key: cord-0727789-2sez0k6y
authors: Sleigh, Adrian C
title: Health-system reforms to control tuberculosis in China
date: 2007-02-22
journal: Lancet
DOI: 10.1016/s0140-6736(07)60292-x
sha: 9cfb80f6fa168e14f5e7dc46a7621965eb7084e1
doc_id: 727789
cord_uid: 2sez0k6y

nan

In today's Lancet, Longde Wang and colleagues report on many remarkable recent improvements in the control of tuberculosis in China. 1 The progress is good news in view of the size and global importance of the tuberculosis burden in China and the faltering of control in the 1990s, as noted by Wang. The fruitful partnership with WHO, the World Bank, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and several governments and non-governmental organisations is also noteworthy, as is the commitment to transparent reporting and health-system reform in China today in the environment after the outbreak of severe acute respiratory syndrome. Better control of tuberculosis in China is also timely in view of the high rates of multidrug resistance, and the emergence of HIV infection in some population subgroups also at high risk of tuberculosis. 2 One group of special concern are work migrants, most often poor young men, who leave the countryside to join the wage economy in towns and cities all over China. [3] [4] [5] [6] Some come from areas such as Henan Province where huge numbers of peasants were infected with HIV from scandalous plasma-donor practices in the 1990s. Many male migrants are at risk of unprotected sex when away from home. And men are also at higher risk of tuberculosis than women in China because the male-to-female ratio of adults with pulmonary tuberculosis is about 2:1 or more, refl ecting a real risk excess rather than diff erential detection or notifi cation. 7, 8 So several factors converge in young male migrant workers to put them at risk of both HIV and tuberculosis, and this convergence must be of great concern.

When over 10% of an entire population is on the move, and when these fl oating people are poorer and have more tuberculosis than average, public health has a big problem. When that happens in China, with a fi fth of the global population and more than its share of tuberculosis, the world has a big problem. This problem is compounded because China's internal work migrants often live and work in circumstances that promote transmission of tuberculosis and impede its diagnosis and treatment. 3, 4, 6 They are usually so poor that the cost of adequate diagnosis and treatment is prohibitively expensive. Indeed, they may not be able to get treated at all unless they return to their home village in the poor interior, because subsidised management of tuberculosis (and other social welfare) is only available through facilities in the area where they were registered at birth. 5 Those born in rural zones are not allowed to switch registration to become urban residents. They have been allowed to leave their area (temporarily) for work since 1992 and now number more than 100 million. China's remarkable economic growth depends on them, but if they get tuberculosis, they have to return home for treatment.

Going home for rural health care in China is not ideal either. Over the past 30 years, that part of the health system has run down because government funding has fallen while everything else has become more expensive. Health facilities attempted to make up shortfalls by charging ever larger fees for diagnosis and treatment, especially for a diffi cult disease like tuberculosis. In China today, patients' payments keep the health services running and the medical staff have been encouraged to supply profi table health goods and services, especially drugs. Their own jobs depend on adequate operational funds, which are largely generated through user fees. Meanwhile, over the same 30 years, the socialist system of universal rural health-insurance collapsed and was not replaced apart from some pilot tests of an under-resourced community-based scheme in the 1990s. 9,10 Until recently, virtually all rural residents, 900 million in all, had no health insurance at all. This Science Photo Library

See Public Health page 691

The printed journal includes an image merely for illustration

Once upon a time, plenty of children were unruly, some adults were shy, and bald men wore hats. Now all of these descriptions might be attributed to diseasesentities with names, diagnostic criteria, and an increasing array of therapeutic options. Medicalisation is a phenomenon explored by Ivan Illich in his seminal 1975 book Limits to medicine. Medical nemesis: the expropriation of health. The term refers to the process by which certain events or characteristics of everyday life become medical issues, and thus come within the purview of doctors and other health professionals to engage with, study, and treat. The list of things that modern medicine lays claim to is a long one, potentially including sexuality, garden-variety unhappiness, childbirth, ageing, and dying. The medicalisation of these life experiences has brought with it benefi ts, but at a price. And those costs, which are not just fi nancial, are not always clear.

One might rightly argue that the expansion of recognised diseases, with drugs and other treatments for them, represent advances, clear demonstrations of the progress of medicine and science. On the other See Essay Focus page 697 situation will change if the current experiments with community-based health-insurance succeed and are then adopted nationally, but in the meantime as many as 10% of rural households have catastrophic medical payments (exceeding 40% of their disposable income) every year. 10 As Wang and colleagues note in their account of revitalised control of tuberculosis in China, the reforms need to go hand-in-hand with reform of the overall health system. In their fi gure 2, they show that fi nance for tuberculosis control was transformed by the infusion of additional funds on top of the stable levels of local government support. Similar multilevel fi nancial support is needed for the entire health system, and the success with tuberculosis control shows what can be achieved in China when sound investments are made.

National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australia adrian.sleigh@anu.edu.au I declare that I have no confl ict of interest.

Progress in tuberculosis control and the evolving public-health system in China

Global incidence of multi-drug resistant tuberculosis

Household poverty, off -farm migration and pulmonary tuberculosis in rural Henan, China

Poverty and the economic eff ects of TB in rural China

SARS and China's rural migrant labour: roots of a governance crisis

The impact of migrants on the epidemiology of tuberculosis in Beijing, China

The eff ect of tuberculosis control in China

Gender and tuberculosis: comparision of prevalence surveys with notifi cation data to explore sex diff erences in case detection

Health fi nance in rural Henan: low premium insurance compared to the out-of-pocket system

Catastrophic payment and health protection in rural China: evidence from the New Cooperative Medical Scheme in Shandong Province