“The (Re)Emergence of Primary Health Care in Urban China” Mark A. Strand, PhD CCIH Conference May 2008

Learning Objectives: Grasp China’s development and challenges in providing primary health care Grasp China’s development and challenges in providing primary health care Understand the balancing roles of big government and small communities in implementing primary health care. Understand the balancing roles of big government and small communities in implementing primary health care. See the role of the Christian NGO to enhance this process See the role of the Christian NGO to enhance this process

 1949 to 1980: 80 % of urban residents covered by work units 90% of rural residents were covered by cooperative health plans  1985 to 2002: The health system was turned over to the market and became dependent on fee-for-service. “ 看病难，看病贵 ” History of China ’ s primary health service system History of China ’ s primary health service system

China’s Challenges Hypertension rate of 28.2% age and 42.4% over age 60. Hypertension rate of 28.2% age and 42.4% over age 60. Urban diabetes rates for over age 20 rose from 4.6% in 1996 to 6.4% in Urban diabetes rates for over age 20 rose from 4.6% in 1996 to 6.4% in Public health uncoordinated and passive Public health uncoordinated and passive With a service pop’n for our CHS of 25,000 in one week our catchment area will have 1915 disease events (2003). With a service pop’n for our CHS of 25,000 in one week our catchment area will have 1915 disease events (2003). Tertiary hospitals expensive and relatively impersonal Tertiary hospitals expensive and relatively impersonal

China’s Challenges No medical records for out-patient care No medical records for out-patient care Frequent use of ancillary tests and sales of meds Frequent use of ancillary tests and sales of meds Rapidly growing urban population, with a goal of 50% urban by 2020, meaning the move of 275 million people into urban areas over the next 12 years Rapidly growing urban population, with a goal of 50% urban by 2020, meaning the move of 275 million people into urban areas over the next 12 years Urbanization resulted in loss of “community” and social dislocation Urbanization resulted in loss of “community” and social dislocation Need to stretch limited health resources Need to stretch limited health resources

Current Policy of China ’ s Primary Health Service System  2003 to now Rural: The New Rural Health cooperative began. 80% of farmers are covered now. “ 农村合作医疗 ” Urban: Community health system was started in 2006 in major cities and all cities should have the system in place by “ 城市社区卫生服务 ”

Spring 2007 Jinzhong Gets Going 6 in 1 CHS 6 in 1 CHS Train nurses and doctors Train nurses and doctors Set up clinics Set up clinics 10 yuan per person for each served 10 yuan per person for each served

CHS Components 六为一体 1. Health Education 健康教育 2. Disease Prevention 预防 3. Health Maintenance 保健 4. Medical Treatment 医疗 5. Rehabilitation 康复 6. Family Planning 计生指导

Rehab Welcome Lobby ( 咨询、接待、挂号、收费） Health Records 中西药房 全科诊室 （慢病管 理） 中医诊室 Prevention （慢病管理） 治疗 （注射， 输液， 观察） Clinical Services Public Health Services 医技诊室 （放射，超 声，检验） Health Ed. H. Main. F.P. The Community Rehab

Community Health Center 社区卫生服务中心 CHS Station 社区卫生服务 站 Clinics 诊所 Nursing homes 护理院 综合 医院 专科 医院 疾控 中心 妇幼保 健中心 卫生 监 督 中心 Consulting and training Other Urban Community Health (CHS) System 城市医疗卫生服务体系框 Hospitals & Specialized HospitalsCDC MCH Management Center Two-way referral Reports Civil Affairs

1. Health Education 健康教育  Cooperated with local CHS center  Started with a HTN screening  Organized by community leaders  Did 3 years ’ group health education  Focus on chronic diseases: HTN, DM, Coronary Heart disease etc.  Serving church as a community member

Health Records 健康档案  CHS training  First step in CHS development  Help to understand situation of the families and their service needs  Started in April 2007  Health education opened the door  Visited 2741 families served 7035 people

2. Disease Prevention 预防  Infectious: TB prevention  Chronic: HTN, DM management

3. Health Maintenance 保健  Well Baby Project in urban nursery schools  Could address many areas

4. Medical Treatment 医疗  Family Medicine work at CHS  Trained and empowered Social Workers

5. Rehabilitation 康复  No work in this area yet

6. Family Planning 计生指导  Still functioning tightly under the Family Planning Commission

Health Systems Significant gap Significant gap Little accountability Little accountability What are some example nations? What are some example nations? Weak Government System Large NGO Systems

Health Systems Large gap, limited communication Large gap, limited communication NGOs struggle for space NGOs struggle for space NGOs serve a small population NGOs serve a small population Limited NGO impact Limited NGO impact Big Government Small and weak NGO

Health Systems Government is strong, and responsible Government is strong, and responsible NGOs are small but effective NGOs are small but effective For responsibility and sustained impact NGOs in strong overlap with government For responsibility and sustained impact NGOs in strong overlap with government Large, Responsible Government Small but strong NGO Serving population Impacting the system

 Regularly visits with government bureaus  Look at newspapers, TV news, internet to understand changes and opportunities  Talk with partners to understand opportunities and to find someone with a vision and passion for the work you are interested in  Have your local staff participate in local government training opportunities.  Do research in the community about local health issues important to the people and the government. Engaging the Government System

Challenges Transitioning from a medical to a CH perspective Transitioning from a medical to a CH perspective Clinical work with weak connection to community health outreach Clinical work with weak connection to community health outreach Govt motivated, so it has support, but under compulsion Govt motivated, so it has support, but under compulsion Community participation is limited, but the argument is made that urgency precludes community involvement. Will this threaten the sustainability and depth of the model in the years to come? Community participation is limited, but the argument is made that urgency precludes community involvement. Will this threaten the sustainability and depth of the model in the years to come? China’s ability to openly embrace a daunting challenge is impressive. China’s ability to openly embrace a daunting challenge is impressive. Through political will, and the talents of 1000s of flexible Chinese medical workers, it is coming to pass. Through political will, and the talents of 1000s of flexible Chinese medical workers, it is coming to pass. Has to happen overnight, compromising quality Has to happen overnight, compromising quality

No community council yet No community council yet It is a privilege to be involved at this level, as a public witness for Christ. But it is not easy to bring the church into community service. It is a privilege to be involved at this level, as a public witness for Christ. But it is not easy to bring the church into community service. We prioritize both skills and the spirit of PHC, which flows from a Christian spirit of love and sacrifice We prioritize both skills and the spirit of PHC, which flows from a Christian spirit of love and sacrifice

“Christian Community and Wholeness” CCIH conference theme. Recent home visit outing, mother with TB

Conclusions Political will is essential. ICDP was difficult. Political will is essential. ICDP was difficult. While now our work is smooth. While now our work is smooth. Implementation of the Community Health Service Model may avert a primary health care disaster in China. Implementation of the Community Health Service Model may avert a primary health care disaster in China. This development has the potential of (re)establishing China as a global leader in cost-effective primary health care delivery for developing nations. This development has the potential of (re)establishing China as a global leader in cost-effective primary health care delivery for developing nations.