To Control SARS, Fix Mainland Health System's Weak Links
Jane Duckett (senior lecturer in politics at the University of Glasgow)
This article originally appeared in the April 24, 2003 issue of South China Morning Post in Hong Kong and is reproduced here with permission from the publisher.
The international press has reported extensively how mainland officials have sought to hide atypical pneumonia cases. Less frequently reported are the institutional weaknesses that have contributed to the mainland's poor handling of the crisis.
The precise institutional arrangements for handling such crises on the mainland are not well understood, but some features of the mainland's health-care system reveal the main sources of those weaknesses. Most notable are new disease-control institutions, a fragmented hospital management system, widely varying quality in health services and unequal access to health care.
Although the mainland has had disease-control mechanisms in place since at least the 1950s, it set up a US-style Centre for Disease Control and Prevention only last year. It is part of the Ministry of Health and heads a national network of centres in provincial and sub-provincial health bureaus. As a new organisation with little experience, it may not yet have put in place effective mechanisms for reporting, tracking and tackling new diseases like severe acute respiratory syndrome (Sars). Local disease-control officials may be accountable first to the local leaders who appointed them, reducing their autonomy and compromising their professional relationships with higher-placed health officials. Reports indicate that in some localities, they have been reporting Sars cases to provincial leaders rather than directly to officials at the national centre.
As mainland leaders have now been forced to admit, hospital management systems have undermined the authorities' ability to co-ordinate information-gathering on Sars cases. Despite reforms since the 1990s, to simplify the fragmented hospital management system by bringing all hospitals under the Ministry of Health management, other ministries, the military and individual enterprises (usually large state enterprises) still run some health-care institutions. There are also many private clinics that may be poorly integrated into the Ministry of Health network. A fragmented system, therefore, continues to hamper efforts by the Ministry of Health, provincial and district health bureaus and the Centre for Disease Control, to track Sars cases. Recent accounts indicate that to overcome this, disease control officials have been confirming cases themselves rather than relying on reports from medical professionals - which is likely to slow the reporting process.
Regional variations in the quality of the mainland's health services also affect the authorities' ability to tackle Sars. Fiscal decentralisation means poor local governments have less to spend on health than their wealthier counterparts. This means less investment in hospitals and drugs, and lower pay for medical professionals, leading to lower standards of care. Doctors in poor areas may be less equipped for identifying new diseases and treating patients, and disease-reporting systems may be weaker. Poor areas are likely to struggle with Sars - a problem that even wealthy Beijing is finding it hard to deal with.
Unequal access to health care may also hamper attempts to track Sars. The collapse of rural collective health systems in the 1980s, and declining health insurance among the urban population in the 1990s, has meant that many poor people can no longer afford to seek medical treatment. As a result, many cases may go unreported, hampering attempts to trace contacts.
Neither the extent of the government cover-up, nor the institutional constraints on handling the disease are fully understood. But institutional weaknesses will shape political responses, just as politics shapes how effectively institutions are mobilised to deal with the task. Although officials at all levels will try to control information for political ends, they may have poor information in the first place, which hampers their ability to act.
Central leaders now seem to realise the importance of bringing the situation under control. They may even have accepted the need to report it more openly. But a combination of political calculations by their subordinates, and institutional weaknesses within the health-care system, will create major obstacles in the fight to control this dangerous disease.