Correspondence
Economic Reforms and Child Health in China
N Engl J Med 1997; 336:228-229January 16, 1997
- Article
To the Editor:
The article on economic reforms and child health in China by Shen and colleagues (Aug. 8 issue) 1 was important not only for reporting an improvement in the growth of children during China's economic reforms, but also because of its inclusion of some rather harsh words about the Chinese government. Two of the three authors are affiliated with the Chinese Academy of Preventive Medicine in Beijing, which is a government institution.
Little more than a decade ago it would have been inconceivable for anybody in China, especially government officials, to criticize government policies openly, let alone to have such criticisms published in a widely read medical journal. As China undergoes modernization, its leaders are becoming more tolerant of differences of opinion and are allowing its people to say what is on their minds.
1 ReferencesTsung O. Cheng, M.D.
George Washington University, Washington, DC 200371
Shen T ,Habicht J-P ,Chang Y . Effect of economic reforms on child growth in urban and rural areas of China. N Engl J Med 1996;335:400-406
Full Text | Web of Science | Medline
To the Editor:
Shen et al. make valid recommendations based on their findings and documented disparities in economic indicators and mortality statistics during a period of rapid economic development, which are mentioned in the accompanying editorial by Hsiao and Liu.1 What has not been adequately pointed out is the important effect this information has already had on national policy and programs in China.
From 1975 to 1985, China was actually reducing the disparity in nutrition between rural and urban children, an accomplishment not often seen in developing countries. Monitoring of the health and nutritional status of China's massive population is ongoing. Effective use of these data to guide national policies and programs can certainly be improved. However, China's health and nutrition leaders are currently using available data for the planning process, and this needs to be recognized.
1 ReferencesChen Chun-ming, B.S.
Chinese Academy of Preventive Medicine, Beijing 100050, ChinaRobert L. Parker, M.D., M.P.H.
Washington County Health Department, Hagerstown, MD 217421
Hsiao WCL ,Liu Y . Economic reform and health -- lessons from China. N Engl J Med 1996;335:430-432
Full Text | Web of Science | Medline
To the Editor:
I was somewhat confused by the editorial by Hsiao and Liu. Numerous problems with China's health care system (rapid inflation, barriers to basic health care, and poverty) are listed, implying that they are the result of China's “free-market fee-for-service system of health care.” Earlier in the editorial, however, the authors state, “The government sets the prices that providers can charge, and all prices except those for drugs and new high-technology services are set below cost.” If the government sets prices, how can Hsiao and Liu claim that China's medical system is a free-market one?
Donald R. Peven, M.D.
Oakwood Hospital and Medical Center, Dearborn, MI 48123Author/Editor Response
The authors reply:
To the Editor: The Chinese Nutritional Surveillance System depends on open discussion of technical and scientific matters for its success in improving policies and programs. This discussion revealed in 1989 that the food quotas farmers had to fulfill at dictated prices to feed the urban populations1 were in fact a massive hidden tax on the poorer rural population. What is extraordinary about the Chinese experience is how well the rural population did before 1985 in spite of this tax. The effects of the measured dismantling of this quota system, as well as other interventions mentioned by Chen and Parker, can be expected to benefit the growth of rural children but will only be visible in future nutrition surveillance data. Nevertheless, we believe that only the reestablishment of an effective primary health care system, combined with adequate nutrition among the poorest, will permit China's rural population once again to achieve the rate of nutritional improvements seen a decade ago. This may require some redistribution of wealth from the cities to the poorer rural population.
1 ReferencesTiefu Shen, M.D., Ph.D.
Chinese Academy of Preventive Medicine, Beijing, ChinaJean-Pierre Habicht, M.D., Ph.D.
Cornell University, Ithaca, NY 14850Ying Chang, M.D.
Chinese Academy of Preventive Medicine, Beijing, ChinaAuthor/Editor Response
Dr. Peven asks how we can claim that the Chinese medical system is a free-market system when the price is set by the government. The term “free market” was used to describe the essential economic aspects of the current system. In the present Chinese health system patients have free choice of providers, most village doctors are practicing as private for-profit practitioners, hospitals and physicians are driven by profit motives and conduct their medical practices accordingly, and the providers compete for patients. Furthermore, the term “free market” does not connote that there is no government regulation. In the most noted free-market economies, such as those of the United States or Hong Kong, government regulations set the rules of the game. Although the Chinese government sets fees, it does not regulate the volume or the quality of health care. Consequently, Chinese health providers have increased the volume of profitable services such as prescribing drugs and ordering high-technology tests to generate greater income. We cited studies that found that doctors overprescribed drugs, intravenous treatments, and laboratory tests.
William C.L. Hsiao, Ph.D.
Yuanli Liu, M.D., Ph.D.
Harvard School of Public Health, Boston, MA 02115-6094
