Roadblocks to health reform in China.

sweeping US$130-billion health care reform plan, the country faces huge obstacles to progress in what’s been described as the world’s largest health care experiment. The plan centres on quickly reforming hospital management while delivering universal access to primary health care through national insurance schemes. But roadblocks have arisen, according to new research presented at the annual world congress of the International Health Economics Association in Toronto, Ontario (July 10–13). For instance, an effort by the Chinese government to reform hospitals by eliminating user fees faces tough opposition from clinicians. Also stymied — by a lack of physicians and money to pay them — is an effort to extend access to basic health care to 800 million rural residents, many of whom live in poverty. At a special forum on the progress of the reforms, Tsung-Mei Cheng, a health policy research analyst at Princeton University in New Jersey, said the fact that hospitals continue to derive almost 40% of their income from user fees confounds efforts to reduce the financial burden of health care for the poor. “In some areas, the out-of-pocket costs of inpatient care have risen despite increased insurance from government, which suggests it didn’t make a difference,” she told the congress. “Hospitals and doctors help themselves by doing all sorts of additional tests and treatments.” The government, Cheng said, “is painfully aware of these problems.” In recent weeks, she noted, it has increased pressure to eliminate user fees and force the adoption of evidence-based clinical processes designed to detect billpadding through inappropriate treatments. On June 22, China’s State Council announced a plan to improve medical care by raising education standards for general practitioners and vastly increasing the number of physicians. The current drive to eliminate user fees would create a system similar to the News CMAJ