Health Care in Rural China: Lessons from HeBei Province (review)

In October 2004 the Chinese government released the results of a comprehensive national survey on diet, nutrition, and disease which revealed that an estimated two hundred million of the country's population were overweight, and medical problems such as hypertension, diabetes, cancer, and cardiovascular disease were on the rise. China had been undergoing an epidemiological transition, and the shift to a market economy in the late 1970s had in fact accelerated this process. These developments brought into focus both the short- and long-term social consequences of changes in health patterns and services as well as the difficulties confronting the government in its attempt to maintain an equitable distribution of health resources. Health Care in Rural China: Lessons from HeBei Province explores three major health issues in rural China in the post-1979 period: the tension between the ideological commitment to providing health care for the people and the new economic constraints, the changes in the health-related behavior of laypersons and health professionals, and the distribution and the quality of health resources and services in a changing social and economic environment.

Authors Ofra Anson and Shigang Sun base their analysis on data collected between 1996 and 1999 in a random sampling of 288 villages in nine counties in rural Hebei, in the environs of Beijing, as part of a joint Chinese-Israeli-Dutch research project. About fifteen thousand residents and 416 doctors were interviewed, and the records of more than twelve hundred patients were examined. This database is supplemented by published secondary sources, both domestic and international. The authors are cognizant of the fact that their analysis cannot possibly address the considerable regional variability that exists, and this recognition is sometimes reflected in their apparent reluctance to draw substantive conclusions despite the inclusion of detailed statistical summaries of their findings. The nature of the data, drawn from rural areas surrounding Beijing, makes it difficult to generalize about rural health in the country as a whole.

Despite these limitations, the study does reveal significant trends that contradict some early and conventional claims regarding the impact of political and economic transition in the late 1970s and early 1980s. According to the authors, the economic changes in the post-1979 period "did not have a long-term effect on the social investment in physical health resources, or their availability in general" (p. 56). The government continues to support and provide public health services although there was some initial confusion as to the division of labor between private practitioners and public clinics as a result of the privatization of primary rural health services. Immunization is now back to almost universal coverage, for instance, and it does not seem that privatization has had a negative impact on preventive work. Moreover, the predicted increase in inequality in the accessibility and affordability of health care resulting from the economic reforms has not materialized. In fact, the authors conclude, the reforms and the new licensing policy of village doctors have actually "increased the access of the rural population to better trained village doctors" (p. 109).

One reason why conditions have not deteriorated, as many had predicted, is the active role assumed by the state to assure the adequate provision of primary care for the rural population. For instance, the government regulates the distribution of primary health care services in proportion to the size of the village population. Government-owned clinics and outpatient services provided by provincial hospitals cater to the needs of poorer villages. The authors insist that this reflects the continued ideological commitment of the regime to provide health care for all, despite the transition to a market economy. This explanation ignores the emerging political and social realities that have accompanied the post-1979 reforms. Rapid economic change is highly destabilizing, and one of the legacies of such change is the growing popular discontent and unrest among different segments of the population, especially among farmers. The...