16
Reforming China’s Rural Health System
In the 1980s and 1990s, the picture began to change. Child mortality continued to fall in China as it had done in the 1960s and 1970s. However, it fell less quickly than in Indonesia and Malaysia, even though Malaysia, like China, had by then achieved a low rate of mortality. In fact, at the start of the 1980s, China switched from being an overperformer (its rate of reduction in the 1960s and 1970s exceeded its expected rate) to being an underperformer. And while Indonesia and Malaysia went on to exceed expectations even more spectacularly in the 1990s than in the 1980s, China’s performance (relative to expectations) slowed further. A similarly mixed story emerges for communicable disease mortality. China’s fight against malaria has been an unqualified success. Before 1949, approximately 30 million malaria cases occurred each year. In 1955, a national malaria control program began and went on to achieve substantial impact. From an estimated 5,528 deaths from malaria in 1955 (Tang 2000), the number of deaths fell to 24 in 1998. The incidence fell from 103 cases per 10,000 population in 1955 to 0.25 in 1998 (Tang 2000). In 1998, indigenous falciparum malaria was found in just two provinces, Hainan and Yunnan. China’s record on tuberculosis (TB) is more mixed; although here, too, there are many successes to report. Prevalence and mortality both have fallen in recent years, thanks largely to the adoption of DOTS (Directly Observed Therapy Shortcourse), which is estimated to have prevented as many as 30,000 deaths per year (Dye et al. 2000; China Tuberculosis Control Collaboration 2004). Between 1990 and 2004, TB prevalence fell at an annual average rate of 2.8 percent, and mortality fell at an average rate of 2.9 percent. This compares favorably with the Millennium Development Goal of the WHO Western Pacific Region—a target reduction of 2.7 percent per year. However, all neighboring countries have reduced mortality faster, and many have reduced prevalence faster. Indonesia, the Lao People’s Democratic Republic, Malaysia, the Philippines, Thailand, and Vietnam did better in reducing mortality; and Indonesia, the Philippines, and Vietnam did better in reducing prevalence.13 Data from the early 2000s on communicable disease mortality also show a somewhat worrisome trend. Overall communicable disease mortality actually rose in China in the early 2000s. This reflects in part the arrival of HIV/AIDS as well as the 2003 SARS outbreak (Figure 2.2), but also the growth of hydrophobia and viral hepatitis. At the same time, China was undergoing a rapid epidemiological transition (Cook and Dummer 2004). Heart disease, stroke, cancers, hypertension, diabetes, and chronic lung diseases began to account for a