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

““The (Re)Emergence of The (Re)Emergence of Primary Health Care in Urban Primary Health Care in Urban

China”China”

Mark A. Strand, PhDMark A. Strand, PhDCCIH ConferenceCCIH Conference

May 2008May 2008

Learning Objectives:Learning Objectives: Grasp China’s development and Grasp China’s development and

challenges in providing primary health challenges in providing primary health carecare

Understand the balancing roles of big Understand the balancing roles of big government and small communities in government and small communities in implementing primary health care.implementing primary health care.

See the role of the Christian NGO to See the role of the Christian NGO to enhance this processenhance this process

1949 to 1980: 1949 to 1980:

80 % of urban residents covered by work 80 % of urban residents covered by work units units

90% of rural residents were covered by 90% of rural residents were covered by cooperative health planscooperative health plans

1985 to 2002: 1985 to 2002:

The health system was turned over to the The health system was turned over to the market and became dependent on fee-for-market and became dependent on fee-for-service. service.

““看病难，看病贵看病难，看病贵””

History of ChinaHistory of China’’s primary s primary health service systemhealth service system

China’s ChallengesChina’s Challenges Hypertension rate of 28.2% age 50-60 and Hypertension rate of 28.2% age 50-60 and

42.4% over age 60.  42.4% over age 60.                           Urban diabetes rates for over age 20 rose Urban diabetes rates for over age 20 rose

from 4.6% in 1996 to 6.4% in 2006. from 4.6% in 1996 to 6.4% in 2006. Public health uncoordinated and passivePublic health uncoordinated and passive With a service pop’n for our CHS of 25,000With a service pop’n for our CHS of 25,000 in in

one week our catchment area will have 1915 one week our catchment area will have 1915 disease events (2003).disease events (2003).

Tertiary hospitals expensive and relatively Tertiary hospitals expensive and relatively impersonalimpersonal

China’s ChallengesChina’s Challenges No medical records for out-patient careNo medical records for out-patient care Frequent use of ancillary tests and sales of Frequent use of ancillary tests and sales of

medsmeds Rapidly growing urban population, with a goal Rapidly growing urban population, with a goal

of 50% urban by 2020, meaning the move of of 50% urban by 2020, meaning the move of 275 million people into urban areas over the 275 million people into urban areas over the next 12 yearsnext 12 years

Urbanization resulted in loss of “community” Urbanization resulted in loss of “community” and social dislocationand social dislocation

Need to stretch limited health resourcesNeed to stretch limited health resources

Current Policy of ChinaCurrent Policy of China’’s s Primary Health Service SystemPrimary Health Service System

2003 to now2003 to nowRural: The New Rural Health cooperative Rural: The New Rural Health cooperative

began. 80% of farmers are covered now.began. 80% of farmers are covered now.

““农村合作医疗农村合作医疗””Urban: Community health system was Urban: Community health system was

started in 2006 in major cities and all cities started in 2006 in major cities and all cities should have the system in place by 2010.should have the system in place by 2010.

““城市社区卫生服务城市社区卫生服务””

Spring 2007 Jinzhong Gets Spring 2007 Jinzhong Gets GoingGoing

6 in 1 CHS6 in 1 CHS Train nurses and doctorsTrain nurses and doctors Set up clinicsSet up clinics 10 yuan per person for each served10 yuan per person for each served

CHSCHS Components Components 六为一体六为一体

1.1. Health EducationHealth Education 健康教育健康教育2.2. Disease PreventionDisease Prevention 预防预防3.3. Health MaintenanceHealth Maintenance 保健保健4.4. Medical TreatmentMedical Treatment 医疗医疗5.5. RehabilitationRehabilitation 康复康复6.6. Family PlanningFamily Planning 计生指导计生指导

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 Hospitals

CDC MCH Management Center

Two-way

referralReports

Civil Affairs

1. Health Education 1. Health Education 健康教健康教育育

Cooperated with local CHS centerCooperated with local CHS center Started with a HTN screening Started with a HTN screening Organized by community leadersOrganized by community leaders Did 3 yearsDid 3 years’’ group health education group health education Focus on chronic diseases: HTN, DM, Focus on chronic diseases: HTN, DM,

Coronary Heart disease etc.Coronary Heart disease etc. Serving church as a community Serving church as a community

membermember

Health Records Health Records 健康档案健康档案 CHS trainingCHS training First step in CHS First step in CHS

developmentdevelopment Help to understand Help to understand

situation of the situation of the families and their families and their service needsservice needs

Started in April 2007Started in April 2007 Health education Health education

opened the door opened the door Visited 2741 families Visited 2741 families

served 7035 peopleserved 7035 people

2. Disease Prevention 2. Disease Prevention 预防预防 Infectious: TB Infectious: TB

prevention prevention Chronic: HTN, DM Chronic: HTN, DM

management management

3. Health Maintenance 3. Health Maintenance 保健保健 Well Baby Project in urban nursery Well Baby Project in urban nursery

schoolsschools Could address many areas Could address many areas

4. Medical Treatment 4. Medical Treatment 医疗医疗 Family Medicine work at CHSFamily Medicine work at CHS Trained and empowered Social Trained and empowered Social

WorkersWorkers

5. Rehabilitation 5. Rehabilitation 康复康复

No work in this area yetNo work in this area yet

6. Family Planning 6. Family Planning 计生指导计生指导

Still functioning tightly under the Still functioning tightly under the Family Planning CommissionFamily Planning Commission

Health SystemsHealth Systems

Significant gapSignificant gap Little accountabilityLittle accountability What are some example nations?What are some example nations?

Weak Government

SystemLarge NGO Systems

Health SystemsHealth Systems Large gap, limited communicationLarge gap, limited communication NGOs struggle for spaceNGOs struggle for space NGOs serve a small populationNGOs serve a small population Limited NGO impactLimited NGO impact Big Government

Small and weak

NGO

Health SystemsHealth Systems Government is strong, and Government is strong, and

responsibleresponsible NGOs are small but effectiveNGOs are small but effective For responsibility and sustained For responsibility and sustained

impact NGOs in strong overlap with impact NGOs in strong overlap with governmentgovernment Large, Responsible

Government

Small but strong NGO

Serving population

Impacting thesystem

Regularly visits with government bureaus Regularly visits with government bureaus Look at newspapers, TV news, internet to Look at newspapers, TV news, internet to

understand changes and opportunitiesunderstand changes and opportunities Talk with partners to understand opportunities and Talk with partners to understand opportunities and

to find someone with a vision and passion for the to find someone with a vision and passion for the work you are interested inwork you are interested in

Have your local staff participate in local Have your local staff participate in local government training opportunities.government training opportunities.

Do research in the community about local health Do research in the community about local health issues important to the people and the government.issues important to the people and the government.

Engaging the Government Engaging the Government SystemSystem

ChallengesChallenges Transitioning from a medical to a CH perspectiveTransitioning from a medical to a CH perspective Clinical work with weak connection to community Clinical work with weak connection to community

health outreachhealth outreach Govt motivated, so it has support, but under Govt motivated, so it has support, but under

compulsioncompulsion Community participation is limited, but the argument is Community participation is limited, but the argument is

made that urgency precludes community involvement. made that urgency precludes community involvement. Will this threaten the sustainability and depth of the Will this threaten the sustainability and depth of the model in the years to come?model in the years to come?

China’s ability to openly embrace a daunting challenge China’s ability to openly embrace a daunting challenge is impressive. is impressive.

Through political will, and the talents of 1000s of Through political will, and the talents of 1000s of flexible Chinese medical workers, it is coming to pass. flexible Chinese medical workers, it is coming to pass.

Has to happen overnight, compromising qualityHas to happen overnight, compromising quality

No community council yetNo community council yet It is a privilege to be involved at this level, It is a privilege to be involved at this level,

as a public witness for Christ. But it is not as a public witness for Christ. But it is not easy to bring the church into community easy to bring the church into community service.service.

We prioritize both skills and the spirit of We prioritize both skills and the spirit of PHC, which flows from a Christian spirit of PHC, which flows from a Christian spirit of love and sacrificelove and sacrifice

““Christian Community and Wholeness” Christian Community and Wholeness”

CCIH conference theme.CCIH conference theme.

Recent home visit outing, mother with TB

ConclusionsConclusions 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 Implementation of the Community Health

Service Model may avert a primary health Service Model may avert a primary health care disaster in China. care disaster in China.

This development has the potential of This development has the potential of (re)establishing China as a global leader in (re)establishing China as a global leader in cost-effective primary health care delivery cost-effective primary health care delivery for developing nations. for developing nations.