China’s coronavirus response slowed by bureaucracy, unstable funding as government never empowered lower level officials

Sidney Leng

The 2002 outbreak of Sars provided the first real test of China’s decades-old Soviet style public health system, but despite some improvement made in the aftermath, the country’s disease control and prevention system has again been proven to be too weak to be effective against the deadlier coronavirus epidemic 18 years later.

Since severe acute respiratory syndrome (Sars), China’s spending on health has grown 10 times, with thousands of local centres for disease control and prevention established across the country.

Yet unstable annual funding, complicated bureaucracy and an insufficient number of trained workers still made it ill-equipped for the latest coronavirus outbreak, according to experts as well as government budgets and statistical yearbooks reviewed by the South China Morning Post.

The Chinese Centre for Disease Control and Prevention (China CDC) – akin to the US government’s Centres for Disease Control and Prevention (CDC) that was founded after the second world war – was heavily criticised for being slow to warn people about Sars.

The China CDC did not issue a bulletin to hospitals on how to contain Sars until April 2003, five months after the earliest case was identified. The outbreak eventually killed 349 people in China before it died out, according to the World Health Organisation.

The same criticism was levied at the China CDC over their response to the coronavirus outbreak in early 2020 even though, in both cases, they did not technically have the authority to issue a warning.

Zhong Nanshan, a medical expert who rose to fame for speaking out about and treating Sars patients in 2003, lamented that China’s CDC is still nothing but “a technical department” and played “a role that is too low” in the medical system during the current coronavirus outbreak.

Unlike the disease control centres in the US, China’s CDC does not operate independently from other government agencies, heeding orders and receiving funding from the National Health Commission, the ministry-level executive department which also controls the country’s birth policy.

The China CDC is a research institution. They only issue reports to assist the National Health Commission to work on outbreaks, but they have no power to [announce] emergencies or take action against those who are spreading the virus

Xi Chen

“The China CDC is a research institution. They only issue reports to assist the National Health Commission to work on outbreaks, but they have no power to [announce] emergencies or take action against those who are spreading the virus. They have no power to mobilise medical supplies or staff members to other areas in China,” said Xi Chen, an assistant professor at the Yale School of Public Health.

“The [Chinese] government could be more proactive to make the investment in the China CDC to allow them to mobilise human resources and medical supplies, and have emergency powers and to assist local governments. All these investments should be done, instead of waiting for an emergency.”

While China manages the world’s largest network of disease control centres – 3,443 were in operation at the end of 2018, around 60 per cent of which were in rural areas – its budget is lower than those for similar agencies in developed countries.

The Organisation for Economic Cooperation and Development, an international bloc of market economies, tracks member countries’ spending on preventive care, which includes education, immunisation, early disease detection, epidemiological surveillance, and preparation for disaster and emergency. In 2017, it reported that Canada spent the most on prevention, 6.2 per cent of its total health care expenditures, followed by Britain at 5.2 per cent and Italy at 4.2 per cent. The US and Japan spent around 2.9 per cent each.

China earmarked around 2.3 per cent of its health care expenditures – 34.2 billion yuan (US$4.9 billion) – for its CDC network in 2017, while the US spent more than twice as much – US$11 billion in the financial year 2017 – even though its population is a quarter of the size.

There was a significant leap in China’s investment in disease control after the Sars failure, but much of it proved to be one-off infrastructure investment, such as expansion of office buildings and laboratories as well as purchases of equipment.

From 2002 to 2005, government investment in China CDC offices and facilities across the country expanded 4.4 times on average, while financing for equipment increased by 7.2 times, according to a research paper written by a dozen heads of local China CDC facilities along with scholars from Fudan University in Shanghai. But at the same time, funding for China CDC’s operating expenses only rose by around 40 per cent.

The investment spree, however, was short lived. Over the decade up to 2012, the share of government’s budget for China CDC fell from 0.127 per cent to 0.105 per cent on average, according to an article in the state-run Guangming Daily in 2015.

“The government’s spending [on CDC] is falling behind economic growth. The god of fortune follows the god of plague,” the article said, referring to the fact that investment rose after a major disease outbreak but then fell back quickly.

Wang Shaoguang, a professor at Tsinghua University in Beijing, described the decreased funding since 2008 as “the fourth crisis” in recent public health history after the Great Famine from 1959 to 1961, the Cultural Revolution from 1966 to 1976 and the pre-Sars era between 1985 and 2002.

“The main reason [for the latest funding crisis] is that a few years after the third crisis, the focus shifted more to medical treatment and less on prevention,” Wang said.

According to official statistics, more than 70 per cent of heath expenditures in China is dedicated to public hospitals and health insurance, while 17 per cent went to public health, which includes the China CDC, although local authorities only allocate a small amount to disease prevention and control.

In Hubei province, the epicentre of the coronavirus outbreak, 67 million yuan (US$9.3 million), or 0.09 per cent of the province’s total budgetary expenditures in 2018, was allocated to disease prevention and control. In Zhejiang province, which, like Hubei, has close to 60 million regular residents, the share of funding was only 0.206 per cent of total government spending.

Hebei province allocated the largest share of its budget, at 0.27 per cent in 2018, followed by Zhejiang, Hainan, and Guangdong provinces.

Last year, Hubei set aside around 75 million yuan (US$10.8 million), which was comparable to the funds allocated for flood prevention, affordable housing, high school education and the United Work Front department.

In 2013 during the outbreak of bird flu, spending on disease control in the city of Wuhan, the capital of Hubei province, topped 680 million yuan (US$97.7 million), but dropped back to 86 million yuan (US$12.4 million) in 2018.

A study of 11 county-level CDCs across five provinces, published by Chinese Health Resources in 2019, showed that the debt ratio of CDCs in less developed areas ran as high as 40 per cent in 2017, compared to the national average of 8.3 per cent.

In 2017, the financial situation of local CDCs was exacerbated after Beijing abolished three types of service charges on health examinations often used to offset their lack of funding.

Many lower-level CDCs in China have relied on paid-for services to support operations, although this contradicts the founding purpose of a fully funded public health institute.

In the city of Heze, in Shandong province, its CDC received funding of 60 million yuan (US$8.6 million) from the government but generated 51 million yuan (US$7.3 million) from fees for health check-ups, among others, in 2014, according to official data.

Compulsory vaccines are given to children in China under a state-sponsored health programme through hospitals and the CDC for free, but it is common for low-level branches to push clients to have optional injections they have to pay .

Insufficient funding has also led to a shortage of staff, with the overall nationwide figure dropping by 20,000 between 2002 and 2018, according to official data.

China requires at least 1.75 CDC staff for every 10,000 people, but it is currently less than 1.4. In 2006, the US reached a level of 9.3, with Russia at 13.8.

One CDC in Beijing lost 32 employees from 2013 to 2017, according to Wang Miao, a researcher from the national centre. Many of those who left had postgraduate degrees and joined other government agencies or companies offering higher salaries. In 2015, half of the 244 staff were paid monthly salaries below the capital city’s average of 7,086 yuan (US$1,018).

Public health experts estimate that there is a 30 per cent gap in China CDC staffing, which could be worse in larger and more populous cities.

In Guangzhou, the capital of southern economic powerhouse of Guangdong province, the gap was 50 per cent in 2018. In Guangzhou’s Panyu district, there was only one CDC employee for every 29,700 people, one-fifth of the required level.

Getting sick is very normal, but when it’s political, it becomes something different

China CDC director

Political pressure has also impeded the work carried out by China CDC, particularly in rural areas.

“The thing is, as long as mosquitoes exist, malaria won’t be gone,” said a director of a county-level China CDC in rural Hubei province, who spoke on condition of anonymity.

“We are mainly serving rural people. Preventing malaria should be one of our jobs, but we don’t do it and a lot of malaria-related medicine expires on our shelves.

“In reality, malaria infections exist all the time. The reason why others don’t know about it is because we can’t report it, otherwise it would get heavy scrutiny from the upper-level government. Getting sick is very normal, but when it’s political, it becomes something different.”

Additional reporting by Kristin Huang and Simone McCarthy

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