COSTOS Y SELECCIÓN DE EQUIPOS

With the introduction of market economy in the early 1980s there were fundamental changes in the way that the health care system was financed.

Firstly, the concept of free health care at the point of delivery, which had been enshrined in the Co-operative Medical System (CMS), disappeared with the collapse of the collective agricultural system in the countryside. Financing of healthcare became the responsibility of provincial and county governments who raise their own taxes. But the amount of money available from taxation for healthcare only covers basic salaries and new capital

investments totalling around 20-30% of hospital expenditure. The shortfall has to be found from user fees.^^

Secondly, a new pricing structure was introduced. This attempts to facilitate equity by providing basic health care, such as the consultation, below cost, but profits can be made from drugs and the use of investigations. This creates clear incentives to overprescribe and overinvestigate.^^ Overprescribing is encouraged further in China by the co-existence of Traditional and Western therapies which are frequently used concurrently.^^’^^

Unnecessary treatments have been estimated to account for 20-30% of the country’s total medical expenses.

Finally, the market has introduced a variety of payment methods for healthcare. These include state-controlled insurance schemes: around half of urban workers or 14% of the total population are covered by either the Government Employee Health Insurance or the Labour Health Insurance. Now there is a small but growing private insurance sector. Modified versions of the CMS now cover around 10% of Chinese rural inhabitants.^'^ The insurance schemes, however, vary enormously in the amount of cover they provide and full reimbursement is unusual. Coverage for dependents is exceptional, so the overwhelming majority of children have no health insurance cover at all.^°' In rural areas almost all health costs are paid out-of-pocket. Serious illness is still a major cause of poverty. It has been estimated that 30% of all those living below the poverty line became impoverished because of serious illness.

2.4.2 Epidemiological transition

Since the early 1950s China has undergone rapid epidemiological transition, that is a shift from a high fertility, high mortality pattern dominated by infectious and deficiency diseases to a low fertility, low mortality pattern dominated by non-communicable

d i s e a s e . B u t the rates of transition have varied widely across the country. Deaths from cancer, cardiovascular disease and morbidity from disease like diabetes are increasing rapidly in the more developed regions, as deaths from nutritional deficiency and infectious disease become rare, while in poor remote regions pre-transition patterns still predominate. By 1996 66% of the total deaths in China were caused by chronic disease and in urban areas this figure was 16%}^^ The infant mortality rate (IMR) for Zhejiang was 22/1000 in 1995 compared with an estimated 100/1000 for Qinghai P r o v i n c e . T h e r e are also substantial differences between populations within provinces, which are concealed by the routine reporting by provincial aggregates. The aggregate IMR figure for Zhejiang covers a range of 14/1000 to 45/1000 across different counties.80

2.4.3 The One Child Family Policy

In setting-out his economic reform programme Deng Xiao Ping realised that control of population growth was essential to China’s future economic growth. The Total Fertility Rate (average live births per female of reproductive age) had already fallen dramatically from 5.9 in 1970 to 2.6 in 1979, through the “late-long-few” policy introduced in the early 1970s. This was largely a conventional family planning programme encouraging later child bearing, longer spacing and fewer b i r t h s . B u t by 1979 around two-thirds of the

population were under 30 and population projections for the Year 2000 were very high. This convinced Deng Xiao Ping that Draconian population control measures were necessary to assist economic g r o w t h . T h e One Child Family Policy was actively enforced from 1982. By 1985 the fertility rate was reported to have dropped to 1.9, although it was later discovered that there was considerable under-registration of births in rural areas and the actual fertility rate was probably closer to 2.5.*°^ But this apparent success, together with its unpopularity, especially in the countryside, led to some

relaxation. Since 1985 there have been alternate relaxations and tightenings according to population projections and local conditions.

The policy consists of a package of measures, including education, access to contraception, encouragement of late marriage and spacing and economic incentives for couples having only one child. In practice, the one-child-per-family rule applies only to urban residents and government workers. In rural areas a second child is allowed after five years. In some places a second child is only allowed if the first child is a girl, an acknowledgement of the traditional Chinese preference for boys. The programme is supported by massive

propaganda campaigns about the personal and societal benefits of small families.

Implementation of the rules depends on local interpretation. Local officials have the power to impose penalties and give rewards for those complying with the Policy. Penalties

include loss of employment, fines and confiscation of personal belongings.

There are emerging concerns that the population control programme is weakening. With the new economic freedom it will not be possible to contain family size through communal pressure and economic disincentives. Furthermore, the increasingly mobile population makes it difficult to track individuals, and the erosion of Communist Party power with the market economy has meant the loss of authority of rural party officials.

The Policy was never intended as a long term measure and several options are being considered for the f u t u r e / T h e Government is hoping that there will gradually be a shift towards a “small family culture” reinforced by improved living standards, assured survival of children and financial security in old age. There is evidence that this is already taking place in the wealthier eastern cities.^^