Healthcare Knowledge As Catalyst For Change In China

Breath the Medcine.

Last week, the Johns Hopkins University Bloomberg School of Public Health published a study based on data from the 2008 National Health Services Survey of China, which found that falls in the home are the leading cause of injury among elderly in China.

The findings in of themselves are not the kind of thing that will make the front page of a major newspaper, but the study is an example of quite a remarkable trend.

To wit, China’s demographic data was simply not complete enough a decade ago to lend researchers the opportunity to discover trends as minute as how and where the elderly are most likely to hurt themselves.  The better we understand a society’s ills — how her people eat and live, how they die — the better we are able to contextualize the impact of governance systems and political regimes.

Just thinking out loud now…for all the talk of a Twitter revolution in Iran last summer, the power of 140 characters is only strong enough to continue fanning the flames of an already stoked fire.  A lasting movement — whether it be one of moderate ideology or something more akin to revolution — needs the power of deep-seeded ideas, and this is best done by increasing knowledge in a society.

Knowledge of healthcare is particularly well suited to the task of bringing about positive societal change.  There is the immediate benefit of such knowledge to empower individuals, families, and communities to make choices that will improve their well-being and, in some cases, considerably lengthen life.  The less obvious benefit is that developed healthcare systems and increased public awareness of public health lead to a shift in the nature of political discourse.  Regimes – democratic, tyrannical, or what have you – are forced to change because the stated and expressed priorities of the people are also now changed.

We are seeing in today’s China how a population more in tune with their healthcare needs is placing ever-louder pressure on the government to create better hospitals, clamp down on corruption in the medical fraternity, and even make the environment a littler greener.  This is not being done through a network of foreign NGO’s or through the editorials of foreign newspapers.  It is happening from the within private homes, and through dialog within Chinese families.  Knowledge has been and always will be the truest catalyst of change.


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  1. King Tubby

    Damjam. Welcome back, but your yellow tie presents major sartorial issues.

    Keeping it dead short. Sure there is a growing awareness among the middle classes in major cities. However, there is no possibility for a slightly inclusive and half decent health care system, until the political regime and system of governance is radically reorganised. The former will proceed from the latter, and not vice versa as I understand your piece.

    • Damjan

      Thank you for the welcome. It’s good to be back. My Gravatar is already in the green room changing. This past Easter the sartorial choice came down to either a yellow or pink tie….yellow won. It looked good in the sun, not so much on film.

      KTubs, you may be surprised, but I agree with your statement because our two points of view are not mutually exclusive. I will try to briefly explain why. Please take this as an incomplete answer (I don’t have the time this morning to pen a ten volume treatise) and I welcome you to continue the discussion until we’re both too tired to continue.

      Some context:

      At the onset of the People’s Republic, China took a largely hands off policy with healthcare, putting the burden on communities to fund and build their own health services. This has resulted in high levels of healthcare inequality from one community to the next, and a major rift between rural and urban health services which have become defacto distinct healthcare systems.

      While the average per-capita expenditure on healthcare in China is roughly $400 dollars per year, a half billion rural Chinese residents make do with a more modest 5-10$, while those rich enough to have private insurance, or (more typically) pay out of pocket, can spend a lot more than the $400 dollar average on a single visit to the doctor (the best of whom are increasingly working in private hospitals).

      Taking a satellite-eye’s view of the situation, China’s nation-level policy makers and healthcare engineers have two different healthcare systems to build. But as we get closer to sea level the actual task becomes more nuanced, requiring the talents of ever more and more people, provincial and local government officials and healthcare specialists. And, of course, this effort needs a lot of money. Tremendous amounts of money.

      Here, at the above water tip of the problem, is where it is tempting to say that the government needs to be massively reorganized before anything can be done, and that much more money needs to be available. What’s the point of demanding better healthcare from the government if it is organizationally impossible to coordinate the type of effort needed to bring real change around?

      Again, one has to look at what transpired sixty years ago. There remains a systemic expectation for Chinese communities to help themselves. The gears of change, in other words, are designed to move only when the people push.

      It is not too cynical to suggest that the country authority is wired in such a way to just ignore the push, or even recoil like a pit viper against it. History gives us plenty of reason to be cynical of the authority’s stated desires to better the country’s social welfare systems. But, it is also no exaggeration to say that making better healthcare available to Chinese citizens is the authority’s top domestic priority. Looking back again historically, poor health in the population has often resulted in regime change.

      Finally on the point of lessons that history imparts, it’s important to remember that just because something was doesn’t mean it will continue to be. Retrospective analysis can only get us so far.

      The sign of change I will refer to are the stated goals of just one piece of the current 900 Billion RMB healthcare reforms. In January 2010 the plan to cover all Chinese people with health insurance was (finally) kicked off. The stated guiding principles were three fold –

      (1) improve health status; (2) spread financial risk/expand insurance coverage of some type; (3) do 1 and 2 in a manner that improves satisfaction of the Chinese people with their health care and health care system.

      That third principle is the core of the matter. It indicates that the current reforms are motivated in large part by the professed needs of the Chinese people, and are not being imposed upon them by an improvisational troop of political grandstanders. The people brought them about. I am aware that the possibility exists of that principle just being another example of the previously mentioned empty talk, but several developments, too complicated to go into in depth here have me thinking that they express a genuine sentiment. (see China’s new drug list, and rural clinic reform programs for more info).

      Now, will the current reforms be perfect? Likely they won’t be even close to it. They might not even be complete. I’ve written more times than I can count on crucial missing components of the reforms like the failure of any of the programs to address misaligned doctor incentives. But, by my reckoning the reforms have already established one important result – shortening the approved drug list – and started on another, the expanding on health insurance. So far so good. If the reforms can just now follow through on establishing more medical schools, and training more healthcare workers of every ilk, then the country is well on it’s way to half-decent.

      The continued execution of the reforms, in my opinion, rests on the people’s willingness to continue pushing for better healthcare services, and this holds several order’s of magnitude more for rural areas, increasing in magnitued with each mile out from Beijing.

      If this sentiment were not to be expressed, then policy makers, who are lets not forget also politicians, would have no reason to do anything.

      • Michiel V

        Bingo! My hat off to you for such an eloquent, complete and spot-on comment. You left me speechless, so I’ll shut up now. Thankyou Damjan.

  2. I have a funny feeling that some private outfits are going reap some very interesting benefits in P.R. China in the next couple of decades in the health care/elderly care fields – if they play their cards right with the powers to be in Beijing.

    • Damjan

      Your intuition is strong. From what I’ve seen and hear, the elderly care market’s fate is tied up with the real estate market’s. I’ve written on this before and I’ll direct you there because it sums up my thoughts on when I see the boom coming –

    • Damjan DeNoble

      Your intu­ition is strong. From what I’ve seen and hear, the elderly care market’s fate is tied up with the real estate market’s. I’ve writ­ten on this before. I can’t post a link here, otherwise the site will trash my comment, but see my post on Asia Healthcare Blog called “Why long term care market in China will open up only after today’s real estate bubble pops”.

    • . . . or, China will be like the rest of the developed world and institute a national healthcare system, old folk will enjoy free-at-the-point-of-use healthcare, and the Kafkaesque nightmare that is the American system will have been safely avoided.

      • Damjan DeNoble

        Indeed. Accessible healthcare for elderly is achievable and improvements can be made now. Making drugs more affordable and making them available in rural hospitals and clinics is a good first step.

        Long-term care is another story. I fear that Kafka remains all too globally relevant there.

  3. King Tubby

    Talk about poster feedback. The yellow tie is now dogmeat and replaced with a serious grey gravitas number.

    Ah gee Damjam. I can see you signing up with the NYT.

    But seriously. I did a couple of fun teaching gigs at hospitals and the medicos and nurses had absolutely no faith in their existing system, and most declared that they would move overseas if they could get a visa. These were nice folk.

    • Damjan DeNoble

      Indeed, your comments had an immediate impact. Vanity!

      I’ve heard the same types of comments from doctors and nurses. It’s a strikingly similar story in developing healthcare systems the world over. UK and US actively recruit overseas medical professional’s to the chagrin of the professional’s home countries.

  4. pug_ster

    “Healthcare knowledge a catalyst for Change in China?”

    I’m laughing while I’m reading this. I have to admit that there are significant problems in China’s healthcare system, but I fail to see what does Healthcare knowledge have in common with political change in China.

    You said “Look­ing back again his­tor­i­cally, poor health in the pop­u­la­tion has often resulted in regime change.” Can you provide us some proof?

    Believe it or not some of the better health care systems are from those ‘tyrannical’ countries like Cuba and Iran where they provide low cost preventive care that saves them money in the long run.

    • King Tubby

      Pug_ster makes a very good point. Cuba has one of the highest percentage of doctors proportionate to total population of any country in the world. Their health system would be the envy of most countries in the world today if this fact was widely known.

      Equally, Cuba would also be a major hub in medical innovation, if not for the vicious and long-standing US trade embargo. You can thank the Miami Cuba crowd for that.

      • Damjan DeNoble

        King Tubby,

        It’s not really a point, since I’m not arguing against Cuba’s healthcare excellence, or (and I’m guessing that you both are assuming this) the Western private model’s superiority. That wasn’t even implied, and I have on many occasions argued the opposite myself.

        See comments below in reply to the healthcare-reform-related, but not above-article-related information, as added by pug_ster and now you.

        If you could formulate a response to the long one I gave you above I would be appreciate it and enjoy it a lot more than what you’re throwing me here. It’s the polite thing to do, considering I did take the time to write you…

    • Damjan DeNoble

      Cuba’s health system is rightfully known as an international success story, and Chinese healthcare leaders should (and already have) study it, applying lessons to China. In fact, I believe – and I’m in the mainstream here – that Chinese leaders should gather input from as many healthcare constructs in the world as possible. Really, if you want to call Cuba and Iran tyrannical, pug_ster, go ahead, but those countries are full of wisdom that’s applicable in the Chinese context.

      Whatever happens, and however the Chinese healthcare system starts to develop, it will be unique just like the country’s healthcare challenges. The most exciting thing about all this is that, in time, China could build a healthcare system that will be in many ways a model for the rest of the very quickly growing world. Even you have to be somewhat excited about that.

      • King Tubby

        Damjam. My Cuba comment was pointing out to Pug_ster that I dont follow any particular line: we had a collision on another site.

        Look in my neck of the woods, we have a universal healthcare system, but it has a serious cost. Maintaining hospital infrastructure and properly trained and accredited docs and nurses chews up about 25% of all tax revenue, and nobody avoids tax. People still complain that it does not deliver to its full potential.

        Sure, that is big rmb to spend on establishing a universal health insurance program, but we have to consider that it is really starting from ground zero with respect to the majority of folk – those without the financial wherewithdal to buy into expensive private insurance.

        I am not denying that this is a popular initiative and it is forcing pollies to respond at a governmental/social (****not political****) level.

        I’m just sceptical about govts ability to implement the program and actually make it work on a routine basis. The medical sector is rife with corruption and administrative nepotism, not to mention inappropriate or downright dangerous prescribing practices. Big Pharma is having a whale of a time and making a windfall profits in China.

        I could go on, but you can see that the gist of my argument is about deliverability and efficacy.

        Finally, we should all step back and not be overawed by the figure you mentioned. I no longer have the reference in favourites, but RMB spent on health and health (single digits of GDP) is totally dwarfed by massive expenditure on maintaining domestic stability.

        • Damjan DeNoble

          For a minute there, I thought that you and pug_ster had formed some sort of odd couple alliance. Thank you for the reply. Let me chew on it for a night and get back to you.

        • Damjan DeNoble

          The gist of my response is two fold. First, I don’t disagree with you. Implementation will be difficult due to the health system’s endemic: incentives for everyone involved, patients and caregivers, are misaligned and for various reasons regulation is lagging far behind implementation of new programs. However, healthcare is hard everywhere and, with 1.7 billion people and a socialized healthcare system that strives to provide subsidized services, it’s especially hard in China. Many deficiencies, therefore, are never going to be worked out. Still, I am encouraged by the comprehensive approach the the healthcare system architects have thus far taken to figuring out exactly what the healthcare needs.

          I got a chance to sit in on some great programs last summer at Beijing Medical School, where foreign healthcare system experts from around the world came to exchange ideas with China’s most promising healthcare students and current healthcare leaders. The level of openness in the dialog was remarkable. And, more importantly IMO, everyone there was aware that there were not magic stick solutions. There were disagreements as to how to go about things, and there were some heavily politicized opinions in the room that bordered on the irrational, so I’m not saying that the new leadership all across the country is panacea. I am saying that my optimism derives from what I judge to be an ever more sophisticated set of healthcare leaders. There’s a long way to go to be sure, but it’s a good thing when leaders are not trying to move forward blindly, and an even better thing when they try to move forward with a high level of knowledge.

          Second, the money figures I quoted are certainly not meant to shock and awe. The significance of that figure is that much of it is earmarked* for infrastructure investment in rural areas. Used that way it can make a big impact. That money is not used as part of an insurance pool. If it was, the impact would be minimal. I agree though, it’s all about what’s actually done, and it’s better to be skeptical than hopeful. Again though, my optimism stems from the people in charge.

          • Michiel V

            I repeat my earlier comment. I have nothing to add, because it has already been said.
            However, to help me place their comments in a (geopolitical) context, could any of you tell me:
            * King Tubby, in what part of Oz do you live?
            * Pug_ster, in what country/region do you live?
            In case anyone cares to know, I live in a T2 city in Eastern China and in-between the unavoidable BCDs I am stemmed with cautious optimism (for which I have not received 50 fen).

  5. Bai Ren

    What increased public knowledge of healthcare?
    What I see here is an article of how a western based center of knowledge production took advantage of china’s increasingly improving system of data collection to publish a study in a western journal.

    While I personally have not made the efforts to investigate the Chinese public sphere’s discussion on the causes of elderly hospitalization (and from there political change), I see nothing in this article to suggest that this is happening except for unsourced flippant remarks like “the immediate benefit of such knowledge to empower individuals, families, and communities to make choices that will improve their well-being”.

    I suspect the first benefactors of this information are those with access to the knowledge, being the economic nut that I am I’d put forward that corporations with Internet savvy staff might get wind of this first and educate the public about it through the release of new products and their accompanying PR campaigns.

    So I ask, “Where’s the 50 cents?”

Continuing the Discussion