China's shift in HIV/AIDS policy marks turnaround on health. Pledge to provide free HIV tests shows China is starting to take action on combating the disease.

Pledge to provide free HIV tests shows China is starting to take action on combating the disease

China's decision to provide free HIV tests for its 1·3 billion people shows that policymakers in Beijing are starting to realise that market forces alone cannot ensure adequate health care.

That is the assessment of Henk Bekedam, the World Health Organization's China representative, who believes a crucial shift in thinking is now taking place due to the severe acute respiratory syndrome (SARS), avian influenza, and HIV outbreaks.

In an interview with The Lancet, the Dutchman said he was hopeful that a rethink of the profit-at-all-costs mentality would lead to improvements in medical services, which have been left behind by China's spectacular economic growth.

“2 years ago, health wasn't even on the agenda, but now there are lots of positive things going on. The change in attitudes towards AIDS has been very dramatic and there are encouraging steps forward in a number of other areas of public health”, he said.

The gains, however, are from a base that has dropped alarmingly in the past 25 years. Once one of the communist party's proudest boasts, the health-care system is increasingly inaccessible to the majority of the world's biggest population. Since the introduction of free-market reforms in 1978, the rural cooperatives that once provided health insurance have been abolished, leaving hundreds of millions of people to pay their own medical expenses.

HIV, SARS, and avian influenza are not just a problem for China, Bekedam points out. “People in other countries should be concerned. China is the world's biggest country. Its people are getting richer and they are travelling more”, he said.

But international concern and a growing domestic awareness of the economic costs of ignoring health problems have prompted Beijing into radical action—first with SARS last summer, and more recently with HIV/AIDS.

After a decade of covering up the spread of HIV/AIDS, the central government promised last week to provide free HIV tests to everybody and to fully cover the treatment costs of poor patients. This follows the launch of methadone and needle-exchange programmes for drug users, and greater efforts to promote the use of condoms and improve their quality.

According to Bekedam, the new HIV/AIDS policy shows Beijing is listening to international advice that it must do more to tackle the disease.

“We are very happy with the changes announced by the government. They have been very responsive. We suggested these moves in February and they have become policy in less than 2 months.”

The urgency is evident in the statistics. Last year the government estimated that the number of HIV cases in China rose by 30% to 840 000, of whom 80 000 have full-blown AIDS. But this is a rough assessment as only one in ten of those infected have been identified. The rest are likely to be unaware that they have the disease.

Bekedam says wider testing will help the government to draw up better preventive strategies and to put more pressure on provincial governments, some of which have been uncooperative.

Non-governmental organisations have criticised Henan province as the worst offender. Terrified by the financial and political costs of owning up to its role in a blood-collection scandal that led to one of the worst infection rates in the world, the local government has detained journalists, aid workers, and health providers who have tried to draw attention to the plight of the worst affected villages.

Obstruction at a local level is a major problem in implementing central government welfare policies in such a large country as China, where the health minister is outranked by the Henan provincial governor. But the intervention of prime minister Wen Jiabao has created the necessary momentum, Bekedam said. Since taking office a year ago, Wen has promised to put more priority on social welfare rather than just economic growth. And last December, he became the first Chinese leader to visit an AIDS hospital and shake hands with a patient—a sign that the communist party nationwide should openly address the formerly taboo subject.

“We've seen three phases in China's approach to HIV/AIDS”, said Bekedam. “Up until the summer of 2002, the government was still ignoring the disease. Then, after the UN warned them of the risks, they acknowledged they had a problem. Now, we are starting to see them take action.”

He cautioned, however, that the change so far was only at a central level. “The next step requires the same political commitment in the provinces. In this respect, SARS taught the country an important lesson: to control diseases, it is important for everyone to get involved. But on HIV, it is still not clear that we have the right political commitment from some provinces.”

If the policies announced by the government are implemented, Bekedam believes China could avoid the UN's worst-case forecast of 10 million HIV/AIDS cases by 2010.

It is a big if. Critics doubt that the new policy will be fully funded or widely implemented. The published guidelines provide no definition of “poverty”—a loophole that is likely to be exploited by cash-strapped care providers in the worst-affected provinces.

Bekedam urged the central government to provide funds. “It is no good them just coming up with good policies. If there is no money to go with it, the poorer provinces won't be able to find the funds themselves”, he says.

But with the economy surging forward at the rate of 9% per year, he says China can bear the costs, which he estimates at a maximum of US$30million per year. WHO has identified at least nine factories in China that have the potential to make antiretroviral drugs, which could bring down drug prices.

Obstacles remain. The owners of such factories prefer the easy money to be made from selling raw materials to pharmaceutical companies overseas, rather than working on the strict quality controls needed to produce the finished product.

But Bekedam believes these problems can be overcome. “China has enormous potential to develop its own AIDS drugs. It could have a global impact. Internationally, the price of the drugs has already fallen from $10000 per year to $200–$300. It can get much lower.”

Bekedam agrees it is not enough just to throw drugs and money at the problem, when testing laboratories are in short supply and counselling remains a rarity. “In the health field, you need a whole system in place before it really works.”

Among the greatest problems is the lack of financial incentives for service providers in public-health plans. This is largely a result of the shift in economic philosophies. In 1980, the government's share of total health-care spending was 40%. By 2000, it had fallen to 15%. Meanwhile the share paid by individuals has risen from 20% to 65%. Social insurance schemes, which once covered 90% of the rural population, now account for only a quarter of all costs—and now mostly those of the urban rich.

This is bad for China's health. In the past 25 years, most of the impressive gains in health indices, such as longevity and infant mortality, have flattened off or, in some of the poorest areas, threatened to slide into reverse as the gap between rich and poor has widened.

“Some provinces may not have seen any gains in the past 5–10 years”, Bekedam said. “The record now is very patchy. Shanghai has health indicators on par with the UK, but in the west of the country, there are provinces with records more like that of Cambodia.”

The consequences of an inadequate health-care system have become apparent in the battle against tuberculosis, an area where China has lost ground since 2000. The problems start young. China is now the only country in the west Pacific region where people have to pay for childhood immunisation. If they contract tuberculosis, they are treated in hospital but there is no public-health specialist there to tell them what they should do to stay healthy and stop the disease from spreading. With little or no counselling about medication, multidrug resistance in China is now twice the level of any other country. Bekedam said the problem has even been noticed in the USA, where health officials have traced new drug-resistant strains of tuberculosis to Chinese visitors.

The lesson, he says, is that the market values that have powered China's economic sprint forward have occasionally hamstrung its health-care system.

“There is room for the market, but it has to be defined to ensure that it doesn't harm people's health”, he said. “We tell our Chinese counterparts very strongly that the government should take responsibility for those aspects of health care where the market mechanism fails.”

The message has been getting through more often since SARS. Bekedam said the central government has quadrupled spending on tuberculosis and HIV and has accepted the need to fund public-health programmes, such as health promotion, health education, and surveillance”

“The government's response has been very positive. There is an awareness of the need to do more and pay more”, he says.

In a sign of the ambitions fostered in the new-frontier atmosphere of China, WHO is encouraging the government to redesign the health-care system, step up investment, and create a new insurance scheme.

China cannot build a health system from scratch, he said, but it needs a clear national plan starting with such basics as how many doctors it has now, how many it will need, and a step-by-step approach to social insurance.

“Someone in the government has to look forward 50 years and say, this is what we want. Then a map can be drawn up to get there.”

International support will be important—though not, he said, in terms of cash. “China wants to learn. They are not asking for big bucks. What they want is information.”

That, he concludes, is why he feels at home in Beijing. “China is a very wonderful place to work. If you have ideas, they listen. Chinese official are starting to realise that the market alone can't do it on health.”