Akademik

The geography of health care is a branch of the sub-discipline known as medical geography and includes the study of the spatial patterns and distributions of health care services in relation to the populations being served. This in turn can be of assistance in the planning of health care systems in various cultural settings. In China, the system of health care delivery has changed significantly since the inception of the economic reforms starting in the early 1980s.

Prior to this period total access to primary health care was guaranteed, both ideologically and practically, through the collective work units (at the rural brigade level or in the urban danwei or work unit). In rural areas the Cooperative Medical System (CMS) organized health care at three levels. The first tier involved the much-acclaimed barefoot doctors (health workers with minimal training) who provided primary care, including prescription medicines. For more serious cases they referred patients to the commune (township) health centres (the second tier), and ultimately to the county hospitals (the third tier).

After the agricultural reforms the CMS collapsed in most areas: the primary health care workers had decreased by at least a third by the early 1990s. Even at the township level the number of clinics decreased significantly. One study based on thirty ‘poverty counties’ observed that by 1993 only about half of all villages had functioning health stations (Liu et al. 1999). By far the biggest negative impact of these changes was felt in rural areas. The gap between the health status of people in the city and those in the countryside widened considerably. For example, using one classic indicator of health status, Huang and Liu (1995) found that country-wide infant mortality rates (IMR) for rural areas had actually increased between 1990 and 1995, climbing from 30 to over 40 deaths per 1,000 live births (whereas in urban areas there was a slight decrease). When IMRs are calculated at regional levels they are much worse in the remote western provinces than in the more densely populated parts of China, and at the county level some areas have been found to have IMRs in excess of 100 deaths per 1,000 live births (Huang et al. 1997; Foggin et al. 2001). Clearly, although it is only one factor contributing to the health status of populations, the geographical variation of health care services available is one of the contributing factors.

There are two types of health care in China, both officially sanctioned and universally practised in varying proportions: traditional Chinese medicine and what is commonly referred to as ‘Western medicine’. White (1999) has emphasized a peculiarly Chinese version of holistic, ‘integrated medicine’ (IM). Launched during the Cultural Revolution, it was intended to be a truly new and scientific synthesis of the best of both Chinese traditional and Western medicine. There are, however, wide geographical variations in the way IM is used and practised and, since the economic reforms, many urban health care institutions have reinstated the division of labour between ‘traditional’ and ‘Western’ medicine.

An example of some of the problems observed in the still widespread but unregulated practice of IM is the often uninformed and massive use of easily obtained antibiotics, thus seriously diminishing their effectiveness not only in China but also around the world.

Foggin, Peter, Armijo-Hussein, Nagib, Marigaux, Céline, Hui Zhu and Liu Zeyuan (2001). ‘Risk Factors and Child Mortality among the Miao in Yunnan, Southwest China’. Social Science and Medicine 53: 1683–96.

Huang, W., Yu, H., Wang, F. and Li, G. (1997). ‘Infant Mortality among Various Nationalities in the Middle Part of Guizhou, China’. Social Science and Medicine 45:1031–40.

Huang, Y. and Liu, Y. (1995). Mortality Data of the Chinese Population. Beijing: Chinese Population Press.

Liu, Xingzhu and Mills, Anne (2002). ‘Financing Reforms of Public Health Services in China: Lessons for Other Nations’. Social Science in Medicine 54: 1691–8.

Liu, Yuanli, Hsiao, William C. and Eggleston, Karen (1999). ‘Equity in Health and Health Care: The Chinese Experience’. Social Science in Medicine 49: 1349–56.

White, Sydney D. (1999). ‘Deciphering “Integrated Chinese and Western Medicine” in the Rural Lijiang Basin: State Policy and Local Practice(s) in Socialist China. Social Science and Medicine 49: 1333–47.