Erenlai - Items filtered by date: Wednesday, 28 May 2008
Thursday, 29 May 2008 00:00

Take time for discernment and followup

One of the dramatic scenes in the Christian New Testament in the Acts of the Apostles is the healing of a crippled beggar by Peter and John. The poor man, disabled since birth, was carried every day to sit by a gate of the temple where he could beg alms from passersby. Seeing the two apostles approaching he extended his hands hoping for a coin or two, but instead of receiving money which they did not have, he is told to get up and walk and he does so leaping and dancing for joy at his good fortune. It is a double miracle, the crippling condition suddenly disappears and this man who never in his life had stood up or walked can suddenly prance about like a seasoned performer.

The two apostles must have gone home very pleased with themselves for the good deed they had performed in God’s name. I wonder if they ever gave a thought or felt any concern for all the troubles that lay ahead for the beggar they had cured. Think of it: all of his life he had sat on the ground or lain on a litter; he had grown up without most of the social encounters that had formed his brothers and sisters. When he first went about after his cure full of curiosity and eagerness he must have seemed like a country bumpkin entering the synagogue for the first time or trying to make friends. He would have to learn from scratch the simple etiquette of eating at table or proper social behavior, how to interact with strangers, officials and friends. He might not even have known how to use whatever toilet or bathing facilities used by non-disabled folks in those days.

All those kind of difficulties were only temporary, of course, and would pass in time, but a more serious problem lay ahead. His family must have been overjoyed at first when he came running home cured, but that would have turned to dismay when they realized they no longer would have the small but steady income from the alms he collected. And now that he could stand up straight, he was in urgent need of a new set of clothes they could ill afford. He had no education and no marketable skill. Would he have to go back to begging for alms or would some relative or friend take him in hand and teach him something that would enable him to work for a living? Or would his family kick him out forcing him to search for some Christian community that would let him in?

I don’t know the answer to those questions, but I hope and presume like the apostles that the miracle was the beginning of a better life. The point of my remarks is not about the apostles at all. They were sure that the miracle would be a blessing and for all we know, they might even have followed up sending some Christian to see how the man was now doing or to take him in hand. My point is, what are we doing? Do we discern first what possible effects our actions might have on the lives of others or do we just act on impulse scattering our favors whenever we can?

I am thinking of the time I was sitting in my wheelchair at a street corner waiting to be picked up by a friend, when a would be good Samaritan seeing me there, grabbed my wheelchair and pushed me across the street, leaving me there without a word, going off, no doubt, proud that he had just done his good deed for the day, while there I was having to find someone else to push me back across the street to my arranged place of rendezvous. Another time I had just come out of an elevator and found myself being pushed madly at high speed down a corridor and left there in the lobby near the front door of the hospital where I worked. My destination had been the dining room in the opposite direction.

There are lots of stories in fact and fiction of how the unexpected windfall of suddenly receiving a million dollars leads to a happy ending for some and to ruin for others. I guess that what I am trying to say by bringing up the story of the cured beggar is that next time you give away a million dollars or bestow some favor on someone you consider first what effects it might have on that person’s life. And it would be a very good idea to follow up what happens so you can intervene if things start to turn sour.

Most people would agree that morality is concerned with right and wrong. Do what is good and avoid what is evil. A person is good if he/she does what he/she believes is morally good and avoids what he/she believes is morally wrong. A person is bad if he/she does what he/she believes is morally wrong. Is a person still good if he/she does something morally wrong thinking it is morally justified? Is a person still bad if he/she does something morally wrong thinking it is morally right?
 
Wednesday, 28 May 2008 22:51

Carnival

"Carnival".
From the Italian “carnevale”, or from the medieval latin “carnelevamen”, originated from the latin words “caro levare” which means “the meat taken away ”, according to the Thesaurus.

Nobody could have suspected that this popular Italian party of the 16th Century would find such a prosperous development five centuries later in Brazil. Since its origins, however, the frontiers between religious and profane intentions were mixed up. Actually, the festival happens in the days that precede Ash Wednesday, when begins the period of Lent during which many Christians reduce their consumption of meat as an expression of repentance of humankind’s sinful condition. However, this popular celebration was - and still is - the occasion for many irreverent and erotic expressions as people moved by a spirit of elimination of repression and censorship live a period of joy and freedom.

The Carnival festival in Bahia is probably the longest – five days - and the biggest Brazilian popular party during which more than one million people dance on the streets of the third Brazilian city.

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a) Operation, recent development and government of the NRHC.
Aware of the failure of the health reform and the disastrous position of access to health in rural areas, the Chinese government tried to remedy it from 2003 on by launching the new rural health cooperatives (NRHC). The aim was to offer health insurance to the peasants who wanted it so that they could have better access to care and treatments.

These NRHC were originally financed as follows:
- rural households were to contribute at the rate of 10 RMB (1 euro) per person, on a voluntary basis;
- the local governments were to contribute an additional 10 RMB per person;
- the central government also allocated 10 RMB per person.

Thanks to this insurance system which was based on a sum of 30 RMB per villager who was willing to pay, the peasant who joined a NRHC could obtain reimbursement of his medical expenses if he were admitted to hospital. However, the rate of reimbursement varied with the reasons for hospital admission and the government declared that it could reimburse only a maximum of 65% of the medical costs of rural residents.

Since 2003, supported by well orchestrated government propaganda, NRHC have been set up in an increasing number of counties and have then covered an increasingly large number of peasants.

In 2003, this NRHC project was running in more than 300 Chinese counties.

In 2004, according to a study carried out jointly by the University of Beijing, the CASS and the Ministries of Agriculture and Health in 2006, of 70,769 peasants, in 257 pilot counties in 29 provinces, the NRHC helped to reduce the proportion represented by medical expenditure in relation to annual average income of farmers from 89% in 2003 to 65% in
2004.

In 2005, NRHC had been set up in 671 counties, and this enabled 177 million peasants to get cover. At that time, a study carried out of 10,000 families in 32 counties from 17 provinces showed that 57% of rural families who had registered for the NRHC programme had applied for reimbursement and had been reimbursed 25.7% of their total medical
expenditure, 731 RMB (73 euros) on average.

Since Wen Jiabao’s speech in March 2006, on the occasion of the 4th session of the 10th National People’s Congress, the government has doubled its financial contribution to the NRHC. Thus, under the new system, a peasant who intends to join the NRHC pays 10 RMB a year, while the central, provincial, municipal and county governments jointly
provided 40 RMB for this rural resident. The NRHC therefore now has 50 RMB per peasant. As to the maximum rate of reimbursement, it is still set at 65% of medical expenses.

At the end of 2006, according to the Ministry of Health, 46.7% of the total rural population (396 million people) had joined a NRHC and the latter were up and running in 1399 Chinese counties. As to the amount granted to the NRHC by the government, it rose to 4.23 billion RMB (423 million euros).

At the 5th session of the 10th National People’s Congress, in March 2007, Wen Jiabao confirmed the government’s commitment when he announced that by the end of 2007, the NRHC would be available in 80% of Chinese counties, that the central budget allocated to the NRHC would be 10.1 billion RMB (1.01 billion euros) in 2008 and that, finally, in the next four years, the government would spend 20 billion RMB (2 billion euros) on improving the infrastructures and equipment of rural clinics and hospitals.

According to the Chinese central authorities, the NRHC should cover 100% of the rural population by 2010.

Compared to the traditional cooperatives which operated in the villages and cantons (xiang) with a small base of contributors, the NRHC have more contributors and are often run by the county’s Health Office. Each county can set up three organisations: the Group responsible for the NRHC which concerns itself with coordination of the NRHC’s operations in the county and supervises the programme in the cantons, the Management Committee of the canton NRHC, and the Supervisory Committee of the canton NRHC. As for the management of the NRHC, it is often entrusted to the county health office and the canton health centre. A special NRHC account is opened by the committee in the local bank. Unlike rural pension funds, which can be invested to generate financial resources, the NRHC funds just stay in the bank, bringing in a small amount of interest. The NRHC Management Office under the responsibility of the NRHC Management Committee manages all the financial transactions. Because of a lack of resources, this office is often on the premises of the canton health centre or county health office. In most cases, the manager of the health centre is also the manager of the NRHC office, and the health centre accountant is also the person who manages the NRHC reimbursements. This traditional practice seems to have continued with the NRHC.

Although the principle of the NRHC remains an important and essential initiative, a number of questions emerge and several challenges will have to be taken up by the Chinese authorities, if the latter want the NRHC to improve the poorest peasants’ access to care and to health in general, in an efficient and sustainable manner.


b) Persisting questions and challenges concerning the NRHC
From international experience and from previous attempts to resuscitate the old rural health cooperatives in China, questions and challenges are emerging which the health authorities will have to resolve so that the NRHC are not just a waste of time.

Following this initiative, a first question which emerges concerns the sustainability of the NRHC, which depends above all on the viability of their three different sources of financing.
Doubts again arise as to the ability of each of the parties to contribute collectively since March 2006 at the rate of 40 RMB per villager registered. One may reasonably think that central government will be capable of pursuing its financial commitment particularly because of tax income, which is rising, and a genuine will to improve the condition of the poorest regions in China.

The current situation shows that the households’ contribution (10 RMB per person) is still feasible, at least for most of them, given that in 2005 this sum represented 0.3% of the average annual rural income (3254.9 RMB)(1). It has to be said that it will on the other hand be a much larger proportion for the poorest households who live below the poverty threshold. However, the government is considering the possibility of support for these most disadvantaged households through its Medical Assistance Programme administered by the Ministry of Civil Affairs. In all, financing problems appear today to come more from
local governments. Whether the local governments can spend 10 RMB or even more per person is even more unclear. As the local governments depend on their own income to finance their activities, they generally have health spending which varies considerably depending on how rich the provinces are and even more depending on the counties. For poor counties where population density is high, even 4 RMB per person may be a large proportion of their health spending per capita. Furthermore, the NRHC initiative comes at a bad time for local authorities: China has recently abandoned several agricultural taxes, which is tantamount to a large reduction in the income of the cantons and counties.

One may then wonder about how willing households will be to pay 10 RMB as a contribution to this NRHC programme. Although the peasants’ willingness to share in the financing of the NRHC depends on numerous factors, one of the main reasons is their perception of the level of reimbursement of medical expenses.
It is first of all important to bear in mind that even collecting 50 RMB per person can cover on average only between 25 and 35% of annual health expenditure in rural areas.

In other words, as observed in a study carried out by Professor Wu Ming, from Beijing University Department of Medicine in 2007, the rate of reimbursement of hospital costs is on average of the order of 27.5%, which means that financing of serious and terminal diseases in peasants is inadequate.(2) Thus, today, despite the NRHC, a lot of expenditure is still not covered.

This is important in the sense that the people responsible for this programme then have every interest in not promising too much if they do not want to see the rapid collapse of this initiative, while retaining the beneficial consequences of joining the NRHC in the eyes of the peasants.

Some recent studies have shown that many households consider that, all in all, this programme gives them little with which to reduce their exposure to the risk of high medical costs. In this case, support for the NRHC could gradually fall. Indeed, according to a number of international experiments, it has been found that it is young people and people in good health who may well leave the NRHC first, and it will then start to make losses and will require other contributions. The latter will lead to an additional exodus of young people and people in good health, the spiral will begin and the programme will collapse. This situation is known in public health as adverse selection.(3)
The question of the impact of the NRHC on the reduction of poverty equally arises today.

In other words, given the current level of contribution, will the NRHC make it possible to reduce the poverty related to heath spending. In 2004, on the basis of the 2003 China National Health Services Survey, Chinese researchers made the following observations:
there are 25,764 rural households in the west and mid-west regions. Their average per capita income is 2062 RMB and their annual per capita health spending is 225 RMB. The per capita income of 14% of households is below the rural poverty line (865 RMB). In 21% of poor households, this is due to medical costs. They then concluded that the 30 RMB proposed by the NRHC will reduce by 27% the number of households which have become poor because of their health spending. They therefore considered that the level of financing was not capable of reducing significantly the increase in cases of people being reduced to abject poverty because of illness. They then calculated that, for the NRHC to make it possible to halve these situations of impoverishment, a total of 54 RMB per person was needed.(4) In 2007, per capita financing of the NRHC is still below that (50 RMB).

According to the estimates of Dr. Ge Yanfeng, from the RCD, for the Chinese health system to be available to all today, it would cost between 150 and 200 billion RMB (between 15 and 20 billion euros), which represents between 5 and 7 times the country’s national income or 1 to 1.5% of GNP in 2005.(5)

The question of confidence between peasants and NRHC managers should not be neglected. This is essential so that country people will join the NRHC, that is to say there can be no doubts about corruption. It is not inappropriate to mention here that numerous attempts at rural health cooperatives have failed in the past because of corruption.
Engaging the beneficiaries in the mechanism of supervision of the NRHC may help to reduce attempts at corruption. It is a solution which is as yet rarely adopted and which is nonetheless being developed at the moment by Harvard University in Kaiyang (Guizhou) and Zhenan (Shaanxi) counties, where villagers sit on the committee which runs the NRHC.
Finally, the question of the portability of this cooperative health system becomes extremely important when one considers the position of migrants.160 Migrants from rural regions moving into the towns (150 million in 2005) continue today to find themselves in no-man’s land where health insurance is concerned. Ineligible for the urban health insurance system because they have no official residence, they are in theory obliged to return to their villages for treatments reimbursed by the NRHC. In practice, if they stay in a town only a tiny part of their expenditure will be reimbursed. For the NRHC to become more portable in
order to improve the access to care of millions of Chinese migrants appears to be a major and urgent challenge for those in charge of health in China.


(1) National Bureau of Statistics of China, China Statistical Yearbook 2006, www.stats.gov.cn
(2) “Chinese government under pressure to make rural healthcare system work”, Xinhua, 21 April 2007.
(3) This is why health insurance in industrialised countries is nearly always compulsory. On this point see: Liu Y. L., “Development of the rural health insurance system in China”, Health Policy and Planning, 2004, 19 (3), 159-165.
(4) Y. Liu, Z. Mao, B. Nolan, “China’s Rural Health Insurance and Financing: A Critical Review”, September 2004, p. 8. Available on: http://web.worldbank.org/
(5) China’s Failing Health Care System Searching for Remedy, Xinhua News Agency, 6 October 2006.

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Wednesday, 28 May 2008 19:56

Combat HIV/AIDS in China

- The main challenges of the national policy -

Although it is undeniable that the Chinese central political authorities have now become aware of the gravity of the situation and the need to act rapidly and effectively against HIV/AIDS, what they have done so far should be considered only as a start. In fact, they are facing a number of important challenges today:

1/The level of knowledge about HIV/AIDS among the people remains relatively low.
Generally speaking, numerous studies concerning the level of knowledge among the different target populations say the level is relatively low. Thus:
A recent survey revealed that only a little more than 67% of Chinese college students had precise knowledge about HIV/AIDS.(1) Other studies show that there are enormous geographical disparities where the level of knowledge about HIV/AIDS is concerned. In fact, young Chinese but also adults living in the west of China appear to be less aware of
the modes of transmission of HIV and the means of protection than people in the eastern part of the country.(2) This disparity is also observed between residents of rural areas and townspeople in China.(3)
A survey carried out in 2005 of 3000 Chinese Communist Party officials with a university degree and who were under 50 years of age showed that more than 60% did not know that there was no vaccine against AIDS and 30% thought that seropositive patients should be isolated so that they could be treated.(4)
Finally, a study on the level of knowledge among waitresses working in bars, saunas and hotels in Shandong province discovered that 63.6% of the women questioned had answered incorrectly more than half of the 33 questions in the questionnaire.(5)
Now, this situation feeds discrimination against and stigmatisation of seropositive persons, on the one hand, and makes it easy to see the large number of at-risk activities which may occur every day in China just through lack of knowledge about HIV on the other hand.
Numerous Chinese public health professionals are therefore demanding that efforts at prevention and education should be redoubled at all levels of society and in all the provinces.

2/Most seropositive people are unaware of their status.
Two figures may explain this fact. On the one hand, in October 2006, the Ministry of Health acknowledged that 183,733 seropositive people had been detected by screening. According to the estimates, China has 650,000 cases. There could therefore be more than 460,000 people who are not aware of their serological status and who thus may well transmit the disease. Consequently, although screening has been increased, extended and regularised, its cover in terms of geography and population still seems to be too low, particularly because of the lack of trained staff. An effort concerning the identification of these seropositive people and the prevention of secondary transmission appears to be essential.

3/The application of national policy of “4 free things and one care” remains uneven.
The Chinese Ministry of Health acknowledged in January 2006 that, although implementation of this policy has been relatively good in places most affected by the virus, this could not be said of the less affected regions. This situation is preventing a large number of AIDS orphans, pregnant women who are victims of HIV/AIDS, and poor people
residing in urban and rural areas who are seropositive from benefiting from the support of the public authorities.

4/Efficient implementation of treatment and care programmes is still difficult.
- In 2006, 80% of recipients of the free treatment were on a three first-generation ARV (anti-retroviral) scheme (AZT/d4T+ddl+NVP) which is known to cause very serious adverse effects. Only 18% of the patients use the (AZT/d4T+3TC+NVP) combination which includes an ARV introduced into China in early 2005, 3TC, which is approved by all the international first-generation treatment programmes. Furthermore, some Chinese and foreign professionals and health officials are expressing concern as to the first signs of resistance to ARVs which could rapidly make the first-generation regimens inefficacious, while the second-generation ones are not yet on the Chinese market.(6)
- Most patients are people from the central provinces of China who formerly sold their blood. Today the people most affected by HIV are the IDU in the west and south-west of China. Although treatment centres for IDU have been established, for political and technical reasons it is sometimes difficult to speed up their introduction and operation.
- Few seropositive children, of whom there are estimated to be more than 9,000, are given treatment against the virus, because China has extremely limited access to paediatric ARV and also very little experience of HIV/AIDS in children.(7) The majority of the latter are
deprived of treatment or treated with adult regimens which have adverse effects which are very severe for them.
- There are numerous obstacles to the clinical management of the treatment: the refusal of certain hospitals to treat seropositive patients, lack of staff to carry out essential laboratory tests, irregular follow-up of patients or, again, the rarity of reports concerning the patients’ data.
- The nature of the rural health system on which 80% of seropositive people in China depend is a burden on the efficient implementation of the National ARV Treatment Programme. On the one hand there are the seropositive patients, mostly without health insurance, who have to pay with their own money for the medical care that they require. On the other hand, hospitals, from county level and below, where the money they get from all their patients is the only source of income that they have. These hospitals are therefore offering – not necessarily high-quality – care services at high charges to residents in rural areas who are seropositive. This situation greatly restricts access to the care which seropositive people frequently need and is consequently an obstacle to the proper progress of the treatment. In addition to this, there are other financial barriers: the cost of drugs for opportunistic disorders (sometimes sold at exorbitant prices by unscrupulous doctors), for routine laboratory tests, for hospital admissions, for transport to and from the places of treatment, etc. The success of the treatment is therefore intrinsically related to the nature and quality of the system of rural health and social protection for the most disadvantaged.
- Finally, implementation of the treatment is still difficult in seropositive migrants who have fled the misery in their villages to join a “floating population” of more than 120 million people in China today. Indeed, if a change in living conditions can influence the body’s
reaction to treatments, the difficulty arises in particular from the fact that, in order to benefit from free treatment, the patient must be a resident of the locality where the department which is going to provide him with the ARV is located. This situation directly affects the migrants’ access not only to treatments and to care but also to the information which they may need.

5/Some forms of cooperation remain sensitive.
The efficacy and sustainability of the programmes against HIV require evaluation and close monitoring of the situation, and these depend essentially on information collected in the field. However, many counties and local health offices see the collection of these data
as a burden and more for the benefit of central government in particular. Despite current searches for a simple system of sharing information, this problem of “down-up” cooperation has until now delayed numerous assessments, and this may have affected the efficiency of some projects.
Cooperation between the authorities from different levels and the voluntary associations is also difficult. Although the number of independent local associations is increasing and the central authorities would like them to join in the projects to combat HIV/AIDS,(8) the situation on the ground is not always straightforward: it is not in fact unusual for local people in charge, who are still mistrustful of the role played by these social organisations, to adopt a coercive attitude to their activities or to prohibit them from some activities. The famous activist, Wan Yanhai, was interrogated at the end of November 2006 by the police in Beijing in the offices of his association, Aixhi, and forced to cancel a symposium on HIV/AIDS, the main topics of which were to be the rights of seropositive people and the quality of blood products in China. What is more, he is thought to have disappeared since then.(9) Lastly, in February 2007, Dr. Gao Yaojie, a pioneer of the fight against AIDS in China, was placed under house arrest by the local government in Henan, which did not want her to travel to the United States to receive a prize from a foundation sponsored by Hillary Clinton.(10)
Finally, numerous activists also stress that the support provided by local governments to the NGOs (11) is often given to what they call “puppet NGOs”, also known as government NGOs (GONGOs).

(1) “Chinese college students have poor knowledge of AIDS: survey”, Xinhua, 23 March 2006.
(2) “Youth in the west lack understanding of AIDS”, Xinhua, 5 January 2007.
(3) “Wang Xin-lun et al. “Survey of knowledge of and attitude to AIDS among residents in rural areas and cities”, Chinese Journal of Health Education, vol. 22, no. 4, April 2006, 260-268.
(4) Rong Jiaojiao, “Educating the masses on HIV/AIDS”, China Daily, 13 February 2007.
(5) Liu-Xi-liang, “Survey of AIDS knowledge and sexual behaviour of female waitresses”, Chinese Journal of Health Education, vol. 22, no. 3, March 2006, 192-195.
(6) “Better drugs urgent for China to combat AIDS”, China Daily, 13 August 2006.
(7) At present, only 200 children are receiving adequate treatment, provided by the Clinton Foundation, and another 50 are being treated by MSF.
(8) “China encourages NGOs’ participation in fight against AIDS”, Xinhua, 22 March 2007.
(9) “Chinese AIDS activist ‘missing’”, BBC News, 25 November 2006.
(10) “[Gao Yaojie, Chinese anti-AIDS militant, is under house arrest]”, Le Monde, 13 February 2007.
(11) Since 2003, the authorities are thought to have allocated 2.5 million euros to 231 projects run by associations in 150 counties in Zhang Fneng, “More Power for anti-AIDS campaigners”, China Daily, 4 October 2006.

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