Tuberculosis in China

The spread of severe acute respiratory syndrome (SARS) in 2003, brought to light substantial weaknesses in the country's public health system.

The estimated proportion of new cases of sputum smear-positive tuberculosis that were diagnosed and treated by the public health program—a key indicator of efforts to control tuberculosis—had stagnated at around 30%, far below the 70% target set by the WHO.

After the SARS epidemic was brought under control, the Chinese government implemented a series of measures to strengthen its public health system.

One group of special concern are work migrants, most often poor men, who leave the countryside to join the wage economy in towns and cities all over China.

Indeed, they may not be able to get treated at all unless they return to their home village in the poor interior, because subsidized management of tuberculosis (and other social welfare) is only available through facilities in the area where they were registered at birth.

Health facilities attempted to make up shortfalls by charging ever larger fees for diagnosis and treatment, especially for a difficult disease like tuberculosis.

Meanwhile, over the same 30 years, the socialist system of universal rural health-insurance collapsed and was not replaced apart from some pilot tests of an under-resourced community-based scheme in the 1990s.

This situation will change if the current experiments with community-based health-insurance succeed and are then adopted nationally, but in the meantime as many as 10% of rural households have catastrophic medical payments (exceeding 40% of their disposable income) every year.

The first, funded in part by the World Bank loan of $58.2 million, covered half of China's population and implemented the DOTS strategy in 13 provinces between 1992 and 2001.

[15] A large cadre of healthcare workers was trained in the fundamental elements of DOTS, firmly establishing these methods as the national strategy for tuberculosis control.

Most importantly, on the basis of results from the 2000 national tuberculosis survey, there was a 36% reduction in disease prevalence between 1990 and 2000 in the half of China that implemented the projects.

[16] Other studies confirmed a serious epidemic of MDR tuberculosis in several Chinese provinces, with rates of multidrug resistance in previously untreated cases that were five to ten times higher than the global mean.

[20] In 2000, nearly 90% of patients with tuberculosis initiated their diagnostic and treatment process in hospitals and non-public health-care facilities, where they were given tests and drugs as long as they could pay.

Even in areas where government subsidies support free diagnosis and treatment of tuberculosis, many CDCs continue to charge patients for ancillary tests and drugs, some of which are of questionable benefit.

The Damien Foundation Belgium and the Canadian International Development Agency have supported efforts to control tuberculosis in several provinces.

The first of the key measures that have been implemented in the three years since the SARS crisis ended was greatly increased commitment and leadership from the government to tackle public health problems.

In March 2004, Vice-Minister of Health Wang Longde attended the second Stop TB Partners' Forum in New Delhi, India,[23] and made a commitment on behalf of the government to achieve the 2005 global targets for tuberculosis control.

In June 2004, the State Council held a video-teleconference with provincial Vice-Governors to discuss steps to accelerate efforts to control tuberculosis.

In December 2004, Vice-Minister Wang Longde and Shigeru Omi, WHO Regional Director of the Western Pacific, co-chaired a high-level tuberculosis meeting in China.

With the new internet-based reporting system for communicable diseases, the tuberculosis program leads the way in the use of information to improve public-health outcomes.

A new five-year initiative program, announced on 1 April 2009, aims to use innovative technologies to improve the detection and treatment of tuberculosis (TB) in China.

Using LEDs rather than standard phosphorescent lights in microscopes forms a clearer image and improves TB detection rates in patients' sputum from 50 to 65 per cent.

As well as diagnosis, new management methods such as mobile phone text messaging and medicine kits with built-in reminder alarms will be used to enhance patients' drug compliance.

[30] Additionally, the five-year plan for implementation of the national HIV/AIDS program aims to stem the rise of the HIV/AIDS epidemic by expanding prevention, treatment, and care activities.

[33] Implementation of these new policies and interventions will require a substantial increase in both domestic resources and international support, especially for poor areas in China's central-western provinces.

Although disease-specific interventions are important, further strengthening of the public-health system will be needed if China is to halve the prevalence of tuberculosis and the number of deaths caused by the disease.

Finally, the government should provide operational costs for public-health services and full salaries for health-care workers, especially at and below the county level, where most of the rural population live.

Ultimately, China's progress in the control of tuberculosis and public-health reform will depend on the degree of political commitment to address these challenges.

In this regard, the indication by Premier Wen Jiabao, speaking at the National People's Congress in March 2006, that public health is a key component of the country's 11th five-year development plan is very encouraging.

[37] With increased governmental commitment and funding to improve public health, China has reason to believe that the prevalence of tuberculosis and deaths caused by the disease can be halved within the next decade.