Initiative on Philanthropy in China
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Do not quote or cite without author's permission Initiative on Philanthropy in China At the Mercy of the State: Health Philanthropy in China by Yanzhong Huang Senior Fellow for Global Health Council on Foreign Relations China Philanthropy Summit Research Center for Chinese Politics & Business and Lilly Family School of Philanthropy Indiana University Indianapolis, Indiana October 31-November 1, 2014 © Indiana University Research Center for Chinese Politics & Business and the Lilly Family School of Philanthropy Introduction Public health and healthcare issues in China have historically attracted individuals and organizations to engage China’s health sector.1 The post-Mao reform processes have triggered increasing interest in the sector by both government and non-government actors. Currently there are 11,521 registered “social organizations” and 70 registered foundations working in the health field, making the health one of the top three fields targeted by nonprofits in China.2 In 2011, medical care trails poverty alleviation and education sectors to attract 7.54 billion yuan, or 9 percent of total domestic charitable donations.3 It is also worth noting that the largest proportion of foreign NGOs’ activities in China are concentrated in the health sector (23 percent), even though health care does not command the largest share of donations from foreign NGOs.4 The growth of health philanthropy in contemporary China begets a series of questions: What is the role of the state in the development of health philanthropy in China? What functions do the health-related philanthropic actors assume in China’s health sector? How effective are they in supporting public health and healthcare activities in contemporary China? What are the limits and constraints they face in addressing China’s health challenges? To answer these questions, this working paper will first provide an overview of the evolution of health philanthropy in China. This is followed by an examination of the functions assumed by health-related philanthropic actors in contemporary China. The effectiveness of health philanthropy is assessed through a case study of the role of the Global Fund to Fight AIDS, Tuberculosis and Malaria (hereafter “The Global Fund”). The limits and constraints of health philanthropy will also be discussed. The paper concludes with a discussion of the limits of China’s health philanthropy and the constraints it faces, which hopefully will shed light on future health philanthropy in China. History of Health Philanthropy in China The health philanthropy has its historical roots in imperial China. For thousands of years, health was viewed as an individual responsibility, not the responsibility of the state. This historical norm, coupled with the state-society relations, opened space for philanthropy in imperial China. While the throne asserted control over the imperial bureaucracy, it bestowed great autonomy to social forces. The formal bureaucratic organ of the central government was only extended to the county level, below which the local society had a definite role to play.5 Local elites driven by a mix of religious and moral obligations supported and/or sponsored healthcare services for the needy. Beginning in the Ming dynasty (1368-1644), rudimentary charitable organizations such as shantang were established in some Chinese cities. In their outreach to the disadvantaged, healthcare services (i.e., distribution of medicines and the establishment of clinics) were one of the key elements of comprehensive services provided by these organizations. Still, it was not 1 Lincoln Chen, Jennifer Ryan, and Tony Saich, “Introduction,” in Ryan, Chen and Saich, eds. Philanthropy for Health in China (Bloomington, IN: Indiana University Press, 2014). 2 Ryan, Chen and Saich 2014: 5 3 NHFPC Health Development Center, September 2013, p. 18 4 Chen, Ryan, and Saich 2014: 31. 5 Tsou 1991: 270 1 until the 19th century, with the parallel development of foreign philanthropy, that health work was prized and prioritized in China’s philanthropy. The missionary movement sought to advance Christianity by providing modern medical care and education to the native Chinese. In hindsight, these missionaries-doctors seemed to be more successful in establishing health legacies in China than in their religious missions. As Xu (2011) documented, U.S. doctors of the modern missionary movement helped people in Canton establish the first hospitals of modern Western medicine, first medical and nursing schools, first public health programs, first women’ health and rights programs, and first modern charitable and philanthropic programs and organizations.6 Between 1900 and 1910, foreign missions founded 323 medical schools in China, including Peking Union Medical College.7 During the Republican period (1912-1949), health philanthropy expanded and became more secular in China. In 1936, medical education accounted for 53 percent of total U.S. educational and charitable investment in China.8 But religious inclinations continued to motive health philanthropy in China. Known as an honest, generous Christian, John D. Rockefeller believed in the importance of giving. In 1913, he created the Rockefeller Foundation, the parent organization of China Medical Board (CMB), which assumed full financial support of the Peking Union Medical College in 1915. Modeled after the Johns Hopkins University School of Medicine, PUMC quickly became the most selective medical school in China, through which modern medicine became a tool of both Chinese and foreign philanthropy.9 By the end of 1937, foreign missionaries had opened 600 clinics and established 300 hospitals with 21,000 beds, most of which offered financial support to the poor who sought care.10The Chinese doctors and nurses trained in such foreign-sponsored medical schools or healthcare institutions subsequently played a significant role in China’s medical modernization as well as in political and social reforms and revolutions. For example, Nelson Fu (Fu Lianzhang), who was a senior doctor trained at the British Christian missionary Hospital of the Gospel in Fujian Province, later became one of the founders of the post-1949 healthcare undertakings. Driven by both China’s long-term enthusiasm for medicine and its exposure to modern medicine, the Republican period also saw the proliferation of non-governmental professional organizations devoted to medical care, including the Chinese Medical Association (zhonghua yixue hui), local medical associations (yishi gonghui), and pharmaceutical associations (yaoye gonghui). During the Russo-Japanese War (1904-05), a Shanghai business leader took the initiative of establishing a Chinese Red Cross society. The organization’s medical focus allowed it to play a central role in coordinating relief centers and hospitals across Manchuria to aid more than a quarter of a million people.11 By 1934, China’s Red Cross association boasted over 120,000 members and 500 chapters.12 Yet the same period also saw the growing statist penchant of the Nationalist government. In 1943, amidst the Sino-Japanese War, the national government took over the 6 Guangqiu Xu, American Doctors in Canton: Modernization in China, 1835-1935 (Transaction Publishers 2011). 7 http://www.tcm-china.info/art/2012/11/22/art_2424_63556.html 8 http://www.tcm-china.info/art/2012/11/22/art_2424_63556.html 9 Mary Brown Bullock, An American Transplant: The Rockefeller Foundation and the Peking Union Medical College (Berkeley: University of California Press, 1980). 10 Zhang Xiulan and Zhang Lu, “Medicine with a Mission,” p. 88-9. 11 Reeves 2014: 217. 12 See Reeves 219. 2 direction of all the activities of the National Red Cross Society of China. While the War ended in 1945, the ensuing Civil War means that the Chinese Red Cross never had a chance to regain the autonomy it had enjoyed in the pre-war era.13 The founding of the People’s Republic of China in 1949 led to unprecedented state encroachment to the philanthropy sector, resulting in more than three decades of “philanthropic eclipse.”14 In a way, the communist state could be viewed as an antithesis to the imperial state. In a major departure of the historical norm, the new regime regarded the state as the sole provider of social welfare services. Meanwhile, it sought to penetrate deep into society and recreate it in its own image. PUMC was nationalized in 1951. By the late 1950s, the party-state was able to create a web of organization which “covers all Chinese society and penetrates deep into its fabric” (Schurmann 1968: 17). The new regime suppressed indigenous philanthropic organizations and absorbed domestic foundations into the state apparatus. The Chinese Red Cross not only became subordinate to the Ministry of Health but also served as a propaganda machine for the communist Party (Reeves 225). Foreign charitable organizations such as Rockefeller Foundation and CMB were forced to leave China. Indeed, China declined the offer of humanitarian aid from foreign countries and international agencies even during the devastating Tangshan earthquake in 1976. As the state co-opted and controlled social groups or eliminated them, it permeated the lowest reaches of society and dictated people’s social life, and, in return, people came to rely on the state for their social welfare and healthcare requirements.15 Post-Mao Revitalization of Health Philanthropy In the late 1970s, China began to embrace reform and opening up, which generated growing demand for health philanthropy. Single-minded pursuit of economic development