For years Liu Fengqin suffered as the undiagnosed tumour in her womb grew. And it was only when she collapsed and no longer had any say in the matter that she was admitted to hospital.

Her tumour which had been growing for a decade, her surgeon estimated, has been removed and her life has been saved. But how and when will she ever be able to repay the money borrowed from friends and relatives to pay her medical expenses haunts her night and day.

"I could not afford to see a doctor," says the 50-year-old from Changbao Village 20 kilometers from Chaoyang in Liaoning Province.

The only breadwinner for her family of three, Liu scratches a living growing corn on a tiny plot of land 0.13 hectares and raising geese. In a year she makes just 1,000 yuan (US$120). Her husband, who suffers from a mental illness, is unable to help and their only son, 21, is away studying at Chaoyang College of Agriculture.

Even when she found blood in her urine, Liu still refused to go to hospital. She bought some herbal medicine from a local private clinic at times, or followed folk prescriptions of soup with donkey hoof and millet or Chinese roses, treating her illness in the cheapest way.

But none of them worked. And it was only when she collapsed in April 2002 that she was seen by doctors.

An examination revealed she had a tumour in her womb which Dr Wang Xianzhen at the No 2 Chaoyang Hospital estimated she had had for over 10 years.

"Her haemochrome level was barely half of that of a healthy person," she recalls. There was the tumour and cyst on her womb and ovaries.

Although Dr Wang helped arrange an exemption for part of the costs of the life-saving operation, Liu was still left with a medical bill of 6,000 yuan (US$723) for blood transfusions, hospitalization and drugs. Two years after she left the hospital, she is beset by worry over how she will ever be able to pay off the debt.

"I owe my brother 2,000 yuan (US$241), both of my sisters 1,000 yuan (US$120) each, and my distant relatives 2,000 (US$241). When can I pay them off?"

Poverty blighted lives

But even the grim statistics of Liu's finances do not put her among the poorest patients Dr Wang encounters.

Chaoyang, just 518 kilometers northeast of Beijing, has a rural population of 2.47 million, 74 percent of the area's residents. However, more than half of those people cannot afford to get hospital treatment when needed.

In Chaoyang, 40,000 rural people live below the poverty line, half of whom have been impoverished as a direct consequence of having medical treatment, said Dr Wang.

"They are not covered by any medical insurance and their only approach to illness is to endure," says the doctor. "But this only aggravates their problems and eventually makes them poorer."

Having seen so many cases like Liu's, after she was elected a deputy to the National People's Congress (NPC), China's top legislature, Dr Wang lodged a bill to re-establish the cooperative medical care system in rural China and increase government funding to township and village clinics.

Zhu Qingsheng, vice-minister of health, estimates that 40 to 60 percent of rural people, or one third of China's total population of 1.3 billion, cannot afford professional medical treatment or find themselves impoverished after being hospitalized. In some poverty-stricken regions, especially in the west, as many as 60 to 80 percent of those who fall sick die at home as they have no money to go to hospital.

Many in rural areas are reluctant to go to hospital because their meagre incomes and medical costs are disproportionate. In 2003, says Zhu, the per capita annual income of rural Chinese averaged 2,622 yuan (US$316), while the average medical bill for every hospitalization was 2,236 yuan (US$270), almost every cent they earned in a year.

At the same time, the township and village clinics, once supported by the State and collective funding and which covered most of the rural population, have been on the wane. In Chaoyang, one-third of township clinics supported by State funding have closed, like the one in the Changbao village where Liu Fengqin lives. Another third are running in poor condition.

At Wujianfang Clinic, considered a "decent" one by the local health bureau, most of the equipment is out of date or in need of repair. The B-mode ultrasonic machine shows no blood vessels, the anaesthetizing machine has its wheels tied in place with plastic cord and there are no facilities to test blood.

"To upgrade the facilities we need around 1 million yuan (US$120,000), while the government allocation is just 50,000 yuan (US$6,000) a year," says Wang Dajun, head of a clinic which serves a population of 35,000 in the township.

Though medically trained, Wang Dajun, like the other 34 employees, earns just 300 yuan (US$36) a month. Not surprisingly the low pay means many medically-trained staff have left to run their own clinics.

"Private clinics, which spend less on equipment maintenance and medicine purchases, can survive more easily," says Wang Dajun, but he is sceptical about the quality of treatment they offer.

Pilot programs

Wang Xianzhen is not the first NPC deputy to call for the restoration of the co-operative medical care system in rural areas. NPC records indicate that a deputy from Shanxi Province in the north made a similar proposal as far back as 1994, and to date, it has received 24 proposals concerning the issue, most of which were filed during the past two NPC sessions, including two by Dr Wang from Chaoyang.

She was thrilled when three months after she submitted her bill in 2003, the Ministry of Health began piloting the re-establishment of a cooperative medical care system in rural areas. The end of 2004 saw the system extended to 310 counties in as many as 30 provinces, municipalities or autonomous regions and involved 69 million people.

And on March 21 this year, Beipiao, a county in northeast Chaoyang, became the latest pilot of the program. All those wanting to join contribute the same amount, 10 yuan (US$1.2), a year, while the provincial, municipal and county governments together put in another 20 yuan (US$2.4) per person. In the event of a person needing to be hospitalized, the scheme reimburses the patient at a rate of between 15 to 55 percent. The percentage of reimbursement is based on the cost of medical expenses incurred, not by the individual contribution.

Li Shuyang, head of the Beipiao Health Bureau, says the response to date has been satisfactory.

"Currently, 360,000 people, or 91.8 percent of the farming population in the county, have joined the program."

Huo Yulan, 51, was the first beneficiary of the program. She was admitted to Beipiao County Hospital on March 20 to have an operation for the hydrocephalus she had endured for years. She had 3,060 yuan (US$370) of the total cost of her nearly 10,000 yuan (US$1,200) treatment reimbursed, a sum equivalent to her family's annual income.

"If not for the cooperative medical care, I might still have been reluctant to go to hospital," says Huo.

Although she still had to find 6,000 yuan (US$723), Huo is eternally grateful the government-orchestrated medical program was able to foot part of the bill. "Now that I'm cured, I will work harder after I recover and try to pay back the money I borrowed from relatives as soon as possible," she says.

In just three months, 143 rural people in Beipiao have been received 460,000 yuan (US$55,600) in medical expenses.

Liu Yajun, Huo's doctor at Beipiao County Hospital, is glad to see more patients coming for treatment from the countryside.

"At this season in previous years, my department of surgery had just a dozen inpatients, most of whose cases had been aggravated by delay. Now our inpatient numbers have more than doubled."

Also delighted at the change, Li Shuyang plans to enhance the 28 state-funded township and village clinics with the new system in Beipiao. Under the system, a patient who spends over 4,000 yuan in a village clinic can have 15 to 55 percent of their medical expenses reimbursed, while in county hospitals he has to spend over 6,000 yuan to get 10 to 50 percent of the costs met by the program.

Wang Dajun, from the Wujianfang Clinic, is concerned over the program's sustainability. "Two million yuan is not a small amount for the Beipiao government," he says.

He recalled that they had tried four times to promote a cooperative medical program from the 1970s to 1990s and all failed.

"But in those times the provincial governments of Liaoning and the municipal government of Chaoyang were not involved," he added, hoping this change could make a difference.

But Liu Fengqin, who had her womb removed and has to somehow find a way of repaying money borrowed to pay her medical expenses equivalent to six years earnings wants to know just one thing. "When can the cooperative medical service come to our village?"

(China Daily June 11, 2005)