One night this spring, a couple from central China's Hubei Province, Chen Zhengxian and his wife Yao Yuanxiang, tied themselves together and drowned themselves in the Yangtze River.

Chen, a farmer from Gongan County, was suffering from snail fever and hepatitis B and Yao was tormented by sciatica. Medical bills were mounting and life savings had been exhausted. They saw suicide as their only escape route and left behind their ten-year-old son, also a hepatitis B sufferer.

The tragedy reflects the grim reality that hundreds of millions of people in rural China do not have access to affordable healthcare. The Chinese government initiated rural cooperative medical services in 20 provinces four years ago but is now coming under pressure to advance the program, which is still unable to meet the rural population's needs.

Under the cooperative scheme, a participant pays 10 yuan (US$1.3) a year, while the state, provincial, municipal and county governments supply another 40 yuan (US$5.2) to the fund. Contributors are then entitled to discounts, provided by the fund, on their medical expenses.

But residents in Chen's village believe the couple would have taken the same course of action even if they had been members of a rural cooperative scheme. The money they needed had far exceeded any possibility of an adequate refund.

"With an average reimbursement rate for hospital fees only standing at a meager 27.5 percent, the current subsidies are still utterly inadequate in dealing with grave and terminal diseases," said Wu Ming, professor with the Medical School of Peking University.

Farmer Ma Yongshan, in Beipiao County of northeast China's Liaoning Province, was stricken by colon cancer and a brain infarction. He received a reimbursement of 6,590 yuan for his hospital fees after joining the scheme.

But he still has 10,000 yuan left to pay by himself, which is not easy for a farmer whose annual disposable income is around 3,000 yuan.

"The program eased my burden - at least I could pay the bill on my own without borrowing. But if 60 percent of the expenses could have been refunded, that would have been a great blessing," Ma said.

Official figures show that 410 million farmers in 1,451 counties, around half of the country's rural population, have joined the scheme, receiving total refunds of 15.58 billion yuan from a fund pool of 21.36 billion yuan.

The proportion covered by the local governments varies according to the specific disease and their healthcare budget.

"Though headway has been made, it will take time for the current scheme - with its wide coverage and low-level refunds - to make a fundamental difference in resolving the problem of healthcare for the rural poor," said Feng Xiucheng, head of the rural co-operative medical office of Gongan County, Liaoning Province.

Figures released by the World Health Organization showed that the Chinese government's spending on health only takes up 2.7 percent of its total expenditure, far lower than an average of 10 percent in developed countries.

"Even in richer cities, people have to pay an average of 60 percent of their medical expenses. Low reimbursements are seriously hindering affordable access to medical care," said Ba Denian, a researcher with the Chinese Academy of Sciences.

"The inefficient use of funds and uneven money distribution -- the lion's share of investment in healthcare actually goes to urban citizens -- has made the medical situation in rural areas even worse," said Xu Qingsong, professor with the Second Military Medical University in Shanghai.

Beipiao is one of the dozens of counties in Liaoning which is trying to encourage all rural residents to join the scheme. By the end of March, some 98 percent of the residents in Ma Yongshan's home village of Wujianfang had joined, up from 60 percent at the beginning of the year.

"More villagers have joined the scheme after seeing benefits," said Guo Zhenhe, head of Wujianfang village.

Under the program, local farmers only need to pay five yuan each every year, half the national average.

The central and provincial governments contribute another 36 yuan for each participant, but the county government pays only five yuan for each member from its revenue from the transfer of land use rights.

Zhao Jiqing, director of the Public Health Bureau of Beipiao, believes that the funding is not enough.

"Without the consistent support from central government coffers, the new scheme can hardly sustain itself. It is imperative the government increases the fund pool to make hospital fees more affordable for farmers," he said.

The central government has pledged to expand the program to 80 percent of the rural population by December and double its investment in rural medical care from 5.8 billion yuan (US$750 million) last year to 10.1 billion yuan this year.

"If the central government could raise its spending on every participant by 10 yuan, the enrolled members will only need to pay an average of 49 percent of the expenses on their own," said Professor Hu Shanlian with the Medical School of Fudan University.

Xu Yadong, vice president of the No. 1 People's Hospital in Beipiao, is a staunch supporter of the rural cooperative healthcare system.

"More farmers have come to the hospital and have begun to take chronic illnesses more seriously after joining the scheme," he said. "In the past, farmers would seldom go to hospital for fear of the high cost even though they were very sick."

Xu said 61.7 percent of the hospital's sickbeds were occupied last year - the figure for the previous year was less than a half.

"More money is needed to fix up local clinics and train medical staff at grass-roots level, otherwise patients will still have to negotiate bumpy roads to see doctors instead of being treated locally," he said.

The rural healthcare system was once a core element of Chinese socialism. After the founding of the People's Republic of China in 1949, rural people had access to subsidized health clinics run by "barefoot doctors", who were basically middle-school students trained in first aid. The primitive service, essentially free, played a role in doubling the country's average life expectancy from 35 years in 1949 to 68 years in 1978.

When China began its economic reforms in the early 1980s, the system was dismantled as the country attempted to switch to a market-oriented healthcare system.

The Ministry of Health has moved to send roughly 5,500 doctors and nurses from Chinese cities to the countryside this year to help treat rural patients, introduce new facilities and train local medical staff.

"Besides upgrading rural medicare facilities and improving the skills of rural doctors, the distribution of charity funds is also necessary," Professor Hu said.

According to Wu Ming, professor with the Medical School of Peking University, the problem of rural healthcare should not be underestimated.

"The fact that 900 million farmers have limited access to medical care is so grave that it could diminish the government's efforts to close the yawning wealth gap by throwing disease-plagued farmers back into poverty," he said.

(Xinhua News Agency April 21, 2007)