Li, a retired farmer who lives in Henan province in central China, has type 2 diabetes. The condition is manageable but comes with large out-of-pocket expenses, a common feature for people in China, especially those who, like Li, live in rural areas and don’t have the best insurance policies.
Li doesn’t like to complain too much, though, and says his children help him with the bills.
“Now a lot of old people have diabetes,” he says. “So it’s not necessarily a severe disease, you just have to pay more attention to it, including using medicine to control blood sugar.”
For people of his age it’s no big deal, he adds. He is more worried about the fact that his once-bustling village is now deserted because all the young people have gone to find better-paid jobs in China’s expanding cities.
But while Li sees his illness as a small problem, it becomes a much, much bigger one for China’s rulers when his case is multiplied by the hundreds of millions of others who are suffering from similar diseases.
Not only are these diseases killing Chinese people at an alarming rate, the enormous cost of healthcare under Communist party rule is swallowing up a large chunk of household income. It threatens major social, economic and political consequences, not least for President Xi Jinping’s flagship policy to reduce inequality and usher in what he calls an era of “common prosperity”.
Li’s medicine costs him 40-50 yuan a month, or up to $7.90, but his income is little more than 100-150 yuan. It is not covered by his health insurance because it is used up paying for other medical needs. He’s well aware that he could be a lot worse off if he needed insulin shots – they would cost double his monthly income.
“Some people will take shots,” he says, “but I would rather not do that because it is quite expensive. I have been taking melbine to control my situation. If I take shots, it would take me 200-300 yuan. My insurance doesn’t cover this”
Individuals accounted for 35% of China’s annual health spend in 2018, paying an average of $185 of the $521 spending per head, according to the global burden of disease study. In the UK the same figure is 16.5%. Out-of-pocket expenses make up a much higher proportion of outpatient care and there can be a low ceiling even on in-patient hospital care of around $850 before the patient has to contribute. They also have to pay up to 80% of costs for medicines.
A third of people face catastrophic healthcare expenditure in their lives, which is defined as spending more than 10% of their income on healthcare. An estimated 15% of the population spend more than 25% on healthcare.
Photograph: Wang Zhao/AFP/Getty Images
Li’s story is repeated throughout China, where western-style health issues such as diabetes have boomed at an astonishing rate along with the country’s economic miracle.
Almost 10% of all adults in China – about 110 million people – currently live with type-2 diabetes. Thirty years ago it affected only 2.5% of the population. Without urgent action to reduce lifestyle risk factors such as unhealthy diet and lack of physical activity, that number is expected to increase to 150 million by 2040 – with major health, social and economic consequences.
The government has launched a plan to reduce the incidence of diabetes, including increasing awareness among 18-year-olds and over, and improving the number of people whose illness is managed.
But the economic shock of falling ill in China is very high: getting sick is very expensive for individual households, as even Li’s relatively modest example shows. It also takes people out of the labour force at a time when the nation’s once-enormous pool of workers is shrinking quickly thanks to low birth rates.
Xi Chen, associate professor of health policy and economics at Yale, says the healthcare burden is higher for diabetes than for problems such as hypertension or high blood pressure. “In the US, one out of every three dollars of Medicare is spent on diabetes,” he says. “If that happens in China it’s a disaster. It was 2.5% prevalence in 1990. Now it’s 10% and growing.”
Li knows that what he eats has changed over the years and links his diabetes, which requires regular medicine to control his blood sugar, with not eating the same volume of greens.
“My diabetes has a lot to do with my diet,” he says. “I eat quite a lot, including rice, noodles and buns, all of which have a lot of sugar in them. I don’t eat enough vegetables. I should eat more vegetables and less noodles.”
