By Hui Li and Ben Blanchard
BEIJING (Reuters) - A one-room shack with a single, bare light bulb on a non-descript Beijing side street is 29-year-old Chinese migrant worker Zhang Xuefang's best recourse to medical care.
Not recognized as a Beijing resident, she does not qualify for cheaper healthcare at government hospitals, and her hometown is too far away to take advantage of medical subsidizes there.
Like millions of other migrant workers, Zhang, on whose labor China's economic boom depends, is forced into a seedy and unregulated world of back ally "black clinics" if she falls ill.
The issue highlights the two-tier nature of China's overburdened health care system and goes to the heart of a heated debate about how to reform the contentious "hukou" system of household registration, a cornerstone of government policy for decades which essentially legalizes discrimination between urban and rural residents.
The hukou system, which dates to 1958, has split China's 1.3 billion people along urban-rural lines, preventing many of the roughly 800 million Chinese who are registered as rural residents from settling in cities and enjoying basic urban welfare and services.
China's new government has vowed to change this divisive system with reforms aimed at sharing more equally the bounty of China's economic growth and consumption-led growth.
Newly-appointed Premier Li Keqiang vowed at his debut news conference earlier this month to press ahead with reforms to narrow China's urban-rural gap, including giving migrant labor more equal access to medical insurance.
No details have yet been announced, so black clinics will remain the affordable last resort for migrant workers.
"Health care insurance and other social insurances are closely linked to hukou. Providing better social insurance is, I believe, an incentive to reform hukou system", said Zhang Shuo, a senior Health Specialist with the World Bank's Beijing office.
"China's urbanization will be unprecedented in speed and scale," Zhang explained, "Portable social insurances is key to encourage labor migration, but it will take some time for a country as big as China."
DARK CORNER OF HEALTH SYSTEM
"Black clinics are the dark corner of China's medical system," said Jiao Zhiyong, a professor at Beijing's Capital University of Economics and Business.
"Migrant workers are their main patrons largely due to flaws in the health insurance system."
World Bank's Zhang also pointed out that China's health care insurance system is a fragmented one, mostly coordinated within counties. But migrant workers usually have to seek medical treatment outside their home counties.
The Beijing government has shut down about 1,000 black clinics a year since 2010, according to government figures.
Many, however, reopen nearby or at the same place only days after being closed.
While China has never published numbers for how many black clinics exist, every so often state media reports deaths at these unlicensed health centers.
In January, Chinese newspapers reported that a migrant worker from Fujian province died from a cardiac arrest hours after receiving an intravenous drip to relieve her cold symptoms in a black clinic in one of Beijing's gritty outer suburbs.
Migrant worker Zhang has seen the dangers of black clinics close up. On one occasion, out of fear that authorities might be nearing the illegal clinic, Zhang's doctor locked her inside the clinic, still hooked up to an intravenous drip, as he fled.
"We don't want to go to those places, knowing that the substandard hygienic conditions affect us, but we really can't afford big hospitals," said Zhang, who once paid 800 yuan, a quarter of her monthly salary, for treatment of a common cold at a government hospital in Beijing.
China has beefed up spending on health care reform with last year's overall expenditure at 719.9 billion yuan, a 12 percent increase from the previous year. Yet last year's figures from the Ministry of Human Resources and Social Security showed that only about 20 percent of migrant workers have health insurance.
"To build a country-wide healthcare reimbursement system is our goal, but there is still quite a long way to go," Hu Xiaoyi, vice minister of Ministry of Human Resources and Social Security told reporters this month.
For those who are insured, reimbursement only comes after payment, and is often complicated by bureaucratic red tape, putting families at risk of bankruptcy when major health problems strike.
"Health insurance works locally, but when we go work in other places, only some provide health insurance, which still requires a lot of procedures. And each could take months and still wouldn't come through," Cao Yong, a migrant worker delegate to parliament, told state radio.