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Health Care in China After Mao by Allen Dobson

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Health Care in China After Mao by Allen Dobson Health Care In China After Mao by Allen Dobson This article summarizes observations made by the author dur­ ing a recent trip to China and compares these views to those of other observers over the past decade. The discussion is undoubt­ edly influenced by the Chinese tendency to speak in terms of the ideal rather than what exists. It was often difficult to sort out "what is" from "what ought to be," even though our hosts appeared very candid, and, for the most part, our observations confirmed what we were told. Interpretation of observations is also colored by China's new surge of leadership, which causes health care policies to be in a continual state of transition. This makes any paper on contem­ porary Chinese health care somewhat outdated by the time it is published. However, there appear to be larger concerns reflecting basic Chinese attitudes toward health care that have evolved dur­ ing the post "Liberation" period and which underlie day-to-day policy fluctuations. The analysis which follows attempts to isolate basic trends from more transitory events to clarify the essential aspects of Chinese health care policy. Introduction of health care financing issues closes the discussion on access to health care. During November and December of 1979, the National Family planning is next introduced as a separate topic, Health Policy Forum, a non-profit group affiliated with because of its importance to Chinese social policy. A George Washington University, sponsored a health study broader discussion of prevention and public health tour of the People's Republic of China. Because the tour issues follows. The final topic is the collection of health group was composed of health care professionals, the care statistics and measurements of health status. The Chinese International Travel Service guided the group paper concludes with an assessment of China's health through six cities, allowing them to observe first hand care accomplishments and speculation about future numerous health-related activities. The group visited the health care dilemmas. following cities: Peking, the capital; Tsinan, a northern industrial city of about one million; Chu Fu, the rural Chinese Health Care Policy: birth place of Confucius just opened to western ob­ servers; Sou-Chow, a city of silk and canals; Shanghai, The Development Of Political Mandates one of the largest cities in the world; and Canton, a sub­ tropical city located 1,500 miles south of Peking. The This article diverges from recent reports on Chinese group visited medical schools in Peking and Tsinan, a health care in that it reports much less political influence traditional teaching hospital in Shanghai, and residential, on day-to-day health care activities. Health care in China communal, and industrial health clinics in several cities. is now in a state of transition from the institutional chaos We also met with provincial level Ministry of Public brought on by the Great Proletarian Cultural Revolution Health officials in Canton and had numerous other (GPCR) of the mid-1960s to the institutional rebuilding opportunities to observe health care as practiced in the and technological advancement called for by China's People's Republic of China. new leaders. This article explores several aspects of the Chinese Health care in China has been an important political health care delivery system. It begins with overviews of issue since the "Liberation" in 1949. Health care was par­ the issues which constitute contemporary Chinese health ticularly important to the founders of the Chinese Com­ care policy and the planning process which guides the munist Party because of the dismal conditions which health care delivery system. I then discuss Chinese phy­ prevailed before Liberation and the experiences and sicians in terms of their training, placement, and philosophies they acquired during the War of Liberation. research activities and contrast traditional Chinese medi­ Chairman Mao Tse-Tung's early interest in health was cal practices to those of Western medicine. The text then primarily related to rural areas and peasants. His gui­ turns to "barefoot doctors" and their provision of primary dance to the National Health Congress in 1950 was fre­ health care services. A discussion of access and conti­ quently quoted to us as constituting the basic political nuity of care follows, indicating the extent to which basic tenets of contemporary Chinese health care policy. In health care objectives have been achieved. An analysis this early guidance Mao indicated the following: HEALTH CARE FINANCING REVIEW/WINTER 1981 41 • Medicine should serve the workers, peasants, and ganda. Chang (1978) indicates that the process of "de­ soldiers. politicalization" was initiated after Mao's death in 1976 • Preventive medicine should be emphasized. by China's new leaders. Health affairs in China are thus • Chinese traditional medicine should be integrated dominated by the transition from political concerns to with Western medicine. rebuilding an effective health bureaucracy and an • Mass movements should be an integral part of Chi­ expanded delivery system through systematic planning. na's health care. The Planning Process These themes were reiterated and expanded upon by The policy and planning apparatus currently carries Mao in the mid-1960s during the GPCR. When we asked out Mao's and now Hua's and Zhao's directives in only what goals China has set for health care in the 1980s, we the most general sense.1 It makes decisions concerning were informed of the "Four Modernizations." This pro­ capital construction, determines production quotas for gram, made public by Chou Enlai in 1975, proposed medical personnel, decides research priorities, handles modernizing China in the areas of (1) agriculture, (2) emergencies, and deals with preventive and environmen­ industry, (3) science and technology, and (4) national tal issues. Planning horizons vary from one to five years, defense by the year 2000. Chairman Hua Guofeng again depending on the complexity of the issues. asserted these principles in 1978 (Prybyla, 1980). While Health policy in China is directed by the leaders of the they are only indirectly related to health care, the Four Chinese Communist Party and refined and planned in Modernizations set the tone for modernization in all sec­ detail by various levels of an extensive bureaucracy tors of the economy. Indeed, not only were the goals of headed by the Ministry of Public Health (Wei-Sheng-Pu). the Four Modernizations prominantly exhibited on large It extends down to all administrative divisions.2 In this billboards at busy intersections in the urban cities we sense the current Chinese planning system is much like visited, but our guides and hosts constantly reminded us that of the U.S., in that a multi-layered governmental of them. structure is called upon to resolve and implement Because residual effects of the GPCR are still evident national health care policy (for instance, our Medicaid in China, understanding current Chinese health care pol­ program). icy goals and objectives requires an exploration of the Oksenberg (1974) notes that the Ministry of Public GPCR's impact on the formulation of China's health care Health in the early 1970s was composed of line bureaus policy over the last 30 years. The GPCR fostered dealing with medical education, medical treatment and debates concerning the role of science and intellectuals, prevention, traditional medicine, maternal and child the nature of social equity, and the impact of existing health, pharmaceutical control, the medical equipment urban-rural resource allocation policies. While medicine industry, and control of schistosomiasis. The Sidels was not the central issue, it was clearly related to the (1974) indicate that early Chinese policy was heavily debates. Up to this point, the Chinese Ministry of Public influenced by Soviet models of health care. This was not Health had attempted to develop secondary and tertiary emphasized during our trip, presumably because of health care activities in urban areas which would support Sino-Soviet discord. Lampton (1977) states that the Min­ primary health care activities in rural areas. For numer­ istry of Public Health contained "at least" a dozen ous political and philosophical reasons, Mao took vigor­ bureaus centrally in Peking, with corresponding struc­ ous exception to this policy as part of his strategy to tures in provinces and counties. Since we were given no develop the GPCR and regain control of China's political organizational charts, the exact structure of the Ministry and social development. In June 1965, the Ministry of of Public Health was difficult to determine.3 Ching (1980) Public Health was openly criticized by Mao, when he observes that knowledge of departments and divisions of referred to the Ministry as the "Ministry of Urban Gen­ major ministries is not widespread. While we could not tlemen's Health" and said that "the more books one determine its exact organizational structure, it appeared reads the more stupid one becomes" (Lampton, 1977). that the Ministry is strengthening its intellectual role and Approximately 80 percent of the Chinese population that technical decision-making (as opposed to the resides in rural areas. During the GPCR, the relationship GPCR's political decision-making) is emerging as a key between urban and rural distributions of resources and planning technique. political power was re-examined. As a result, policies related to rural health were either newly developed or re­ emphasized. The GPCR's agenda included the use of mobile medical teams, an increased emphasis on preven­ 1During September 1980, Chairman Hua confirmed that he tive services, the development of auxiliary medical per­ would relinquish his role as Prime Minister (separate from his sonnel from local populations, a questioning of medical role as Party Chairman) and that his successor would be Zhao training policies and intellectuals in general, the in­ Ziyang, a man noted for his innovative experiments with eco­ creased use of mass campaigns, a rehewed interest in nomic profit incentives and decentralization.
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