About 36 per cent of Chinese who fall sick now turn to self-medication while 13.1 per cent go without any sort of treatment altogether, according to the latest nationwide survey on medical services in China. It is estimated that ordinary Cinese fell sick about five billion times last year (03). This means that of the number, about 1.8 billion instances were treated with over-the-counter medicine, while another 660,000 million went untreated. The survey, conducted between September and October last year (03), is one of the three nationwide surveys on medical services which have been conducted by the Ministry of Health (MOH) since 1993.

Results of the 2003 survey, released on the MOH's website earlier this month (dec), showed that more people were falling sick, but fewer were going to see the doctor because they simply could not afford it. ""Medical expenses have become the third largest expenditure for families after food and education,'' a summary of the survey results said. ""The average expenditure for one hospital admission is now equivalent to the average annual income of a rural or urban resident.''

The ministry's study showed, for instance, that the cost for outpatient treatment in the cities and rural areas rose 85 per cent and 103 per cent respectively between 1998 and 2003. In the same period, the average per capita income growth for urban residents was 8.9 per cent, while that for rural residents was only 2.4 per cent. The problem of spiralling healthcare costs in China is also one that has locked itself into a vicious cycle: as more potential patients stay away, clinics and hospitals already starved of government funding raise charges keep the business afloat - through prescribing more expensive medication and treatment - thus driving more people away.

Anecdotal evidence further suggests that the issue is one that has severely strained the patient-doctor relationship, leading to more medical malpractice lawsuits. In recent years, China has moved aggressively against high-profile outbreaks and diseases, stepping up efforts to combat Aids and developing a vaccine for Sars. But if the three surveys are any indication, a more fundamental healthcare crisis is ticking away quietly in the background.

Warning Signs Through The Years

Between 1993 and 2003, the Health Ministry took the pulse of the country's healthcare services with three major surveys, each involving more than 50,000 households in over 90 counties. Taken as a whole, they present one of the most authoritative and comprehensive look at the changing healthcare needs of the world's most populous nation in the face of an ageing population and rapid urbanisation.

The picture that has emerged is not a pretty one. The 2003 survey estimated that the total number of times the Chinese have fallen sick each year was 5 billion - an increase of 710 million from the 1993 study. In the cities, infectious diseases are giving way to chronic, non-communicable ailments like diabetes and high blood pressure. Diseases involving the respiratory, digestive, muscular and skeletal systems now form the major health problem facing urban Chinese. In the rural areas, infectious diseases have declined, but still pose as much of a problem as chronic illnesses.

Yet, more people than ever are shunning the hospitals and clinics in favour of cheaper remedies at the pharmacy. What's alarming is how the problem has persisted on a large scale for over a decade with no solution in sight. The problems had been identified as early as 1993, where the first nation-wide survey on medical services pointed out: ""Medical costs are rising too fast, and have exceeded the country's economic growth and the people's ability to shoulder the cost. This has suppressed the growth and usage of medical services.''

Fast-forward to 2003, and the survey showed that those citing ""economic difficulties'' as the primary reason for not seeking any medical treatment have risen from 14.3 per cent in 1993 to 34.8 per cent in 1998 to 38.2 per cent in 2003. The 2003 survey also showed that among those who should have to be hospitalised but were not, 70 per cent said it was due to the prohibitive costs.

Asked if China is losing track of a more fundamental health problem as attention is increasingly focused on headline-grabbing outbreaks, the World Health Organisation's representative in China, Dr Henk Bekedam, told The Straits Times: ""Your point is very right. ""The main question is whether people have access to basic health services when they need it, and I think the third health survey gave the indication that it is not. If you look at the report carefully, it says two things: there is health insecurity and inequity in China, and that is the main challenge for the government.''

A weak basic healthcare system also jeopardises the success of health programmes to combat Aids, Sars or tuberculosis, he cautioned. ""If the basic health system is not working well, at the end of the day, you get stuck with the problems,'' Dr Bekedam said.

Market Reforms Gone Wrong?

Health experts trace the root of the problem to the market-oriented healthcare reforms initiated in the 1980s when the community-based system was dismantled. Healthcare funding fell as the government retreated from the sector, with local resources strained further by the fiscal decentralisation of the post-Mao era, which required the provincial governments to fund its own health services.

""At the heart of these policies was the belief that a hardened budget contraint and increased competition would raise economic efficiency and improve access to healthcare,'' wrote Dr Huang Yanzhong in the Harvard Health Policy Review in 2002. Though the reforms provided people with more alternatives, it worsened the disparity of access to medical care and failed in key public health tasks. The community-based health insurance scheme in rural China virtually collapsed, dropping from 90 per cent in 1979 to just 11 per cent in 1983.

According to the 2003 medical services survey, 79 per cent of Chinese in rural areas and 45 per cent in urban areas now have no medical insurance of any form. Dr Huang added: ""Market-oriented healthcare reforms were detrimental to China's public health by depleting rural areas of health facilities and personnel, promoting unnecessary drug sales as an engine of revenue growth, and requiring private consumers to shoulder the burden of rising health care costs.''

The structural faults in the healthcare system have also bred a series of related problems on the ground. An Asian doctor who has worked in southern China for more than five years said rising medical costs were driving the patient-doctor relationship downhill rapidly. The lack of medical practice insurance has also increased the practice of defensive medicine, a situation where Chinese doctors routinely over-prescribe intravenous drugs for minor ailments or order a long series of pre-surgery tests for fear of being sued for malpractice, said the doctor who asked not to be named.

Costs are also rising as many hospitals opt for expensive medical technology, which may not always be necessary. The Asian doctor added: ""Many hospitals have invested in expensive machines. What could be reasonably done by careful physcial examination, say stethoscope examination, you now see higher technology being applied.""This jacks up the cost.''

More ordinary Chinese are turning to self-medication as a result, though the impact from such a move is far from clear. The three health surveys have so far not assessed the quality of self-medication, or concerns about the over-use of antibiotics, delayed treatment, and counterfeit drugs. WHO's main concern on this issue is the quality of the drugs the Chinese are buying over the counter, said Dr James Killingsworth, the agency's Beijing-based country advisor for health system development and finance.

People may opt for cheap drugs instead of the right ones for their ailment. Irrational use may also lead to a build up in antibiotics resistance. Worse, they could be buying expired drugs without knowing. ""All these comes down to the question of not only what kind of guidelines you have, but also how do you enforce them,'' said Dr Killingsworth. ""How does the government in such a big and populous country get to the local level to enforce rational use of drugs and overuse of anti-biotics?''

Uncertain Road Ahead

China has set an ambitious target of covering every one of its 768 million rural residents with basic healthcare insurance by 2010, while a separate scheme for urbanites has covered about 109 million Chinese by the end of last year (03). But sceptics, including commentators in the state media, have openly questioned if China can achieve the target by 2010 in light of the complex problems at hand.

Health experts say the Chinese government is painfully aware of the problems, though there is little consensus on the best cure for the structural problems in the health care system. Chinese health experts are mostly divided on where reforms should go next, if comments at a recent forum on hospital management are anything to go by.

Some called for bolder changes to the ownership structure so that more private hospitals can be set up, while selected state-owned hospitals go private or become non-profit entities. The official China Daily estimates that over 96 per cent of all hospitals above the county-level are state owned. Experts like Professor Zhou Zijun of Beijing University's School of Public Health said China needed a clearer definition of the types of medical services the government is responsible for, and leaving non-basic care to private hospitals and funds.

Others like professor Li Ling, a specialist in health economics at the China Centre for Economic Research, were unconvinced. High medical expenses do not come down naturally by transforming the hospital's ownership, she was quoted saying by The China Daily, adding that government hospitals were best still placed to lead any health care reforms.

""There's no blueprint in health,'' said WHO's Dr Bekedam. ""If there was one, I'm certain China would be willing to adopt it.'' He added that the most pressing task now is for the Chinese government to define a public health package that would be provided to everyone for free, and ensuring the service providers are properly paid for it.

The three national health services surveys also provide important signposts for where management reforms and changes to resource allocation should head toward, Dr Killingsworth said. He added: ""Policy makers need to look very carefully at evidence to see where to invest and how to invest in light of the changing disease and demographics patterns. ""Maybe there's going to be a shift towards worrying about urban basic health services in addition to worrying about rural health services. That will be an expensive double burden.''

Speaking to The Straits Times on the sidelines of a recent press conference, China's vice minister of health Huang Jiefu said that the government was pushing for reforms in the public health system, as well as improvements in rural and urban medical care. ""This must go through long term effort, but the govt is putting in more resources,'' he added, assuring that a basic medical care system would be in place by 2010.

But as a commentary in the China Daily pointed out recently: ""This sounds good for our rural residents - if their sick can wait six years.''