This paper presents a chronology of the development of the Chinese rural health system and its responses to environment-related health problems. During the early years of the People’s Republic, the health system was very successful in reducing the transmission of infectious diseases through environmental improvements. Since the transition to a market economy, environment-related preventive programmes have been given less priority and a variety of new environment-related health problems and risks have emerged. More recently, the Chinese government has made strong commitments to improve the performance of the health system and increase access by all. Its focus has been on strengthening medical care and developing new forms of health finance. It has paid little attention to environment-related problems. However, as the pace of health reform accelerates, it will be important to ensure that it take environment-related problems into account.