county, Song and his wife earn less than 10,000 yuan annually by constructing houses in the five-thousand-people village, peopled by the Miao nationality.

In 2006, Song suffered severe piles and kept bleeding for a month. At first, he chose to stay at home instead of seeking treatment.

Like Song, it is common for many Chinese farmers to "expect self-cure in face of small illnesses and await death in the face of big illness".

But the severe health condition compelled Song to visit the doctor, but neither the clinic in the village nor the county hospital could handle his complex problem.

The medical resources in Guizhou and the larger inner regions of China could hardly match big cities like Beijing, which is home to more than fifty Class-A hospitals. In Guizhou, however, there are only six such hospitals and most of them are based in Guiyang, the provincial capital.

Song traveled by bus and train to Guiyang, but he left immediately after the check-up. "They told me to pay an initial fee of 8,000 yuan if I wanted hospitalization, which went far beyond my capacity." At that time, two of Song's children were attending secondary schools.

He then went to Kaili for an operation at the People's Hospital. The costs were still high, as he spent 4,500 yuan for 11 days. "After the operation, they advised me to stay in-house for another 15 days for further monitoring, but I checked out. I was squarely short of money."

The hospital required him to sign a letter, claiming that "everything is irrelevant to the hospital after discharge."

The good news came in the spring of 2007, when he was notified of a new rural cooperative medical scheme. Under the program, Song pays 10 yuan per year, and the government contributes another 10 yuan. If hospitalized, up to 80 percent of the expenditure can be reimbursed.

Path of reform

In spite of the improved benefits experienced by Song, the medical care system of China has long been criticized. The focus is on the soaring medical fees, lack of access to affordable medical services, poor doctor-patient relationships and low medical insurance coverage.

Statistics from the Ministry of Health show that the personal spending on medical services has doubled from 21.2 percent in 1980 to 49.3 percent in 2006, while the government funding dropped to 18.1 percent from 36.2 percent in 1980.

For this reason, medical services, along with tuition fees and housing, is called one of the "three new mountains" that greatly diminish Chinese citizens' sense of happiness, after the reform and opening up.

In 1997, the State Council issued a historic decision, defining medicine as a social welfare sector, which for the fist time meant to correct the previous concept that medical services were a type of commercial product.

In the next ten years, China implemented a series of medical reforms, such as the basic medical insurance for urban employees and the new cooperative medical scheme for farmers.

But the Development Research Center of the State Council, an influential think-tank, concluded in a report in 2005 that "the medical reform in the past decade is basically unsuccessful".

In October this year, the long-awaited health care reform plan was released for public debate. A main target is to set up a health care system that covers all urban and rural residents by 2020. Breaking with the market-oriented reform over the past 20 years, the new plan defines government's responsibility by saying that it plays a dominant role in providing public health and basic medical service.

"Both central and local governments should increase health funding. The percentage of government's input in total health expenditure should be increased gradually so that the financial burden of individuals can be reduced," the draft says.

The plan also promises to tighten government control over medical fees in public hospitals and to set up a "basic medicine system" to quell public complaints about rising drug costs.

Different from the past when the policy was solely made by the authorities, the central government entrusted nine domestic and overseas organizations to conduct independent research, including the World Health Organization and Mckinsey Company, whose ideas were incorporated into the draft.

In just one month, the draft received 35,000 pieces of advice. But it once again aroused heated debate. An online survey by Sohu, a major portal site, finds that as many as 87.83 percent of pollster were unsatisfied or could hardly understand the 10,000-word document, a compromised product of experts and officials involving 16 departments.

Bai Yansong, a famous anchor of China Central Television, says the draft is characteristic of its "obscure language, academic expressions and emptiness in substantial content".

Observers are more concerned of the new plan's effectiveness.

Liao Xinbo, deputy director of Guangdong Provincial Bureau of Health, says the draft has no new highlights as compared with the guiding policy in 1997, and that it does not touch on the key issues of unbalanced distribution of medical resources and mounting personal expenditure. The crux of the problem, according to him, is the insufficient government funding.

Echoing his words, the total health expenditure by the government made up 4.76 percent of GDP in 2006, seeing a noticeable decline from 5.33 percent in 2000.

"Insufficient government funding will result in the disorientation of public health institutions and inadequate provision of medical service for the public," he writes.

But Gu Xin, a professor of government management from Peking University, voices concerns that the government-dominated plan, if approved, would return China's public health service back to the planned economy, which might "consolidate the power of bureaucracy and create a hotbed for corruption."

For the Guizhou farmer Song, messages sent by the drafted plan may be felt in years ahead. "My only hope is that I will not be tormented by serious illness any more."

(Xinhua News Agency December 25, 2008)