The transformation of the 3-tier health network in rural China 1979-1990
Since 1979, the organisation of Chinese health care has undergone extensive changes as the result of government health reforms. These changes have particularly affected the '3-tier health network' of rural health care organisation. The '3 tier health network' which is a vertically organised linkage of village, township and county health units, has formed the basic health structure for the rural areas since the early 50's. The '3 tier network'(3TN) has been subject to the introduction of a market competitive system which is the economic responsibility system. Township hospitals have been placed under the control of township government, and a decision has been made to introduce a county level hospital of Chinese traditional medicine(CTM) for each county. Changes in the basis of health care financing and the encouragement of private practice have accompanied the decline of the co-operative medical system (CMS), a system of health insurance set up in the 1960's. On the basis of the empirical study described below, this thesis argues that there is an urgent need to evaluate these reforms, and develop policies for China's 800 million rural residents, focussing in particular on the 3TN. In 1989,7 counties, 12 townships and 30 villages were chosen by a structured random sampling technique in Jiangxi Zhejiang and Shandong provinces in East-China. A survey was carried out, covering health organisation, health personnel, the economics of rural health and health services for rural residents in county, township and village. In this survey, a comparison was made of the various types of health system, including those that have come into being since reform policies were instituted. In addition, the survey also considered the general influences of health reforms on the health service for rural residents and the management situation of the 3TN. This study found that in general the health reforms weakened the 3 tier health network in the rural areas. The health status of rural residents has deteriorated due to privatisation of the rural health care market. The main effects observed were the financial crises of township hospitals, high turnover and lack of health personnel in the rural areas, a standstill in preventive health, and the limited utilisation of health services by rural residents, since private health care replaced the CMS. The thesis argues that the main cause of these negative developments is health policies because the process of health policy making is 'top-down' in China, lacks community participation and is affected by political factors. The policies made during health reform actually worsened the already uneven allocation of health resources between urban areas and the rural areas. Urban areas have an inequitably large share and the gap continues to widen. The thesis suggests that Chinese health policy and organisation should put the stress on the rural areas once more, as happened during the 1960's and 70's. The reestablishment of the CMS is a better way to guarantee the health of rural residents and to implement primary health care. This method of health financing could be applied not only in China but throughout the developing world.