One early spring night, Chen Zhengxian and his wife, Yao Yuanxiang, tied themselves together and drowned in the Yangtze River, leaving behind a 10-year-old son - a patient of hepatitis B. A farmer from Gongan County in central China's Hubei Province, Chen was down with snail fever and hepatitis B. Yao was suffering from sciatica. With medical bills mounting and their life savings exhausted, they saw suicide as their only escape route. 

This tragic incident reflects the grim reality that millions of people in rural China face today - the lack of affordable healthcare. Four years ago, the Chinese government had initiated the rural co-operative medical service scheme in 20 provinces. It is now under tremendous pressure to advance the programme, which has still not been able to meet the health needs of the rural populace.

Under the rural cooperative scheme, each participant has to contribute 10 yuan (US$1=Yuan7.7) a year, while the state, provincial, municipal and county governments add another 40 yuan to the fund. Contributors may then avail of discounts - provided by the fund - on their medical expenses.

But residents of Chen's village believe the couple would have resorted to suicide even if they had availed of the scheme, as the amount they needed exceeded any adequate refund. "With an average reimbursement rate for hospital fees standing at a meagre 27.5 per cent, the current subsidies are inadequate for dealing with grave and terminal diseases," said Wu Ming, Professor, Medical School of Peking University.

Ma Yongshan, a farmer of Beipiao County in northeast China's Liaoning Province, was stricken by colon cancer and a brain infarction. As he was a member of the scheme, Ma received a reimbursement of 6,590 yuan for his hospital fees. But he was still short of 10,000 yuan that he had to pay from his pocket - not easy for a farmer whose annual disposable income is only around 3,000 yuan. But Yongshan is still grateful. "The programme has eased my burden - at least I could pay the bill without borrowing. It would have been a great blessing, though, if 60 per cent of the expenses could have been refunded," said Ma.

Official figures show that 410 million farmers in 1,451 counties - around half of the country's rural population - have joined in 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 budgets. "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 in Gongan County.

Figures released by the World Health Organization reveal that health only accounts for 2.7 per cent of the Chinese government's total expenditure, far lower than the average of 10 per cent in developed countries.

"Even in the cities, people have to pay an average of 60 per cent of their medical expenses. Low reimbursements are seriously hindering access to affordable medical care," said Ba Denian, a researcher with the Chinese Academy of Sciences. According to Xu Qingsong, Professor, Second Military Medical University, Shanghai, "The inefficient use of funds and uneven money distribution - the lion's share of investment in healthcare actually goes to urban citizens - have made the medical situation in rural areas even worse."

Beipiao County is one of the dozen counties in Liaoning where the local administration has been trying to encourage all its rural residents to join the scheme. By the end of March 2007, almost 98 per cent of the residents in Ma Yongshan's home village of Wujianfang had signed up, up from 60 per cent at the beginning of the year. The reason probably being that under this special programme, local farmers only need to pay five yuan each every year - half that of the national average.

Interestingly, while central and provincial governments contribute another 36 yuan for each participant, the county government pays only a sum of five yuan for each member. Thus, elaborates Zhao Jiqing, Director, Public Health Bureau, Beipiao County, "Without consistent support from central government coffers, the new scheme cannot sustain itself. It is imperative that the government increases the fund pool to make hospital fees more affordable for farmers," he said.

The central government has pledged to expand the programme to 80 per cent of the rural population by December this year and double its investment in rural medical care from 5.8 billion yuan 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 per cent of the expenses on their own," said Professor Hu Shanlian, Medical School of Fudan University.

Xu Yadong, the vice president of the leading 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 high costs even if they were very sick."

He adds, "More money is needed to fix up local clinics and train medical staff at the grassroots, 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. But even this primitive service, essentially free, played a significant 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 patients, introduce new facilities and train local medical staff.

According to Ming, 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.