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China's Fragile Rural Health-care System Braces for Lunar New Year Travel Surge

The Takeaway

The annual Spring Festival travel rush in China sees tens of millions of travellers leave large cities to reunite with families, prompting an influx of COVID-19 in rural areas as a result. Structural obstacles make rural health-care systems in China weak and leave countryside residents vulnerable. This means that another public health crisis could be on the way, just as the country celebrates its first Chinese New Year without restrictions in three years.

In Brief

On January 14, 2023, China announced that 59,938 people had died in hospitals with COVID-19 since most pandemic restrictions were dropped in December 2022. The confirmed death toll, likely an undercount, gives a glimpse of the first post-reopening peak. The Spring Festival travel rush, running January 7 to February 15, brings worries of a second and deadlier wave, as workers in major cities return to smaller towns and villages.

China’s countryside, home to 37 per cent of the population, is poorer than its cities despite progress made on poverty eradication in recent decades. In the countryside, there are higher numbers of elderly people, people living with disabilities, and young children. Health-care resource metrics, including ICU beds per person, are lower in rural communities than urban ones in almost every Chinese province. These factors make the countryside extremely vulnerable to COVID-19. Recognizing these challenges, China’s State Council and the Central Rural Work Leading Group (CRWLG) co-published a work plan for rural pandemic management on December 20, 2022, calling on township and village authorities to create more fever clinics and build databases of vulnerable individuals.


China’s rapid dismantling of its zero-COVID policy has led to an extraordinary wave of COVID-19 infections. The Chinese CDC’s internal estimates reportedly show that around 250 million people, or 18 per cent of the country’s population, were infected in the first 20 days of December 2022. January 8 marked China’s last major pivot away from zero-COVID, as borders reopened and almost all restrictions for travel were essentially removed. This move coincides with the beginning of this year’s Spring Festival travel rush, which authorities anticipate will entail over 2 billion trips. As of 2021, 171.7 million internal migrants have rural household registrations, but work in cities outside their home townships, suggesting a significant amount of holiday travel will see people moving from urban to rural areas.

Since the National Health Commission (NHC) stopped publishing its daily COVID-19 updates on December 25, 2022, there have been concerns that case and death counts are being under-reported. The State Council only counts those who die specifically of respiratory failure caused by COVID-19 infection as ‘COVID-19 deaths.’ This narrow definition appears to have been relaxed for the January 14, 2023, data release: the 59,938 deaths included 5,503 who died directly from respiratory failure, with the remainder dying from a combination of COVID-19 and underlying conditions. Several anonymous medical professionals in China told Reuters that they were discouraged by officials from recording patients' deaths as caused by COVID-19 – something many ‘netizens’ encountered with their family members’ death certificates.

Disparities in record-keeping and a lack of transparency will be a dangerous combination in low-resource communities. Where there are no tertiary hospitals, patients die at home and are excluded from official data. Many rural communities did not see outbreaks for most of the pandemic due to the zero-COVID policy and have not been heavily exposed to public health messaging on masks, hand-washing, or social distancing.

The emphasis on data collection in the State Council’s work plan points to the authorities’ concern about being unable to grasp the full scope of outbreaks across rural China. The NHC also said it has distributed 1.17 million fingertip pulse oximetres across rural communities, with each village clinic receiving two.  While policy measures to ensure supply and improve triage will ease the strain on resources, China’s rural health-care challenge is crippled by years of underfunding and a lack of trained personnel, meaning that temporary resource mobilization may still not be enough to patch systemic gaps.

What's Next

  1. Local governments scramble for essential supplies

The December notice from the central government also called on local authorities to ensure vegetable supplies throughout the winter. Given that most of China’s food supply is grown in rural areas, authorities there must ensure food security in addition to handling infection waves. On a national level, there are growing concerns that higher inflation will reach China soon and drive up the costs of living during an already difficult winter.

  1. Elderly care re-enters public consciousness

Treatment of the elderly, particularly vulnerable ones in rural regions, has long been a heated topic in China. There are 118 million seniors in China who live alone or with their spouses, and their conditions received widespread attention during zero-COVID lockdowns. The challenges of caring for an aging society are once again in the spotlight, as reports of COVID-19 deaths emerge from rural regions, with Chinese New Year highlighting the traditional family structures that continue to sustain elder care in China.

  1. A nation divided

Cities like Shanghai and Beijing are estimated to have already passed their first peak, and major Chinese cities are returning to “normal.” Gatherings and celebrations will occur while infections spread and the death toll climbs throughout the Spring Festival holidays, with pandemic experiences likely shaped along regional and socioeconomic lines.

• Produced by CAST’s Greater China team: Maya Liu (Program Manager) and Irene Zhang (Analyst).