Chinas Healthcare: from Barefoot Doctors to Current Health System - Research Paper Example

China’s healthcare: from barefoot doctors to current health system. Introduction: China’s Early Health Systems China has a very ancient civilisation which has passed down traditional forms of medicine through the centuries. This takes the form of herbs and special foodstuffs produced from local substances, and treatments like acupuncture based on knowledge systems very different from Western medicine.1 In Chinese philosophy the concept of ch’i (material force) is said to be at the basis of both hsing (body or form) and shen (spirit) and this means that Chinese ideas about health and wellbeing include both mental and physical dimensions, and imply a state of balance and harmony between the two.2 The great philosopher Confucius taught also that this harmony should be carried on in society: “For a Confucian, the meaning of life can be realised only in learning and practice through self-cultivation and self-transformation, in committing oneself to the welfare of the family, community and society.”3 Confucius taught that the family unit should look after itself, with parents caring for their children and notably also, children taking care of the health and welfare of their ageing parents.4 When the People’s Republic of China was formed in 1949 the population was mostly rural and poor, with a life expectancy at birth as low as 37 years and infant mortality of about 250 per 1,000 live births.5 Levels of literacy were low, and transport networks were very inefficient, leaving rural communities to fend for themselves as best they could without any proper healthcare at all. The communist government organized a number of central plans, and the first one, called the Five Year Plan, was started in 1950. The needs of the poorer people were very obvious, and healthcare was a key element in this plan. Four key principles were agreed for the foundation of healthcare in the second half of the twentieth century: “(i) health care should be provided to workers, farmers and soldiers by publicly owned and financed health services; (ii) health services would ‘walk on two legs’, that is, combine traditional Chinese medicine with Western medicine; (iii) give priority to public health, with emphasis on the prevention of communicable and infectious diseases and mother and child care; (iv) combine health care with mass health campaigns…”6 Progress towards these objectives was slow in the early years of the new People’s Republic, and was hampered by factors like the huge distances involved, lack of funds, and low levels of education. By 1958, however, a large number of rural health workers had been trained in short three or six month programs, and were actively meeting the frontline needs of rural populations. During the “Great Leap Forward” period from 1958-1965, there was a period of fast industrialization, but also of famine and increasing poverty, all of which did not help the people to make their local healthcare system effective. The barefoot doctor concept. These early healthcare workers were not fully trained doctors, but usually local farmers who spent about half of their time doing healthcare work, and the other half continuing with their agricultural work. They had skills more akin to a paramedic, and some training in basic infection and disease control, obstetrics, and simple surgery, and they had a specially designed manual for daily guidance.7 Because many Chinese farmers work in muddy rice paddies, these workers came to be known as “barefoot doctors” and they formed the backbone of the rural Chinese healthcare service right through until the early 1980s. A team trained additional workers called “health aides” were recruited also, and they devoted only about 10% of their time to health related activities, usually assisting the barefoot doctors in preventive activities.8 By the end of the 1960s the barefoot doctors were spreading out to the farthest corners of the country, and China had a relatively inexpensive and almost universal provision of basic healthcare. The period 1966-1976 was called the “Cultural Revolution” and had many negative consequences for the people of China. One good thing that came out of it, however, was an improvement in the training of barefoot doctors through the enforced service of highly educated doctors from urban areas, who were relocated into the countryside in order to help the poor. This was an example of Mao Ze Dong’s ideology of supporting the workers, and also a form of social engineering: “Mao was strongly opposed to creating a constituency of highly trained and politically independent professional, particularly lawyers and doctors.9 People who had been trained in Western medical knowledge were regarded as potentially disloyal to the communist ideology and this meant that they were more likely to be arrested and relocated. A negative consequence of the Cultural Revolution, however, was the difficulty that educated people had in maintaining their skills, or engaging in advanced research, and often also in continuing with essential health programs that were necessary to combat infectious diseases: “The number of practicing doctors declined from 1.05 per 1,000 inhabitants to 0.85, the number of health facilities declined by 33 per cent.”10 The goal of the barefoot doctor: to serve the people. A key feature of China’s barefoot doctor system is that it was community based, and free to the users at the point of contact. The community selected the candidates, paid for their training, integrated them into the decision making and prioritisation of community goals, and made them an important part of social and political life. The activities of the barefoot doctors included the following: “outpatient consultations, home visits, preventive health and anti-epidemic work, maternal and child health and family planning, health education, maintenance of drug supplies and other administrative affairs.”11 They were paid for these services, giving them some security and because they were selected from the local community they enjoyed good relations with the general populations, and were highly respected members of the community. Evaluation of the barefoot doctor program. The barefoot doctor program has been evaluated by many studies and the general consensus seems to be that the system was highly effective and above all suited to the special circumstances of extreme poverty in which it was born. The period between 1952 and 1982. Despite the “ten years of madness”12 that was the Cultural Revolution, saw a rise to a life expectance in China from 35 to 68 years, a decrease in infant mortality from 250 to 40 per 1000 live births, and the reduction of the prevalence of malaria from 5.5% to 0.3% of the population.13 This is an astonishing achievement, and all the more so because it was carried out by inexpensive, part-trained workers with less than two years specialized training after leaving school. Admittedly the starting point was a very low base, but nevertheless, the barefoot doctors proved that a developing country can tackle huge scale problems effectively through a combination of government direction from the top and delegation of responsibility right down to the village level. By giving ownership and modest resources to small units, working together to a big plan, the system had a clear agenda and a consistent means of making and measuring progress. The socialist culture bound people together in a joint effort to improve their health, and the barefoot doctors were the key point of delivery. Scholars who analysed the transformation of the free barefoot program into a fee based system noted that the emphasis shifted to treating existing ailments, and many of the preventive initiatives, such as immunization, were reduced or in some cases, even cancelled.14 China’s current health system. In the early 1980s when China began to open up to outside forces, and when the a freer market economy began to take effect, responsibility health care was devolved from central government agencies, which had guaranteed a free but very basic service. The result has been very mixed, with different local providers charging varying levels of fees, and providing variable services. By 1989 almost 60% of the local doctors were charging fees from their patients.15 The breaking up of the system has caused a number of inefficiencies, and a great deal of inequity, but on the other hand rising standards of living and better education on matters of health have helped to maintain levels of general health at steady levels.16 In the years since this reform was introduced, the situation for some has improved, but there is a worrying lack of coverage for large numbers of poorer people. Increasingly hospitals offer both traditional Chinese medicine and Western style medicine, but this increases costs. Those who live in the cities, and can afford health care insurance, can make use of the full range of facilities, and have the choice of the two approaches. This section of the population tends to suffer more chronic and degenerative disease, whole those who live in in rural areas, and who are generally much less wealthy, suffer more from infectious diseases.17 Employer contribution schemes are useful for supporting those in work, but they do not usually cover dependents, and in the country areas, there is no system to help pay for care. Critics observe that “this leaves the vast rural population, children, and those who are unemployed or retired uninsured.” 18 There are ethical and cultural tensions too with nurses reporting a continued pressure to participate in euthanasia and population control policies.19 It seems that much has been lost, especially in rural areas, with the disappearance of the original barefoot doctors program. References Anson, Ofra and Sun Shifang, Healthcare in Rural China: Lessons from Hebei Province. (Aldershot: Ashgate Publishing, 2005). Bloom, Gerald and Tang, Shenglan, Health care transition in urban China, (Aldershot: Ashgate Publishing, 2004). Fogarty, John E. A Barefoot Doctor’s Manual: The American Translation of the Official Chinese Paramedical Manual. (Philadelphia, PA: Running Press, 1990). Gong, You-Long and Chao, Li-Min, “The Role of Barefoot Doctors,” American Journal of Public Health 72 (1982): 59-61. Hesketh, Therese and Zhu, Wei Xing, “Health in China: The healthcare market, British Medical Journal 314 (1997): 1616-8. Hou, Ruili, “Can or should China’s Free Medical System survive?” China Today 61, No 4 (1992): 5-28. Hsiao, William C.L., “The Chinese Health Care System: Lessons for other Nations, ” Social Science and Medicine 41 No 8 (1995):1047-1055. Huang, S.M. “Transforming China’s Collective Health Care System: A Village Study,” Social Science and Medicine 27, No 9 (1988): 879-888. Hui, Edwin, “Chinese Health Care Ethics” in Harold G. Coward and Phinit Rattanakun, (eds), A cross-cultural dialogue on health care ethics, (Ontario: Wilfred Laurier University Press, 1999): 128-138. Liu, Meina; Zhang, Qiuju; Lu, Mingshan; Kwon, Churl-Su; and Quan, Hude, “Rural and Urban Disparity in Health Services Utilization in China,” Medical Care 45, No 8 (2007): 767-774. Liu, Xingzhu and Wang, Junle, “An Introduction to China’s Health Care System,” Journal of Public Health Policy 3, (1991):104-116. Lu, Henry C. Traditional Chinese Medicine: An Authoritative and Comprehensive Guide. (Laguna Beach, CA: Basic Health Publications, 2005) Pang, Samantha Mei-che, Nursing Ethics in Modern China: Conflicting Values and Competing Role Requirements, (New York: Rodopi, 2003). Smith, Christopher J., China in the Post-Utopian Age, (Boulder, CO: Westview Press, 2000). Yao, Xinzhong, An Introduction to Confucianism, (Cambridge and New York: Cambridge University Press, 2000). Read More