Future of China's health system lies in its own hands

The current issue of the distinguished British medical journal The Lancet - its fifth China-themed issue and one timed to coincide with the 100th anniversary of the China Medical Board - throws a harsh light on China's health challenges.

The overarching theme is basically the future of that health. Now that the country, in a remarkable run of progress in the 65 years since independence, has successfully extended life expectancy - from 40.1 years in 1950 to 76 years in 2011 - the causes of death have shifted to more closely resemble those of more high-income nations.

Those being non-communicable diseases and injuries, woes that come about from doing things that people can do something about, namely: tobacco use, alcohol abuse, bad diet and lack of exercise (add environmental pollution to the list) that lead to death from cardiovascular disease, diabetes and cancer. Call it the dark side of progress.

"China could take advantage of what has been learnt about prevention and control of non-communicable diseases and injuries," the lead study, penned by Cheng Huang, of the Department of Global Health at the Milken Institute of Public Health at George Washington University, says.

Those lessons are summarized in something called the World Health Organization's best buys - a list of affordable, feasible and cost-effective intervention strategies that can be scaled to match-up with any resource setting.

The long-term success of China's health care system, of course, will depend on the caliber and talent of the workforce China is able to crank out. While the country has the largest medical education system in the world - with 500,000 students graduating from 590 institutions in 2012 alone - there's a catch. Many of those graduates choose not to practice medicine but rather seek jobs in other industries.

Why, is a bit of mystery. The authors suggest that medical education focuses too narrowly on biomedicine and technology, teaching through rigid methods - huge classes, teacher-controlled lectures and rote memorization. All clinical training is confined to hospitals, rather than giving interns and residents exposure to community clinics or rural settings. Little wonder graduates' knowledge of primary care and prevention is limited, The Lancet editors write.

There is also the issue of violence against doctors, which can have a chilling effect on career decisions. In response to an editorial entitled Violence Against Doctors: Why China? Why now? What next?, Liu Yueju of the Third Hospital of Hebei Medical University, writes: "Why China? Because China spends only 3 percent of the world's total health expenditure on 20 percent of the world's population. Scarcity of funding is the root of the problem. The government has not spent enough money on doctors' salaries, forcing some of them to prescribe more drugs to make a living."

Investing more resources in the health care system would also bolster the New Rural Cooperative Health Insurance System, Liu argues, to manage simple diseases at the township- and country-level hospitals, thus easing the workload of doctors at provincial-level hospitals who are compelled to see as many as 100 outpatients a day, at the expense of focusing more time on their most difficult and complicated cases - the ones most likely to go off track from neglect and inflame tempers.

The special issue also includes a profile of Yan Guo, a professor of public health at Peking University Health Science Center's School of Public Health, who for years has been at the forefront of efforts to reinvent China's primary care services in remote rural areas.

Graduating from high school during the "cultural revolution" (1966-76) in the early 1970s in a small town in Hebei province outside of Beijing, Guo was sent to work in the countryside.

"Because my grandfather was a doctor, I was nominated to be a barefoot doctor in my rural community," she told The Lancet's David Holmes. She got nine months of training and went back to the community.

When the universities reopened, she applied and eventually graduated from Beijing Medical University in 1982. Her experience and research drew her attention to the disparities between maternal and infant mortality rates in the big eastern cities and the remote areas of the west, where the "rates were two or three times higher".

"We found that almost half the deaths in the western part of China happened at home or on the way to the hospital," she said. When asked why they did not go to the hospital, the main three responses were: It's too expensive, it's not necessary or it's too far away. Her research and advocacy have helped decrease and nearly eliminate the gap between rural and urban maternal mortality rates.

If China makes its health risks a priority, learns lessons from the experiences of other countries and puts its own scientific and creative resources to increase medical knowledge, the authors say, "It will provide a health model for the world".

Contact the writer at chrisdavis@chinadailyusa.com.