Chen Zhu: from barefoot doctor to China's Minister of Health.

Even by the standards of the construction site that is 21st-century China, Chen Zhu has embarked on an ambitious architectural project. By 2010, the country's non-communist Minister of Health aims to have laid, supported by the State Council, the foundations of a stronger public health-care system for China's 1·3 billion people. Not only does this mean investing billions in infrastructure, training millions of health workers, and new medical-insurance schemes, it also involves the difficult task of persuading hospital directors, pharmacists, and bureaucrats that health-care services are primarily public goods rather than markets.

Given the scale of the undertaking and the vested interests that must be overcome, the task is revolutionary, which may explain why Prime Minister Wen Jiabao chose Chen, a political outsider, to take it on. The Shanghai-born academic is only the second non-communist in 35 years to hold such a senior post. His route to the top is unorthodox. During the Cultural Revolution, he was sent to the countryside for 5 years, where he taught himself basic medicine and became a “barefoot doctor”. He later specialised in haematology, gene cloning, and DNA sequencing. After taking his doctorate in Paris, France, at the Hôpital Saint-Louis, he returned to China, later becoming Vice-President of the Chinese Academy of Science.

Chen has a track record of establishing institutions, including a biomedical research institute in Guangzhou, a biomass energy centre in Tianjin, and several institutes for the Shanghai Institutes of Biological Sciences. But nothing compares to his current task of rebuilding China's health system. A fluent English speaker, Chen is candid about the challenges caused by the shift towards market economics in the 1980s: “People didn't realise there could be a failure of the market mechanism in certain social areas, such as health care”. For Chen, the 2003 severe acute respiratory syndrome crisis was a turning point: “For some time, the medical care system was given more attention—big hospitals and medical centres. Of course these are necessary. But in the meantime, the importance of public health was a little weakened. The issue became very acute during the SARS outbreak.”

But Chen emphasises that economic reforms have also had health benefits. In the past 30 years, life expectancy has increased from 68 years to 73 years, and infant and maternal mortality rates are at the lowest levels among developing nations. With a growing economy, the government budget has surged to US$700 billion, which means more cash for health care. Extra cash is long overdue. The financial burden of medical treatment in China has been disproportionately borne by individuals. Chen is trying to change that through medical-insurance schemes to cover 90% of the population by 2010, introduction of the concept of “essential medicines”, and greater investment in grassroots health services.

Most controversially he hopes to buy back control of major public hospitals. These institutions have become dependent on revenues generated by their 15% extra commission on drug sales. Chen says this system encourages hospitals to unnecessarily prescribe and sell expensive drugs. “This is definitely something we must get rid of. But it isn't easy”, he says. Hospital directors have so much independence that they can decide by themselves what equipment to buy and whether to acquire land for new facilities. Chen wants to establish a system of management boards and regional planning. An infusion of public money is crucial. “If we don't invest, how can we have control? This is a very complicated issue but we believe this is a must”, he says. Chen also plans to lift the state share of hospital budgets from 6–8% to 25–30%. A pilot project will begin next year. The ministry is in discussion with local authorities, medical bodies, and the directors of hospitals. “We must be very prudent, very careful because this is a very sensitive area. So we won't do it immediately in Shanghai or Beijing. We will choose a medium size city with relatively good economic and social development because you need money, huge money”, he explains.

Chen denies that this shift away from the free market is turning back the clock. While the past 30 years of change unleashed entrepreneurial initiative, he says it is now time to promote justice and equality in basic health care: “What we are going to take is a revolutionary concept, but in practice we are using the approach of reform. You cannot make heaven overnight. You need to have a step-by-step approach.”

Philosophically, Chen is advocating a whole new way of thinking about health care. “We should enlarge our vision”, he says. As well as treatment and disease prevention, “health care should cover essential areas like food safety, clean drinking water, environmental protection, and occupational safety in a country with very rapid economic growth. These things are fundamental and not easy.”

Chen's task is formidable. In China's political structure, a Health Minister ranks equal to a provincial governor and Chen faces the challenge of coordinating the 17 other ministries and agencies that have a say in health policy. Hospital directors and pharmaceutical executives will not easily give up lucrative lines of business. With the global economic downturn, the finance ministry may think twice about providing the huge sums that “health for all” will require. But Chen is leading an overdue shift from wealth to health. Clearly a committed, brilliant academic with experience in both China's poor countryside and elite overseas institutions, he now faces his greatest test.