Reaching the grass-roots / by Deng Yuzhen

0 (1J (]) Cl c (1J "' c (1J :5 0 I s 0 0 J:: 0.. Reaching the grass-roots Thanks to a three-level health network in county, town and village, a relatively com- plete medical and health delivery system now covers the whole of China's vast rural areas by Deng Yuzhen Q mong more than 1,000 million people who live in China, 800 million live in the countryside, away from the big cities. The Chin- ese government has always at- tached great importance to medical and health services in rural areas, and considers this development as an area of high priority. The result has been to put an end once and for all to the lack of both doctors and 20 drugs, and to curb the spread of diseases. Since rural economic reform be- gan, there has been remarkable suc- cess in controlling acute and chronic infectious diseases as well as parasi- tic diseases. According to statistics available in November 1985, the incidence of 24 infectious diseases had been reduced by 16 per cent as compared with the corresponding period of 1984. Schistosomiasis, to give one example, was eradicated from 247 counties in 1984, and was reported to have been eradi- cated from another 34 counties in 1985. China's experience over the past 30 years or so has shown that the development of medical networks for disease treatment and preven- tion at three levels- the county, the township and the village - can suc- ceed in solving both the lack of medical doctors and of drugs in the countryside. Today, at the county level there are county hospitals, hospitals for traditional Chinese medicine, health and anti-epidemic stations, maternity and child care centres, health schools, drug control insti- tutes and other specialised insti- tutions for disease prevention and treatment. These establishments provide guidance for medical and health services in the county as a whole, and serve as centres for disease prevention and treatment as well as for training grass-root medi- cal and health personnel who will work in the grass-roots sector. At the township level, there are health centres which offer both pre- ventive and curative care. Their responsibilities are to carry out medical care, prevention, health education and information, mater- nity and child care, family planning and other technical services. The centres also have responsibility for giving technical advice to health establishments in the villages. At the village level, health facilities are now available at clinics in 87 per cent of these communities. A good example of this well-estab- lished three-level health network is Jiading County in Shanghai Munici- pality, which was designated as a WHO collaborating centre on pri- mary health care in 1980. Since then there have been 11 health institutions established at county level including a central hospital, a health and anti-epidemic station and a maternity and child care centre. In addition, 19 township health centres and 266 village clinics have been started. In order to keep abreast of the new situation arising from the de- velopment of rural economic re- form, in 1985 the health authorities throughout the country took the initiative of strengthening the man- agement of health infrastructure in W ORLD HEALTH, June 1987 the countryside by encouraging all concerned to develop multiple health services through various channels and in different forms . In a number of counties, the need was for specialised hospitals. For exam- ple, in Shanxi Province there were 329 small specialised hospitals, 80 per cent of which were at township or town level. Again to keep pace with the new situation, Conghua County in Guangdong Province has since 1984 focused its efforts on reorganising the village clinics by putting them under the dual super- vision of the township administra- tion and township health centre. There is one health clinic for each village, which is run collectively, based on a system of independent accounting, whereby the villagers assume sole responsibility for the profits and losses of their own accumulated fund. Methods such as these have suc- ceeded in strengthening health facilities at the grass roots. Since the reorganization, the health infra- structure in China's rural areas is taking various patterns. Today 52.92 per cent of village health clinics are run by the collectivity or by rural doctors on a contract basis; 10.08 per cent are run by rural doctors working jointly; 31.5 per cent are run by individuals; 3.39 per cent are run by health centres which extend their services to vil- lages, and 2.11 per cent are run in other ways. In the country as a whole, 40 per cent of rural medical workers have won the title of ru- ral doctor after passing qualifi- cation examinations. In addition, 1,680,000 part-time rural midwives and medical assistants have com- pleted training courses. All these rural doctors, midwives and medi- cal assistants are working actively in the countryside and represent reliable manpower for primary health care. Thanks to the establishment and development of the three-level medical networks, a relatively com- plete medical and health delivery system now covers the countryside and plays an active and effective role in developing primary health care. Generally speaking, most dis- eases can be prevented, treated and controlled in the peripheral health facilities, while more difficult prob- lems can usually be tackled by the medical and health institutions at county level. • W ORLD HEALTH, June 1987 Zimbabwe: from supermarket to cafeteria After independence, Zimbabwe embarked on a new health programme with energy and pragmatism. When one approach to pnmary health care proved inefficient, a better method quickly replaced it by H. Anenden ~ n many African countries, the post-independence era has seen the emergence of a new con- sciousness about the importance of health in the development of the nation. Although the basic infra- structure such as hospitals and pharmacies had been provided by the former colonial authorities, these were usually concentrated in the big towns, whereas the country- side was summarily left to its own devices. Health development in The government's policy is to set up a rural health centre not further than eight kilometres from every person in the country. Environmental sanitation is one of the responsibilities of these centres. Photo WHO/Liba Taylor post-colonial Africa therefore had to tackle simultaneously not only the training of more medical prac- titioners, an increase in the number of hospitals, dispensaries and health clinics, and the manufacture of pharmaceutical products, but also the decentralisation of health services and the devising of new approaches to meet new circumstances. Zimbabwe is one of the late- comers in the confraternity of inde- pendent nations. In the wake of the numerous political and economic problems, the country had also to face a restructuring of the health system so as to reach the more remote and indigent areas. A national survey carried out in 1984 by the Ministry of Health among 5,000 children (aged one to five) in eight provinces showed that nearly one third suffered from malnutrition, and another third had · borderline status. Even in the capi- tal, Harare, a large proportion of children showed evidence of under- nutrition and dietary deficiency of micro-nutrients. Communicable diseases are also widespread among the adult black population, with a high incidence of tuberculosis among blacks as well as malaria cases, and intestinal and urinary parasitic infestations. Many communicable diseases are due to the unhygienic conditions in which people live. 21