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Replacing the prereform cooperative healthcare system is a patchwork of fee-for-service private clinics and hospitals, many of which provide substandard care. A study of four hundred village clinics published in 2001 reported that two-thirds did not keep patients’ medical records and only half of the injection tubes and needles were sterilized.27 Rural doctors and medics are poorly trained and many of them have no licenses. A reporter found that about 40 percent of the scores of clinics he visitcd did not have licenses.28

Consequently, both the access to and quality of healthcare in rural China have declined dramatically. Whereas 85 percent of the rural residents had health insurance in 1970, less than 20 percent of them were insured in 2003.29 According to the 1998 National Health Service survey conducted by the Ministry of Health, 37 percent of farmers who got sick could not afford to seek medical treatment, and 65 percent of sick peasants who should have been hospitalized were not admitted because of inability to pay. Both figures were higher than in 1993, when a similar survey was carried out. In 1993, nearly 77 percent of rural women gave birth at home and only a third of rural children had physical checkups. The overall access to healthcare hardly improved ten years later. The 2003 National Health Service survey revealed that 49 percent of the Chinese population do not go to the hospital after they get sick and 30 percent of the patients who ought to be hospitalized are not, due to unaffordability of care.30

For rural residents who cannot afford health care, the consequences are often dire. Poor health has become the chief cause of poverty in rural China. In Henan province, 40 percent of the rural residents fell below the poverty line again after they were struck by disease and lost their ability to work; in Shaanxi province, the figure was 50 percent, and in Jilin province, the figure was 60 percent.31

Even in urban areas, considered privileged relative to the countryside, access to healthcare has been declining as the costs of healthcare rise rapidly. According to the Ministry of Health, 27 percent of the urban residents in 1993 were uninsured; by 2003, the percentage of uninsured in the urban population had risen to more than 50 percent, and 44 percent of urban residents who got sick did not go to the hospital for treatment in 2003.32

Deterioration in the public health infrastructure and declining access to health services may be responsible for the persistently high levels of some communicable diseases. For example, at the end of the 1990s, 10 percent of the population had hepatitis A, and 5 million people were stricken with tuberculosis.33 A Ministry of Health report disclosed that, in 2002, 810,000 people suffered from schistosomiasis, a debilitating disease.34 China was also ill-prepared to deal with an emerging HIV/ AIDS crisis. Estimates of the infected ranged from 850,000 to 2 million in 2002. The rate of infection was growing at 40 percent per annum in 2003-2004, according to the Ministry of Health.35 At this rate, the number of infected will most likely exceed 10 million by 2010.36 Although the rate of infection was high, the government’s spending on AIDS prevention and treatment averaged only 15 million yuan a year in the 1990s. Despite a modest increase in funding—when the amount was increased to 100 million yuan in 2001, in addition to a one-time appropriation of 1.25 billion yuan—the total government resources available for AIDS prevention and treatment remained insufficient.37 Alarmed by this trajectory and the Chinese government’s inadequate efforts, the United Nations issued a report in 2002 titled “HIV/AIDS: China’s Titanic Peril.” It warned that China was on the verge of a public health and humanitarian catastrophe, and singled out, as factors contributing to the spread of the epidemic, “insufficient political commitment and leadership at many levels of government, insufficient openness