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Guardian www.guardian.co.tt Monday, May 30, 2016
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Over the past six decades, China
has been experimenting with radically
different forms of health care systems.
As the country struggles to figure out
the best way to get healthcare to 1.3
billion people, the rest of the world
can learn from its past successes and
failures, researchers wrote recently in
The New England Journal of Medicine
(April 2016 edition).
Back in 1949, healthcare was free to
everyone in China. The communist
state operated all clinics and hospitals,
and it employed all doctors, nurses and
Then in 1984, the government started
implementing free-market reforms.
People lost their free medical care. And
by 1999, only seven per cent of those
living in rural regions had health insur-
Hospitals began to act like for-profit
companies. Doctors and nurses were
often rewarded for increasing hospital
profits. To patients, it seemed like every-
one was just out to make a buck---or
a yuan. And the public became increas-
ingly angry and distrustful of doctors.
In 2008, the government began to
abandon a system based largely on free-
market principles and made a com-
mitment to providing affordable health
care for all by 2020. About 95 per cent
of the population had health insurance
Dr David Blumenthal, a co-author
of the NEJM commentary, spoke to
NPR about the rapid evolution of
China s healthcare system. Blumenthal
is the president of The Commonwealth
Fund, a private foundation in New York
City that supports research on health-
care issues and policies.
What projects worked well in China
and might be something for other
countries to try?
One success was using community
care workers. China pioneered what it
called "barefoot doctors." These people
were not highly trained technically, but
they received training in primary and
preventive care and maternal and child
Barefoot doctors provided health
services in rural areas at the village level
and in underserved areas. They
improved the basic health of people
living in those areas. Barefoot workers
really knew their patients. They were
their friends and neighbours.
Barefoot doctors made dramatic
improvements in the health of China.
For instance, they helped drop the
infant mortality rate in the country
from 200 per 1,000 births to 34 deaths
per 1,000 births between 1952 and
1982. Could barefoot doctors be help-
ful in developed countries, such as
The idea of community health work-
ers has gained a lot of traction in both
the developing world and in developed
countries. The idea has spread to the
point where it s no longer even con-
sidered innovative. Community health
workers, like nurse practitioners, provide
needed primary care in rural and under-
served areas in developed countries.
When China switched from universal
healthcare under communism to a
largely free market system, millions of
people were left without insurance cov-
erage. What were the consequences?
One caution that emerges from China
is that if you leave patients totally
unprotected against the cost of illness,
while at the same time organising the
delivery of services around maximum
profit, you create a very damaging cycle.
Patients feel vulnerable and increasingly
suspicious of doctors motives. The
result can be extreme public dissatis-
faction with political consequences.
How extreme was the distrust of
About ten years ago, I began hearing
stories about patients attacking their
doctors physically, even killing them.
There was civic unrest in rural areas
and riots caused by the distrust of med-
ical care and physicians.
In your letter, you say China lacks
a history and a culture of medical pro-
fessionalism. What do you mean?
In China, there has been no definition
of what the roles of healthcare profes-
sionals are compared to businessmen,
merchants and industrialists.
In the West, we tend to assume that
physicians will abide by professional
norms and standards. The standards
are self-perpetuating. They include an
appreciation of learning, a commitment
to self-improvement and a condem-
nation of taking advantage of patients
financially. Physicians, nurses and other
providers don t always live up to the
standards, but they believe in them.
They learn them in school and early in
In China, those norms and standards
didn t have a chance to develop. Con-
fucian society was followed by com-
munist society followed by capitalist
society. Professionalism wasn t given
a chance to develop in any of these
What hurdles lie ahead for China s
I do think the coverage side is going
well. But they haven t figured out how
to create a genuine primary care system.
There are village health workers, and
then there are specialists. The culture
assumes the only good care is from a
specialist in a hospital.
What China can
teach world about
YOUR DAILY HEALTH
News and Advice
Barefoot doctors acted as primary healthcare providers at the grass-roots level in China. Often they grew
their own herbs in the backyard. They were still involved in farm work, often spending as much as half of
their time on this. This meant that the rural farmers perceived them as peers and respected their advice
And it s a communist, single-
party system with corruption. The
Ministry of Health is very close to
the hospital industry, which runs
like a for-profit industry. The
industry has been successful in
limiting efforts to reform the sys-
tem. That s like pouring oil on fire.
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