Prof Dileep Mavalankar, Director, Indian Institute of Public Health, Gandhinagar, and Prof JK Satia, Senior Advisor, Public Health Foundation of India recommend measures that can be adopted from China’s healthcare system to improve our own health indicators
Earlier, PM Modi had invited Chinese premier to Ahmedabad and India, and now he has visited China accompanied by the CM of Gujarat and other high officials. China’s achievements have been lauded by one and all. It is the manufacturing powerhouse of the world, a great economic giant and a major military power. Besides this, China has achieved significant progress on social parameters such as education, health and equity. India is lagging far behind on these parameters. Hence, to catch up we need to learn some simple lessons from China going forward. Modi must be complemented for facilitating the India China trade relationship building efforts undertaken in one year.
Media’s focus has been on China’s economic success including large and sophisticated manufacturing, deep economic ties and significant FDI from the West. However, we want to highlight some of the basis of social change – especially improvement of the health systems that have formed the bedrock for a highly productive, intelligent and competitive society of China. This transformation started in the times of Mao Zedong (Mao Tse Tung), and continued with Deng Xiaoping and subsequent leaders.
Village level primary care
Firstly, Mao gave great importance to public health and basic medical care at the village level. China under Mao developed a formidable public health system which helped get rid of many old diseases through mass public actions. It saw improvements in water quality, sanitation, and control of snails, flies, rats and other disease-causing animals in rural areas. China also established the ‘bare foot’ doctor system where each and every village had a three-month trained health assistant who lived in that village and provided basic medical care, preventive advice and services. He was not a private practitioner who could exploit the sick but a salary-based preventive and curative health assistant employed by the village commune. Thus, for a long time in China, basic primary healthcare and treatment of simple diseases became available to all population in the rural areas. This was supported by small to medium size hospitals in townships dotted across the country. Free, universal, primary healthcare became a norm in large parts of rural China early on leading to a healthy workforce.
In India, we still do not have adequate village-level primary care service even after so many years of independence. What we have is an unwilling cadre of government employees with weak monitoring who travel from one village to another and provide some preventive care and MCH services. Only recently we have revived the village health worker concept in the form of Accredited Social Health Activists (ASHA) – originally started by Raj Narayan – taking the cue from China’s barefoot doctors, when he was the health minister. But ASHA is similar to an LIC agent working on commission-type incentives and hence focuses only on certain preventive activities. She has very limited practical training or role in curative care, which was the most attractive point of the Chinese barefoot doctor. Dissatisfied with the barefoot doctor inspired primary care system and to match global standards of care, now China has an ambitious healthcare reform plan with the goal of providing modern, affordable and equitable basic healthcare for all by 2020. The reform plan seeks to expand coverage to insure more than 90 per cent of the population, establish a national essential medicines system to meet everyone’s primary needs of medicine, improve primary care delivery systems to provide basic healthcare and to manage referrals for specialised care and hospitals, making public health services available and equal for all, and piloting public hospital reforms.
Political commitment
After the Cultural Revolution in 1977, a major thrust was given to improving and forcefully promoting family planning (FP) and population control. Much is written about China’s coercive FP programme with one child policy. What is not written about is the great political commitment to FP in China, and the very strong delivery services created for reasonable quality FP services throughout the country. This system had many family planning clinics, well-staffed and equipped to provide services to the clients in each township and extension services to each village community. I have personally seen some of these clinics and services. They were of high quality, well-staffed and available.
India’s record on family planning is variable. We, as a nation, have failed to regenerate the correct level of political commitment for providing family planning services of high quality and safety to each village and town. The extension services, called Information Education and Communication (IEC), created in 1960s was practically dismantled through neglect in India. Focus remained on numerical targets for sterilisation and to the methods which led to poor-quality sterilisation camps, deteriorated human rights (dignity) and consequent reports of infections and deaths periodically following such sterilisation camps. There is practically no effective system for quality checking and improvement in health programmes, especially as far as family planning is concerned.
Monitoring, control and discipline
The last lesson from China in health is the degree of monitoring, control and discipline maintained in their healthcare system. They keep meticulous numbers on various aspects of health programmes and monitor each and every element of services minutely. Poor performance is not tolerated. Managers are punished with transfers or dismissal if the performance is very poor. All doctors and nurses are available during office/duty hours and work for the public system. In India, we are not able to enforce such discipline from our employees. A World Bank study showed that on any given day 30 per cent of health and education department staff is not available for work when they are supposed to be on duty.
We hope that Modi and other high dignitaries pay some attention to how China has improved its health parameters. Without a healthy workforce we cannot realise the dream of Make in India.