A project of Volunteers in Asia by: China Health Care Study Group Published by: Christian Medical Foundation 150, Route de Ferney Geneva Switzerland This publication is out of print in 1983, Reproduced by permission of the Christian Medical Foundation. Reproduction of this microfiche document in 'any form is subject to the same restrictions as those of the original document , -. ; i ; >’ L.;..LL... .- . / ,*!I’ , .,’ :. I ?b ’ ‘i .- I ,I, ..-’ - .-- .;L,‘L- ^. ,-I _ -i . .v 1‘ ..i” ::- -- -. c _ ‘P., * -- ‘- -7 . Health Care In China : an introduction The Report of a Study Group in Hongkong E.H. Paterson, Chairman Susan B. Rifkin, Secretary Geneva Christian Medical Commission 1974 Errata: Page 59 should foilow page 5’7 and page 58 should follow p?gcs 59. page 19: for 1335 read 1835 Copyright 1974 Christian Medical Commission 150, Route de Ferney Geneva, Switzerland ’ AU rights reserved Printed in Hong Kong Taosheng qublishing House 50 Waterloo Road, Kowloon Photos from Hsinhua News Agency and the Foreign Languages Press, Peking CONTENTS Foreword by John H. Bryant . . . . . . . . . . 7 Preface by L. K. Ding . . . . . . . . . . . . . 9 Introduction . . . . . . . . . . . . . . . . .12 Chapter I: Chapter II: Chapter 111: Chapter IV: Chapter V: Chapter VI: Conclusion . Appendix: The Relationship of Health to National Development Goals . Health Care Organization . . Epidemic Disease Control . . Population Policies . . . . . Traditiona and Western Medical Practices . . . . . 1 . . Manpower for Health Care . . . . . . . . . . . . l P The Prevention and Treatment or Mental. Illness , . . . . . . . . Annotated Bibliography . . . . . . . . . . . . n 17 . 33 l 53 * 73 . 87 101 123 128 135 S FOREWORD The charter of the Christian Medical Commission of the World Council of Churches includes the task of providing its constituency with such information as may assist the churches throughout the world in carrying out their re- sponsibilities for providing heahh care to man and com- munity in light of the widespread interest in what has been happening in China in the last quarter century, it seemed appropriate to the Commission .in 1972 to explore what might be learned from the Chinese experience. The Com- mission, acting through the office of the Lutheran World Federation which was engaged in studies of China, arranged for the appointment of a group of medical and sdciai stien- tists in thong Kong and asked them to provide it with a relatively brief and introductory answer to the question, “What in the Chinese experience of rebuilding a health care system might be of value to communities in other cultures and social systems?” This booklet is that group’s answer to the question. The Christian Medical Commission is publishing this report ,because we believe that the information will be of value to health workers both in the developing and in the indus- trially developed countries where the failures in health care systems stand out so sharply against the technological and economic advancement. The opinions and judgements expressed in this book do not necessarily reflect those of the Christian Medical Commission. Since the manuscript is the product of a group effort, individual members of the Study Group may not necessarily concur with every view expressed. On behalf of the Christian Medical Commission I wish to express my thanks to the members of the Study Group, to its executive secretary and to others who have been engaged in the production of this book. There will be many health care workers throughout the world who 7 will stand in their debt. John H. Bryant, M.D. Chairman, Christian Medical Commission Director, School of Public Health, Columbia University PREFACE 956, after many years of training in medical insti- tutions in the USA. I returned to my birthplace to help estab- lish Christ Hospital in Kapit, Sarawak. Ninety miles from Sibu, the nearest city along the tortuous Rejang River, Kapit a village market for the 50,000 Iban people who live scattered throughout the dense jungles of this area. When we arrived, there was only very rudimentary medical care is to these people, who suffered from the preventable diseases so common in the tropics. It soon became apparent that the new hospital, if it were confined to its institutional walls, would make little dif- nce to the health of the Ibar,,;. To make available the th care that they needed meant travelling to the “long houses” where the people liv-d, teaching about good health habits, sending trained auxiliaries to aid with child-births, giving preventive inoculations and treating common diseases. The Kapit program had to be a community-oriented program rather than an institution-based Western style health care project if it was to meet local needs. Seventeen years later, in December 1972, I went to Bangkok as a Hong Kong delegate to participate in the First Asian Ecumenical Conference on the Role of Health in the Development of Nations. Delegates from fifteen Asian na- tions, most of which are classified as “developing countries”, came together to examine their common health problems and exchange ideas about possible solutions. The group was an impressive array of Asian Christians. As deans of medical schools, as secretaries for local medical associations, as direc- tors of national health and population projects and as mission medical workers, these people were deeply involved in shap- ing the future of their national health care systems. As I listened to these participants discuss and debate the issues, I began to realize how people from all over the re- gion who shared the problems that we faced in Kapit also shared the same assumptions about how these problems must be solved. Among these assumptions were: 9 1) 2) 3) 4) As Health care must not only be confined to hospitals. Heath workers must stop duplicating Western health care patterns which provide the most advanced medical technologies in large curative institutions often avail- able only to the selected few who can afford them, or to those living in the urban areas. To distribute the existing resources, community health care programs must be developed. This means building primary health care centers and emphasizing rural health care projects. Emphasis must be placed on developing the type of education and training programs necessary to meet existing local conditions. The training of medical aux- iliaries of many grades must have priority. Training must stress courses relevant to existing problems. Finally, iii’ Christian values are going to be meaningful and relevant to the future of Asian health care systems, health worker; must serve the community. As the Asian Ecumenical Conference on Development which met in Tokyo in July 1970 stated, “health is a basic human right; it is among the gifts of God to man”. If this right is to be assured, Christian health workers must commit themselves to this goal. They must be willing and able to provide health care to the people wherever they live. to the :role the Church should play in realizing these changes in the broader context, the Bangkok health con- ference recommended: “As part of the health development program, we of the Church should strive to influence Governments and other 10 Health is more than the mere absence of disease. Health is “the creation of conditions of physical, mental and social well-&zing, so that the individual and the society may realize their full potential”. In essence, this means that those involved in the delivery of health care must think of more than purely medical matters. We must understand that the goal of health is care for people and we must Iearn to respond to the needs of people as individuals. interested medical bodies to provide better health care facil- ities and better conditions of living. And as the Church could play an important role as an innovator, a motivator and a demonstrator, let Christian medical bodies endeavour to establish pilot projects on the effective delivery of health services as a model for others to emulate and to help the communities to play a meaningful and creative part in mak- ing their own lives more healthy.” In contemplating how thz Cilurch could develop such models, there was much interest in the Chinese experience in solving health problems. After all, reports on China indicated that the Chinese had implemented on a wide scale many of the suggestions discussed at the Bangkok health conference; The conference doubled my conviction that a study of the Chinese health care system 1, ‘z terms of its relevance to other countries would be a most timely and worthwhile project, After Bangkok, I am assured of the interest in this topic among Asian health workers., I hope those in other nations as well will find some useful information in this publication. L. K. Ding, M.D. Chairman, Committee on :-Iealth, Christian Conference of Asia Vice-Chairman, China Health Study Group 11 INTRODUCTION The Director of the Christian Medical Commission, Mr. James McGgvray, addressing a conference on internation- al health called by the American Medical Association in 1969 discussed four problem areas that trouble those throughout the world who are engaged in the provision of health care. I-Ie defined these problem areas as: “(1) the economic factors of health care delivery systems; (2) the present medical manpower system as an effective approach to massive epidemiological problems; (3) the di- lemma posed by what we do know about disease and what we do not know about the delivery of health care; and (4) the tensions between the clinical care of individuals and concern for the health of the community”. While very large amounts of money have been spent by both governments and voluntary groups to build and operate curative institutions, the increase of such services has failed to improve substantially the health of the people of the developing world. Mr. McGilvray suggested that one of the major reasons for the lack of adequate return on the tremendous investment of money and people in health care throughout much of the world is that the allocation of re- sources has been based on a series of faulty assumptions. These assumptions are, in brief: that more and better cura- tive facilities will assure improved general health standards (a belief that seems to ignore the fact that these expensive facilities are available only to the few); that only highly trained manpower can deliver good health care; that medical care can be independent of such activities as health educa- tion and other preventive measures; and that “disease and hospital-centered systems” are, without reservation, the most appropriate means to solve the problems of a community’s health. Decisions made on the basis of these assumptions have failed by and large to alleviate the problems; Most nations’ health care systems do not respond to the real health care needs. Mr. McGilvray’s conclusion that radical changes are called for is difficult to gainsay. 12 The issue may be approached in another way. Any person responsible for the planning of health care services or the allocation of the scarce resources in a community or a nation must ask himself three questions: 1) Who are to get the health care services? Shall it be the few (the privileged) or the many? The young or the old? 2) What kind of services are to be provided? Shall the emphasis be on the cure of the ill or the protection of the healthy? On the common or the esoteric diseases? 3) How will the services be delivered? By what combina- tion of expensive, highly qualified and para-medical personnel? By what kind of organization and institu- tions - clinics or specialist hospitals? The answers to these questions in too many countries must disturb the conscientious person, whether he be a pub- lic servant or a worker in a voluntary health care system, For all too often the answer. however complex the situation may be, can be summed up about as follows: What health . services are available are provided by highly qualified practi- tioners in increasingly expensive institutions to the relatively few who, when they fall ill, can afford to pay the price, There is throughout the world an increasing im- patience with this picture, a widespread clamour for change and a search for new models and methods. In recent months, for a variety of reasons*which in- clude the increasing availability of information, much in- terest has focused on what is happening in the People’s Republic of China. Here is an example of a radically dif- ferent approach to health care. The Chinese system empha- sizes: (1) the expansion of health care to reach the general population, with a new stress on rural areas where most of the people live; (2) the use of a broad range of auxiliaries and the retraining and integration of traditional practitioners into the system; (3) the recognition that health care is an integral part of over-all social, political and economic devel- opment; and (4) the introduction of preventive and com- munity health programs which assume that health care is 13 much more than curing diseases. The initiative for the present volume was taken by the Christian Medical Commission, a speci&zed agency of the World Council of Churches. Believing that there was need to assess the Chinese health care system to determine its relevance for other countries - f&t of all the developing countries, but the industrialized nations as well - the CMC, enlisting the administrative help of the Lutheran World Feder- ation China Study Program, requested 2 group of qualified professionals resident in Hongkong to undertake a study on its behalf. The China Health Care Study Group began its work in July 1972. It was composed of the following mem- b ers: Dr. E-H. Paterson, M.B.B.S., F.R.C.S., Me&cd Superinten- dent, United Christian Hospital, Kwuntong, Chairman; Dr. L.K. Ding, M.D., f ounder and director of the Chinese Medical Research Centre, Vice-Chairman; Richard B. Blakney, hospital administrator, United Chris- tian Hospital, Kwuntong; David Y.F. Ho, Ph.D., lecturer in psy&&gy, Hongkong University; Dr. Thomas Lee, M.B.B.S., pediatrician in Nethersole Hos- pital; Raymond L. Whitehead, Ph.D., lecturer in ethics, Chinese University; Asia Research Consultant, National Council of Churches, USA; Rhea M. Whitehead, Asia Research Consultant, National Council of Churches, USA. Susan Rifkin, research fellow in the Science Policy Research Unit, University of Sussex, England, was generously seconded by the University to serve a executive secretary of the Group and to draft this Report. The study project was financed through a generous grant from the Arbeitsgemeinschaft fzr Weltmission in Ger- many. The Group collected information from Chinese medi- cal publications, from interviews with people who had served in the Chinese medical services, and from published and oral 14 evaluations by foreign specialists who had travelled in China in the last years. Three members of the Group visited China and contributed their first-hand observations to the study. The purpose of this Report is to examine the Chinese health care system not only because of its own intrinsic interest, but especially in order to stimulate thinking about alternative solutions to the problems of health care in other countries. Therefore the various chapters treat of topics in which the Chinese experience seems to have some possible lessons for other nations. In choosing these topics, the Study Group did not wish to imply either that China has no other achievements in health care or that there. are no areas in which there have been unresolved problems. These topics simply represent those which we feel have the most interest to a broad readership. We have included as an appendix a brief description of the prevention and treatment of mental illness, a fiela in which the Chinese have developed a some- what unique approach. Each chapter +ses a series of ques- tions about the broad concern of heal?: Tare, discusses brief- ly what is known about the Chinese app;*hach to the problem and appends a document to illustrate the Chinese under- standing and response to the problem. At the beginning of this book two points should be noted. The fust is that it must be remembered that the Chinese revolution did not change society overnight. The fundamental change brought to China with the communist government in 1949 was a commitment to seek ways for the more equitable distribution of the nation’s resources. The goal approaches reality only through a slow process of continuing change. In China the pressure for change is con- stant and omnipresent. The second is that in this study we have been able to only describe the general health care policies in China and give some of the arguments why these policies are rational. We cannot fmally judge the effectiveness of the system. One reason is that at present it is impossible to obtain adequate knowledge of the health care system. It is difficult for the outside researcher to gain access to the information 15