Communicable disease control in China: From Mao to now

Hipgrave, David

The introduction of market reforms in 1980 heralded the collapse of China' s brigade system, the CMS and the funding for the barefoot doctors (19) , many of whom abandoned this work in favour of farming (which became more profitable with the abandonment of collective agriculture), or moved to the cities in the context of relaxed movement control) (20) . From 1979 to 1984, CMS coverage fell from 80-90% of peasants to 40-45%, and those schemes remaining offered variable and limited coverage (14) . By 1986, rural CMS coverage had fallen to 9.5% (15) . The number of the newly-named "village doctors" fell to around 1.2 million by 1984, and their supervision and regular retraining also decreased dramatically (14, 21) , resulting in falling standards despite them handling almost 50% of the nation' s clinical work. Having lost their income from the CMS, village doctors have ever since relied on generation of income from fees and the sale of drugs, resulting in abandonment of public health work and major problems with over-prescribing of drugs and inappropriate use of parenteral preparations (20) (21) (22) (23) (24) (25) , problems that are only now being addressed (26) . Payment for health care became the responsibility of the individual; government spending on health as recently as 2008 averaged less than 1% of the national budget (27) and the plummeting affordability of health care resulted in persistently low rates of rural hospital bed occupancy (15, 28) and slower declines in infant mortality and the crude death rate (7, 29, 30) . Urban-rural disparities in health funding, facility quality, staff allocations and service uptake rose dramatically, demonstrating burgeoning inequity in China' s health sector (15, 21, 29) . Financial decentralization was applied in both the commercial and public sectors, leaving province and county governments to mostly fend for themselves, with minimal support from the national government (14) ; government funding as a proportion of total health expenditure fell from almost 40% in the early 1980s to below 20% by 1993 and has remained below this figure until 2007 (21, 31) . It has risen sharply in recent years. Another source has the government' s share of total health expenditure falling from 32% to 16% from 1978 to 2002 (32) .