Communicable disease control in China: From Mao to now

Hipgrave, David

One reason for this numeric increase but relative decline in public health funding was the increasing number of public health staff and facilities. As with curative services, government successfully reduced the cost but maintained the operation of public health services and CDC by encouraging self-sufficiency through the charging of fees for inspections and vertical programs, and there is good evidence of reduced wastage and improved productivity and efficiency in this regard (34) . However, again there were problems with over-servicing of facilities who could afford the fees and ignoring weaker ones with greater problems. In food safety, this was shown by the rising incidence of hepatitis, typhoid and paratyphoid from 1979 to 1988 (19) . Public preventive health activities (public goods without direct benefit to consumers) that were not profitable were often neglected or ignored; fees were even charged for vertical disease control programs (such as those against TB and schistosomiasis) despite national targets indicating their priority in the 7 th and 8 th five-year plans (7), an acknowledgement of the reliance on their implementation by staff whose participation could only be guaranteed with a financial incentive (or who charged fees regardless of services being notionally free). New charges for specific activities such as vaccination, control of schistosomiasis, TB, leprosy and also MCH reduced their uptake and impact. However, rather than cancel vaccination fees, the government introduced an immunization insurance scheme to counter falling coverage (apparently with good effect) (15) , and fees for routine vaccination were only officially banned in 2007; the sale of optional vaccines (including several of the new vaccines recommended by WHO) remains a significant source of income for CDCs in China. Decentralisation of social service funding resulted in differential services according to counties' and townships' ability to fund them and the level of prioritization of public health by local authorities. Vertical lines of communication and control of the health system by health authorities also weakened (19) . Administration of township health services gradually devolved from county to township governments, and the township health facilities divided into clinical and preventive sections, with separate funding, revenue and reporting streams (15) . Most EPSs reported to local government rather than to higher levels within the health hierarchy, exacerbating the politicization of data and probability of its desensitization. Local government was usually more concerned with economic than social indicators, and disinclined to report bad news like disease outbreaks. They were also disinclined to spend public money on CDC when they could use it to make the county rich.