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Making health care affordable in China.

When Shi Liuchang, a worker at a state-owned electricity plant in Pingdingshan, Henan province, China, was diagnosed with hepatitis B in 1982, his work unit gave him a blank cheque to pay the medical bill. "All I had to do was bring the cheque to the hospital to have it filled in with the total cost when I was discharged," he explains. The 1000 yuan bill for a second three-month stay in hospital in 1987--the equivalent of US$ 268 at that time--was also picked up by Shi's employer. But by 2000, the cost of a two-week stay in hospital had spiralled to over 10 times that amount and his health insurance no longer met the cost. At a time when his monthly salary was 900 yuan, Shi had to pay over 6000 yuan out of his own pocket as his health insurance only covered 4000 yuan of the bill. And things got worse. In 2007, he was diagnosed with liver cancer, after he had been made redundant and was no longer covered by an employer-based health insurance scheme. "After being 'retired' for quite a long time, I could not get any type of insurance because I had hepatitis B. It is impossible with commercial insurance," Shi, aged 58, recalls. It was not until 2007 that he finally got insured through an urban cooperative health insurance scheme, but even that only provided partial coverage for inpatient care at designated hospitals. Beforehand, Shi has received treatment in the city. Now he was restricted to the local clinic, which lacked staff and facilities to treat liver cancer. "They refused to refer me in the provincial capital-level hospital, saying that cancer was a terminal disease and no matter where I got treated, the final result would invariably be death anyway." Later that year, Shi managed to round up 120 000 yuan (US$ 17 600 by today's rates) to pay for some of the treatment at the prestigious Beijing Cancer Hospital. "This was a big fortune for me, but without the operation I would have died," he says. Still, he has completed only one of three recommended follow-up rounds of chemotherapy, as 18 000 yuan per round is prohibitively expensive, and he fears bankrupting his family. Shi's story is a microcosm of Chinas health-care financing issues, of how, over three decades of economic liberalization, hospitals became driven by profits and access to care became uneven. His experience of battling a chronic disease also illustrates the health problems affecting Chinas ageing population--problems the government has recognized are in need of new financing solutions. But current efforts fall short. Health insurance reimbursement levels are often woefully low, while health insurance schemes are limited in scope and fail to address the key issue of how health-care providers are paid for their services. Moreover, compared to their rural counterparts, urban residents like Shi, are the lucky ones. In the countryside, the rural cooperative health schemes that covered over 90% of peasants in the 1970s collapsed in the 1980s as Chinas agricultural sector was privatized. Although rural health insurance schemes have been reintroduced, out-of-pocket expenditure remains high and rural health-care services remain inadequate. For consumers, out-of-pocket expenses including user fees are the main problem, but for the health authorities there are three challenges to reforming Chinas health-care financing structure: how to raise the money, how to pool what is raised and how to reimburse service providers. The government realized that patchy health insurance coverage was a problem in 2003, when the outbreak of severe acute respiratory syndrome exposed weaknesses in the country's health system. But it was not until 2006 that health officials recognized that reinforcing the health system was just as important as prevention and treatment of infectious diseases. [ILLUSTRATION OMITTED] "In 2007, the central government began to subsidize community health-care services in central and western China at the level of 3-4 yuan per urban resident, which the local authorities are required to match," says Dr Lei Haichao of the Department of Health Policy and Regulation at Chinas Ministry of Health. …