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

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

2. Learning Objectives: • 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. • See the role of the Christian NGO to enhance this process

3. History of China’s primary health service system • 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”

4. China’s Challenges • Hypertension rate of 28.2% age 50-60 and 42.4% over age 60.   • Urban diabetes rates for over age 20 rose from 4.6% in 1996 to 6.4% in 2006. • Public health uncoordinated and passive • With a service pop’n for our CHS of 25,000in one week our catchment area will have 1915 disease events (2003). • Tertiary hospitals expensive and relatively impersonal

5. China’s Challenges • No medical records for out-patient care • 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 • Urbanization resulted in loss of “community” and social dislocation • Need to stretch limited health resources

6. 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 2010. “城市社区卫生服务”

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

8. CHS Components 六为一体 • Health Education 健康教育 • Disease Prevention 预防 • Health Maintenance 保健 • Medical Treatment 医疗 • Rehabilitation 康复 • Family Planning 计生指导

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

10. Urban Community Health (CHS) System 城市医疗卫生服务体系框 综合 医院 专科医院 疾控中心 妇幼保健中心 卫生监督中心 Hospitals & Specialized Hospitals CDC MCH Management Center Two-way referral Consulting and training Reports Community Health Center 社区卫生服务中心 Clinics 诊所 CHS Station 社区卫生服务站 Nursing homes 护理院 Other Civil Affairs

11. 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

12. 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

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

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

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

16. 5. Rehabilitation 康复 • No work in this area yet

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

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

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

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

21. Engaging the Government 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.

22. Challenges • Transitioning from a medical to a CH perspective • Clinical work with weak connection to community health outreach • 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? • 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. • Has to happen overnight, compromising quality

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

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

25. Conclusions • Political will is essential. ICDP was difficult. • While now our work is smooth. • 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.