During recent field work in a village in south Kangding county, Kham Aid staff were present when township officials arrived to announce a new health care program. Every household was asked to send one member to the meeting, which took place in the yard of the village school. Many of the 40-odd people gathered were women and they sat in the back with their baskets of wool and yarn, industriously spinning or coiling it while the meeting went on. Two women passed the time by picking nits from each others' hair. Male villagers sat, a little more attentively perhaps, in the front. Children ran around. New arrivals straggled in throughout the meeting. There was a great deal of socializing.
The messenger was the vice deputy chief of the township, who brought flyers printed in Chinese and Tibetan to distribute. The village party secretary introduced him, for the man could not speak the local dialect. The township official explained the program and his words were translated. Only a few villagers could make any sense of the flyers, for most were unable to read either language.
The new health program is being unrolled in all poor rural areas of China, but not everywhere simultaneously. For example, in Neijiang county, eastern Sichuan, the program was introduced one year ago. The basic cost is 10 yuan per person, per year regardless of age or health. To this amount the government contributes 40 yuan for a total annual premium of 50 yuan (about $7). There are a great many rules and restrictions, however. It took over an hour to explain them all.
First of all, families must join all at once - they may not enroll just their sickest or most at-risk individual members. Very old people, especially those without children, may enroll for free. Care must be provided by government clinics and hospitals, not by unregistered facilities. There is a list of approved drugs; anything not on the list is not covered. Patients must first seek care at their local township clinic. If their case is too serious to be handled at that level then they will be referred upwards. For costs to be covered by this insurance plan, patients cannot just go directly to the county hospital; they must go through this referral process and collect documents to prove it at every step.
The program does not cover all medical costs. At the township clinic, it covers only 50% of those costs that exceed 50 yuan per incident (in America we would call this a "deductible"). At the county level, the deductible is 200 yuan and at higher levels it's 800 yuan. The most any one person can be reimbursed in a single year is 18,000 yuan. Of course all requests for reimbursement must be accompanied by receipts and the proper paperwork.
The paperwork required may be challenging for some rural Tibetans. First of all, one needs a hukou (household registration). Wives (or husbands) who have married into the village from other areas may not have a hukou and to get one will delay the family's enrollment. Excess children (more than 3) cannot get a hukou unless they are first registered with the government which means that their parents will need to pay the excess birth fee (fine). If a family finds this prohibitively expensive, then these extra children won't be insured.
For a rural Tibetan family the possibility of illness or accident is an ever-present and frightening thing. One only needs to look at the poorest families to see why: families that are extremely poor often have become so because of loss of one or more major breadwinners. A serious illness requiring a complicated medical procedure or long-term hospitalization can completely wipe out a family's economic resources, reducing them to extreme poverty in a very short time. Children may be pulled out of school so they can work. Herdsmen may severely reduce the size of their herds, making them vulnerable to snow disasters and disease among their livestock. With reduced food resources, malnutrition is likely, bringing with it even greater vulnerability to illness.
Disability is perhaps even worse than death because a disabled person needs to be taken care of by a family member, thus removing a second person from food production and income-earning activities. The rigors of rural life, poor diet, great distance to clinics, poor training of doctors, and the tendency to delay medical care until the situation is dire means that a much larger proportion of families in Tibet experience medical crises in a given year than in developed countries.
As a result, a great many villagers were eager to sign up for the new government program. Many people had their money out and were ready to pay on the spot. The township official explained that he could not just take their money. There was a registration procedure that involved listing family members on a form, with their ages. While this may seem to be a simple matter, it quickly became enormously complicated. The main problem was how to render Tibetan names in Chinese characters on the list. Few villagers could write in Chinese or read their Chinese ID cards even if they had them. Yet if the list was not accurately written, one could easily imagine the problems that might result if the ID card of a person claiming medical benefits does not exactly match his or her name on the official list.
Kham Aid Foundation staff have some concerns about this program. We have seen before how government doctors (and even some private doctors) tend to over-prescribe medicines. This is partly driven by demand - in rural areas, a patient who is told to "rest and drink fluids" will probably feel cheated. The Tibetan medical tradition is strongly reliant on taking of medicines, and some Tibetans barely bother to distinguish one type of medicine from another, feeling that any medicine is good for you. We have heard of one educated Tibetan who thought that, if he had forgotten his own medicines at home, it would be just as good to take someone else's, regardless of the type of illness.
Furthermore, doctors in China often recommend hospitalization for conditions that would not require a hospital stay in the West - or that might not be a threat at all. For instance, one pregnant woman was told she should be hospitalized after a blood test showed her cholesterol level was above normal. (High cholesterol is normal for pregnant women).
Over-prescription and over-hospitalization is driven by a desire to increase hospital revenue. Until now, patients' inability to pay high medical bills has tended to put the brakes on unnecessary care (and necessary care, too). Now that the government will be footing half of the bill, unnecessary care could sky-rocket. This government insurance may therefore in time become unsustainably expensive. Yet there's no denying the magnitude of the need for rural people for a stronger health safety net. Let's hope that corruption and incompetence do not overwhelm this well-intentioned program so that it can provide the health security that people so badly need.