He later claimed 24,000 yuan - 20 percent of the money - back. "The refund is a lot more than I could hope to earn in a year," Zhang said. Although he was grateful for the reimbursement, he will still have to slave away for several years to clear the debt.

A serious illness can turn a farmer's life upside down - as the most recently available Ministry of Health statistics demonstrate. In 2003, the average annual income for China's 800 million rural population at that time was 2,622 yuan (US$328). In 2004, the average medical expenses were 2,236 yuan (about US$280 U.S. dollar)

The latest national health survey in 2003 revealed that about 73 percent of people in rural areas who should have sought medical treatment chose not to do so because of the cost. It seems some impoverished farmers would rather visit Hades than a doctor.

"Current reimbursement rates are rather low, and many counties have not supplied an adequate amount of money to the fund," said Li Ling, a professor from the Chinese Economy Research Center in Peking University.

In a report by the National Audit Office, which researched 15 counties in central and western provinces in 2005, reimbursement rates were lower than 29.2 percent, compared with more than 40 percent in counties in east China.

The 15 counties only spent half of the pooled fund in 2004, as county governments were "careful in the preliminary stages of the program, raising reimbursement limitations to avoid a fund deficit", according to the report.

Poorly-equipped village clinics and a shortage of manpower were other inescapable problems, the report said.

Some local governments have publicized measures to raise extra funds to finance the co-op system.

Song Xiuyan, governess of northwest China's Qinghai province, said she had cut staff luxuries to supply the province's portion of the fund.

"We'd rather not renovate houses and not buy new cars to ensure the farmers can go to hospital when they are ill," she claimed.

The Qinghai government was able to add an additional 4.3 yuan for every farmer into the fund through such measures but many people believe that the rural healthcare system should be placed at the top of the priority list so it does not have to rely on superficial cost-cutting methods.

The drive to promote the co-op scheme comes in reaction to potential social instability in the countryside. In April last year, a man in Lianshui county, east China's Jiangsu province, killed his own family and attempted suicide to relieve them of a debt created by medical charges that they could not afford to pay.

The rural healthcare system was once a core element of Chinese socialism. After the founding of the People's Republic of China in 1949, rural people had access to subsidized health clinics run by "barefoot doctors", who were mainly middle-school students trained in first aid. The primitive service, essentially free, played a role in doubling the country's average life expectancy from 35 years in 1949 to 68 years in 1978.

When China began its economic reforms in the early 1980s, the system was dismantled as the country attempted to switch to a market-oriented healthcare system.

But the government failed to establish a viable substitute and between 1980 and 2004, the central government's share in funding for the health sector dropped from 40 percent to 16 percent, according to the World Health Organization. It was 44 percent in the United States, 66 percent in Australia and 85 percent in Japan.

The Chinese government also felt peer pressure from countries such as India, where 72 percent of the rural population enjoy a free medical service, according to the People's Daily. In several European countries, governments usually pay for 80 to 90 percent of their people's medical expenditure, said the newspaper.

"On one hand, the government should convince people of the merits of the policy. On the other, they should improve management and supervision of the program, and really substantiate their promises," said Wu Ming, a health professor with Beijing University.

Only then, it seems, will there be fewer shadows lurking outside hospital doors, mulling over what to give up: health or hard-earned cash.

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