China is undergoing a radical shift in its health policy towards the poorest, particularly in rural areas, and research is playing a major role. Here Gerald Bloom, visiting Professor at Beijing Normal University, co-chair of the China Health Development Forum, and Fellow of the Institute of Development Studies in Sussex, UK, tells the story, with lessons for the world about the relation between research and policy-making.
>RHN: You’ve been working on health reform in China since the 1990s, and participated in a major project to improve health care in rural China. Over the last few years, China has begun a significant shift in health policy and action, particularly towards the rural areas, with increased government spending. How did that policy arise?
GB: People have been publishing papers for a long time on the difficulties that arose in China during the transition to a market economy, with people having difficulty getting access, with the cost of health care rising – and that hospitals or health workers have incentives for selling drugs [to improve their income]. That evidence has been building for a long time.
>RHN: With research from many sources.
GB: Well, both research and, if people visited rural areas, they heard it. It started slowly, and it’s been building.
>RHN: The government was already making statements of concern about the problems in the 1990s, wasn’t it?
GB: Well, at that time it was mainly at the level of Ministry of Health, not at Prime Ministerial level – which it’s now reached. But yes, people were acknowledging the issues and problems.
“There’s a challenge in identifying a problem: if you don’t have a practical solution, senior policy makers find it difficult to know how to respond.”
But there’s a challenge in identifying a problem: if you don’t have a practical solution, senior policy makers find it difficult to know how to respond. And for many reasons there were plenty of debates, plenty of worries, but there wasn’t a clear solution. The Chinese situation is very complex. For example, what could policy-makers do about the fact that during the Cultural Revolution in the 1970s, many people got jobs who hadn’t been trained, and, certainly couldn’t be fired?
>RHN: The bare-foot doctors.
GB: More than that. Medical schools were closed for a time. But people still got jobs, they learned on their job and did some decent work, and by the 1990s, they had 20 years’ experience, they’d given a fair part of their life to health work. It wasn’t their fault they didn’t have wonderful training.
But that created enormous constraints, and enormous political problems. And that’s just one example of whole sets of problems the government faced, way beyond what we might call health policy. From a senior policy maker’s point of view, the problems were slowly becoming obvious, but the solutions were not in the least bit obvious.
>RHN: From 1997 to 2007, you were a member of the core supervision team in a major project on health in China, the Health VIII Project supported by the World Bank. Could you tell us about that?
GB: Well it was one of the government’s ways of testing some reform strategies.
>RHN: Government in the sense of the Ministry of Health?
GB: Well, since the World Bank was involved, it was the Ministry of Health with strong support from Ministry of Finance.
>RHN: So the health problems seem to be moving up the political agenda, at that point.
“This was the first World Bank project that wasn’t either a specific disease program, or focussing on a particular aspect of the health system…. Ultimately, it was implemented in more than 90 poor counties.”
GB: Well, in 1996 there was already a big national meeting on the issues, which meant there was already an acknowledgement that there were problems in both urban and rural areas. This was the first World Bank project that wasn’t either a specific disease program, or focussing on a particular aspect of the health system. I think there was an acknowledgement, by that time, that the problems were systemic and a project was designed to attempt system reform. Ultimately, it was implemented in more than 90 poor counties.
The Chinese took the lead. There were plenty of negotiations between Ministry of Health and Ministry of Finance, Ministry of Planning, and, of course, the World Bank also had views, and so the final design was a negotiated compromise.
The Chinese system is highly devolved, and in major health system reform what you’re asking local governments in poor areas to do is to manage a fairly substantial change process.
The World Bank project was a loan, which in the Chinese system was on-lent by central government to poor counties. They had plenty of incentives not to spend this money on technical assistance, so DFID came in a year or so later and, essentially, gave support for additional Chinese technical assistance.
One thing that became clear in the project was that to enable people to try out major changes, it was extremely important to have a pretty substantial and well organised supervision, as well as access to training and access to troubleshooting and support.
>RHN: What lessons did you learn for research for policy-making in times of such rapid transition?
GB: Where things are changing very fast, people have to be enabled to experiment with new ways of doing things. And government needs to build in some capacity to assess what works and what doesn’t. If it is dealing with poor areas it wants innovation in a context of major constraints in human resources and it needs to provide ways to help people try new things.
I think researchers need to link to where the new things are being tried. Research that documents the problems was useful in China, there’s no doubt it’s been useful.
The research alerted senior policy makers and, ultimately, the most senior people said, ‘there is a problem here, and something needs to be done’. But that doesn’t bring a solution – and it frightens policy makers.
So for policy makers to act they have to see there’s a big problem, but they also have to see there’s a way forward. They need more than a vision of a future health system. They need a realistic understanding of the next steps and of potential problems that might arise from alternative reform options.
I think what Health VIII demonstrated is you need to bring good researchers and program managers together with local people who are implementing change, and help with the implementation of that change, and as much as you can, get some systematic evidence on what works and what doesn’t.
The project managers made substantial efforts in the latter phases of the project to gather evidence of its impact and to summarise key lessons for future reform efforts.
Some of the project experts were researchers and some were managers. The problem for the researchers was to find ways to work with local people to help them solve problems in a very practical way – and to derive lessons from this experience for other people.
>RHN: You seem to be talking about a kind of “science with sympathy” for managers and politicians, and their need for management and political judgement.
GB: Well, when I was on one Health Eight supervision mission, at one point we visited a city, which is the next level up from a county, and we met the Deputy Mayor, and his analysis of the project was what he called ‘the three imbalances’, and I found that helpful.
One imbalance was between what he called the ‘old command economy style’ and the market; and by that he meant the need for people in the health facilities actively to go out and seek patients [to make more income], rather than wait for them to come.
Another imbalance was between what he called hardware and software, which was really between buildings and systems.
All these things were known to us. But the third imbalance was a very interesting one: it was between the perception and understanding of people at the centre, and of those locally. And my understanding of that, was that people at the centre have new ideas, and can think through what the future might look like, but local people are very used to clever ideas coming, some work and it’s great, and some don’t and then you’re the one that’s blamed – and so they tend to take, in some ways, a more conservative view – or a view more grounded in the real circumstances.
“These people need ways to solve their problems. And it’s that clash between new ideas, some from abroad, some just from rapidly developing areas, and local people who actually are managing change, that is the productive one.”
These people need ways to solve their problems. And it’s that clash between new ideas, some from abroad, some just from rapidly developing areas, and local people who actually are managing change, that is the productive one.
>RHN: There’s also a problem in the rapidity of change itself, isn’t there? You can’t really do solid, objective science when external factors are changing so rapidly; you don’t quite know what’s the cause of the effect that you see. But that’s inevitable in those circumstances, I suppose.
GB: I think the message there is that any illusion we have that a highly studied model from the UK or elsewhere can be applied immediately to a very different environment, is misguided.
Also, the management of change is the most difficult thing to do, but I’m not sure I would say it’s not scientific, or doesn’t need science; it just needs quite good researchers who can pick up what are the big constraints, and look at ways of overcoming them. Even more important is the need to document what works and try to explain why it works.
>RHN: You are also talking about a way of increasing the scientific culture within management, aren’t you? It’s blending the two disciplines.
GB: Well, that’s one way of looking at it. It’s accepting that we don’t have perfect models for health systems, but we have to find effective ways of solving problems and adapting to new circumstances, for every different endeavour.
>RHN: When you compare with the separation in the West between the worlds of management or policy making, and academic research, there doesn’t seem to be much overlap, does there?
GB: I live in England. It’s changed a bit, but when I first went to China, in the early 1990s, a crane at a building site was a very rare sight. At that time, one quarter of the world’s cranes were in Shanghai. I recall a conversation in China with a colleague – we were in a taxi and a bit lost, and I said, oh, what about satellite navigation? And he said, it’s impossible, here in the cities, because the roads are changing so fast!
In the UK we are used to research and policy making in a slowly changing environment, and our thoughts about research and its influence on policy largely concerns what we might call ‘fine-tuning’. Our National Health System was built in a few years, in a period of rapid change, but that was a long time ago. Well, what’s happening in China is they can’t use satellite navigation even to drive around their cities, because they’re changing so quickly.
So, yes, they are managing change, they’re not managing a static situation, and that’s a very different management problem. A lot of companies now talk about the big difference between managing change in response to changing realities and business as usual.
>RHN: What is the relationship between researchers and policy makers like in China? If I ask the kind of obvious, Western question: look at the way the Chinese political system treats the media and journalists with a great deal of suspicion and control. Then think of researchers’ independent research and publishing, potentially, critical material, and you’d imagine that researchers would be also under the same suspicious eye. Are there any difficulties?
GB: I don’t really know the answer to that question, but this is clearly a major challenge. There is rapid change in China. In rapid change good things happen, and many stresses and bad things happen. If senior policy makers don’t have access to knowledge when things go wrong, then things can go very wrong.
So on one level policy makers desperately need access to knowledge. But, of course, worldwide, and I am sure in China, there’s always the problem of the bringer of bad news. I, personally, do not know where these boundaries are in the health sector and how it works, but I am sure that there are issues there.
>RHN: In 2005, two well-connected government health researchers in China, Ge Yanfeng and Gong Sen, published a widely publicised document that highlighted problems in the health system. Where did that come from? Is this something that’s connected to the Prime Ministerial level, now, so we’re going up one level in government?
READ ON: For stories related to this report and its follow-up, search for “Ge Yanfeng” on the official news service.
The report is published in English as Ge Yanfeng and Gong Sen: An Evaluation of and Recommendations on the Reforms of the Health System in China (Beijing: Project Team of the Development Research Center, 2005), 400 pp: China Development Review (Supplement), 7(1): 1-259 (2005).
GB: Well, they are in the Development and Research Centre of the State Council, which does report to Prime Ministerial level. I don’t know the details of why they decided to do the study, but, essentially, they pulled together reports that had already been written, and synthesised the findings, as – let’s call it – a situation analysis for senior policy makers. And they certainly identified that it wasn’t possible just to keep going along the same route.
They reported that there were serious problems and that they were, potentially, getting worse. And, I guess, what’s important is that a year or two before, there was a major change in government priorities, in favour of giving more attention to problems of poverty, or of making sure that development was more inclusive, and, explicitly, paying more attention to the health sector. So already, by the early 2000s, government at a fairly high level was commenting on the importance of health reform.
And then there was the SARS epidemic and, it just so happens, that the city most affected was Beijing, where all the senior bureaucrats live, as well as the senior politicians.
So everyone, in their daily life, when they couldn’t fly around the country, and where there were all sorts of controls, even in moving around the city, became very aware of the importance of an effective health system. And at that point, the Deputy Prime Minister was seconded to be Minister of Health, for a time.
>RHN: So SARS, itself, might have had an impact on the increased attention to health?
GB: It was important – in a very personal way, drawing attention to people, the consequences of a breakdown in public health system. And people recognised that, if individuals had to pay a lot of money for health care, there were big incentives on them to conceal if they had a fever. So it was very clear and very obvious to everyone that public health was important. And that, obviously, changed the perceptions of policy makers, and, I guess, made them much more open to understanding the seriousness of the problems that were emerging.
So then, basically, the findings that had been collected for years were synthesised by that team of Ge and Gong, working at a very high level.
>RHN: But the conclusions of the Ge and Gong report are very striking. China Daily for example said that the report said that a ‘business and market orientation of the medical and health system is absolutely wrong, and conflicts with the proper goal of public health’. That’s a pretty extreme statement for a government that in general embraces the market system. Is that what they concluded?
GB: I think one has to be very careful in trying to pick your way through rhetoric. On the one hand, almost all rural health facilities are government owned; on the other hand, they generate most of their revenue from user charges. As China has moved towards the construction of a market economy the creation of an effective regulatory system has lagged behind. Their report pointed out what happens in a highly unregulated market. It emphasises the need for government to take responsibility for the performance of the health system both in terms of finance and regulation. But what form that will take, I think, is still, very much, being debated.
>RHN: So what does work? To go back to the Health VIII study that the World Bank supported, what would you say were the conclusions from that? Did that give China some guidelines as to what it can do?
“In the project, maternal mortality fell by 40% in eight years, which is quite striking.”
GB: Well, I can certainly say what happened with maternal health, where, in the project, maternal mortality fell by 40% in eight years, which is quite striking. Maternal health is unusual, in that there is a chain of maternal and child health centres, extending right from the centre down to county level.
>RHN: Centres that existed before the intervention?
GB: They did. Independent of the project, the government had announced a priority for reducing maternal mortality, and started to require these centres to do mortality reviews, and to encourage deliveries in hospital. This was something where you could set clear targets. It’s more difficult for other things, but they set clear targets, and they monitored performance.
>RHN: What were the main causes of maternal mortality the intervention had an impact upon? Were they to do with obstructed labour, or were they to do with infection, or to do with mothers not even going to the clinic?
GB: I don’t have the exact figures, but before the intervention in many counties 20% of women gave birth in health facilities. Early on, we visited health facilities and people would say, oh, there are cultural resistances to change. But, actually, the facility was dirty, there might not be curtains on the windows, there clearly wasn’t an attitude of service, they were unpleasant. Or even, most extraordinary, in Qinghai, on the Tibetan plateau, they weren’t heated, even though peoples’ homes were.
>RHN: And unhygienic, probably.
GB: Well, I’m sure they were. We would go to hospitals, and there would be one or two women, who were the maternal and child health people, but all they really did was keep records on births in the countryside, no-one was coming for delivery.
But now you go to those same hospitals and the obstetrics department is the busiest. Partly the buildings were improved, partly there’s a government policy now, which strongly discourages home deliveries and village midwives. This isn’t a simple good and bad, either, because for remote areas, this may be a problem.
And there were also changes in attitudes, in the sense that now, in the facilities, there’s a rice cooker and free food, there’s a commode, so people don’t have to go outside to go to the toilet, there are pictures on the wall.
>RHN: So more women want to come, in fact?
GB: The rate of institutional deliveries is well over 70%. A high percentage of women are now delivering in hospital. Now, partly it’s the project; the buildings are nicer, the attitudes are clearly different, and the morale, when you meet the people now, feeling very proud of their obstetrics department, is totally different.
But also, every household has a television, almost every household has someone working in the city and they are bringing attitudes from the city. So I think people also value what they perceive to be a modern approach to childbirth.
>RHN: So what you’re saying, really, is that the fall in maternal mortality is down to what might be called quality of care factors?
GB: To a large extent, linked to underlying economic and social change.
Now, there are problems. An obstetric service has been set up, basically, but in some places there are too many caesarean sections. And problems have arisen when people are not referred quickly enough to a referral facility. Although people are now using hospitals for deliveries, much more needs to be done to establish a high quality county-level obstetrics services.
>RHN: But it’s not a personal cost problem? It’s not the widespread problem of farmers who just can’t pay to go to hospital?
GB: That is still a big problem. It does seem that even in a county that’s doing better, people in the more remote areas, where they may not have a nearby township that’s adequately staffed, are still more at risk, and they’re obviously going to be the ones who are less able to pay.
So, no, there are still problems, and in some places, government now is paying subsidies for deliveries, and many of the Cooperative Medical Schemes pay subsidies for hospital deliveries. So, no, there is some subsidy coming in, but there are still, almost certainly, are problems that remain, particularly in the more remote areas.
>RHN: Why do you think China has become so concerned, apart from the SARS issue, about the health of its poorest, who are mostly in the rural areas in the West? There are many countries in the world that don’t care about their poorest, to anything like the extent that’s apparently being shown by China. What’s the motivation, do you think, in China?
GB: First of all, the level of health spending in poor areas is still very low, so there are still many problems. But I think the main motivation has been linked to a new development strategy, and a concern that, if people are left too far behind, it will create enormous tensions. So I think there’s concern, at the highest level, not to allow these inequalities to worsen. However, there is still little funding for rural primary health care and health safety nets for the poor are very small, so poor people have plenty of problems getting access to basic health care.
>RHN: So what lessons are there for other countries?
GB: Well, lesson one, which is not a new lesson at all, is that government has to play an important leadership role if you want health systems to work well, and to adapt to changing circumstances.
And lesson two, particularly as you move towards a market economy, is that government strategies have to change.
Then the big questions arise. What are the pros and cons of different government strategies? And there, I don’t think there are clear, simple lessons.
I think the other big lesson from China is the importance of local innovations, and a corollary of that is that people in different environments, who are innovating, need a chance to assess what each other has done and to exchange lessons.
They also need to learn from experiences in other countries. We aim to enable countries to share experiences about innovations that work. There are no outside quick fixes.
>RHN: You talk about local innovation. So there are local ideas that vary, even at county level, from place to place, that can possibly be shared – and possibly not be shared, for cultural reasons?
GB: When things are changing slowly it’s quite easy to develop a very detailed view of the impact of different contexts, and to decide what applies and what doesn’t, to different environments.
When things are changing quickly, we have to struggle a lot to systematise our knowledge, and there are no easy answers to the question of which kinds of innovation are easier to transfer, and which aren’t. One job of a research consortium [among countries] is to systematise findings and lessons from experience for learning and sharing with others.
>RHN: And it’s also important for there to be better communication amongst these groups about what works and what doesn’t work?
GB: That’s very important.
>RHN: You are co-chair of the China Health Development Forum, with Zhang Zhenzhong, the Director of the China Health Economics Institute, which exists to link researchers and policy makers. Could you tell us a bit more about that?
GB: We felt that policy-makers and researchers need opportunities for informal exchanges of findings and discussions of the likely impact of alternative policy options. It is also important to encourage exchanges between people working in different government sectors and between researchers from a variety of scientific disciplines. This is especially important in contexts of rapid change, where it is difficult to predict the outcome of any particular intervention. The China health Development Forum was set up with this in mind.
>RHN: And is it working?
GB: We had an excellent beginning at a large meeting in 2000, which provided an opportunity for a very fruitful exchange of ideas between researchers, policy-makers and health system managers about the problems that were emerging. We have organised a number of smaller consultations, often linked to a major research activity.
For example we will organise a meeting very soon to discuss recent research on ways to improve access to reproductive health services in poor counties.
We plan to strengthen our work in response to the accelerating reforms. This makes it even more important that there is effective feedback on local experiences with the implementation of new policies.
READ ON: The office of the WHO representative in China
We have also organised exchanges of experiences with the adaptation of heath systems to social and economic change between China and other countries in Asia, Africa and Latin America. We plan to strengthen this aspect of our work.
Please write your comments below, click preview, and then submit