19 A more effective mechanism should be devised to protect the poor from user fee increases; the current mechanism in place in China to exempt the indigent from fees is not working. As household expenditure data showed there is a weak relationship between household income and the average price paid for treatment, that is, households in the bottom income quintile spend a disproportionately high share (13 percent) of their total health expenditure on one annual visit. They also spend more on drugs, which are generally not subsidized. Of total private health spending, the poorest households pay 77 percent on drugs compared with 68 percent by the richest quintile. Thus, the burden of paying for service charge and drugs is higher among the poor than the better off. Since this disproportionate burden prevents the poor from using public health facilities, then improving access for them may require selective price reductions for essential services; the poorest hard-to-reach group should be exempt from paying fees, which may be compensated for by _increases_ in public spending and other insurance fees. This needs an appropriate pricing policy that differentiates prices by the income of users Finally, improving the quality of public health services would enhance utilization. One indicator of the quality gap is the variation across income groups in the amount of household expenditure on public health, but another indicator, available from the 1993 NHS, is that 15 percent of households do not use public health facilities due to the lack of beds (4.1%) and the absence of proper services and treatment (11.3%). Interprovincial variation is even wider. Another indicator is that the poor are less likely than the better-off to receive treatment by qualified and trained doctors when they are sick. Spending on medical equipment, supplies, drugs, and physical infrastructure in township health centers and the redeployment of trained personnel in needy areas would considerably improve the quality of services available to the poor.

# **Addressing Emerging Problems:**

_Strengthening the Information. Education and Communication (IEC):_ The disease burden in China implies that about two-thirds of premature deaths and disabilities stem from such risk factors as excessive smoking, improper diet, alcohol intake, the lack of exercises, environmental abuse, or dangerous sexual practices. These factors are linked to the behavioral choices of individuals and have a combined synergistic effect. Discouraging these unhealthy choices by individuals is difficult, given the complexity of emotional, intellectual, and social influences that shape the decisions of population. One viable strategy would be to have the government join with the private sector to strengthen the IEC network and its efforts to deliver one overriding message-that eliminating or reducing exposure to risk factors via immunization, maternal weaning, waste disposal, screening of treatable diseases, and changes in life styles is more effective and less expensive than the longer-term secondary treatment. The message should be delivered by the mass media, communication technologies, post-primary school curriculum, and reinforced by teachers and community workers.

_Passing Legislation:_ The findings on the burden of diseases clearly suggest that the government should enact various legislative measures and restrictions to alleviate sufferings from NCD and injuries in the future. For example, to reduce the risks of obstructive pulmonary disease which will account for more 14 percent of total DALY lost from NCD by 2020, the government should place legislative ban on cigarette smoking in public places, and among the younger population, as well as on the advertisement and promotion of any tobacco goods and trademarks. Together, these measures would gradually reduce morbidity and mortality from smoking-related diseases. It should also consider increasing taxes on tobacco as a disincentive to smoking, to