HEALTH CARE: LESSONS FROM

HEALTH CARE: LESSONS FROM CHINA AND CUBA Richard G. Younge, MD, MPH New York, New York Health has improved in Cuba and China during the past quarter of a century. Some of the improvements in health occurred as economic conditions improved in both countries, but there are other similarities of health care delivery in China and Cuba. Collective activity plays an important role in health care in both nations; both do health planning centrally, but local communities control the daily activities of the health services that they use. Techniques that have improved health in underdeveloped nations might be applied in underserved areas of the United States. capita wealth. Cuba's population is more concentrated in urban areas than China's. For these reasons, some aspects of China's and Cuba's health systems have developed differently. Internists and pediatricians provide most of the medical care in Cuba, whereas in China, nonphysicians predominate. Traditional and folk medicine play a more important role in China than in Cuba. Health policy makers in the United States can learn from the health care systems in China and Cuba. Both countries' health care systems suggest some approaches to improving health in the United States. Health improved in China and Cuba as social and economic conditions improved. Collective activity plays an important role in health in both countries. Both allocate health resources and set health Requests for reprints should be addressed to Dr Richard G. Younge, The Council's Center for Problems of Living, 1727 Amsterdam Avenue, New York, NY 10031. goals centrally, but health programs are planned and implemented locally. Health care in China and Cuba has these similarities despite the many differences between the two nations. Before the revolution in 1959, Cuba had two developed industries: sugar and tourism; existing modem health resources were concentrated in Havana. Most of Cuba's physicians left after the revolution. On the other hand, China, a rural, agrarian society, had little industrial development before its revolution in 1949 and had insignificant modern medical resources. China has 100 times the population of Cuba but lower per IMPROVED HEALTH IN CHINA AND CUBA Cuba and China have made significant advances in health status during the past quarter century. Cuba's health statistics compare favorably with nations which have greater economic resources. ' In the years since the July 1959 Revolution, Cuba has eliminated malaria.2 The infant mortality rate has declined from 36.4 per 1,000 live births in 1967 to 19.4 per 1,000 live births in 1979.3 The maternal mor- JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 74, NO. 4, 1982 391

tality rate from all causes declined from 118.2 per 100,000 live births in 1969 to 47.4 per 100,000 live births in 1979.3 Improvements in the mortality rate due to toxemias of pregnancy and maternal hemorrhage contributed significantly to the decline. Maternal mortality due to toxemias of pregnancy went from 35.0 per 100,000 live births to 4.2 per 100,000 live births during this period. Mortality due to maternal hemorrhage dropped from 31.7 per 100,000 live births to 1.4 per 100,000 live births between 1960 and 1979.3 The success of the health system in China has been described by several authors.4 5 Health statistics from Shanghi show a decline in infectious disease morbidity and mortality. Cancer, heart disease, and chronic lung disease, which are the health problems of more industrialized nations, have become more prevalent.6 HEALTH AND SOCIOECONOMIC STATUS Some of the progress in improving health in China and Cuba results from improvements in the people's economic status and a more equitable distribution of goods and services. Both governments have committed themselves to elevate all the people to an acceptable standard of living. As this has been done, health has improved. Similar improvements in living conditions contributed to the decline of the tuberculosis mortality rate in the United States during the pre-antibiotic era.7 In China and Cuba, improved nutrition, safe water supplies, vector control, and new housing construction have helped to reduce the burden of infectious diseases. Even though the standard of living remains well below that of more industrialized nations, the basic needs of food, clothing, and housing are being met. Cuba's efforts to improve nutrition have included the development and expansion of the dairy, citrus, and fishing industries. Before 1959 fish was not a significant protein source in spite of the fact that Cuba is surrounded by ocean. The dairy industry has grown enough to ensure that all school-age children can receive one liter of milk a day. A recent nutrition campaign encouraged pregnant and lactating women to increase their consumption of dairy products. Cuba has developed new breeds of cattle that are more adapted to tropical climates. Despite all of the improvements, Cuban health planners fear that recent, poor crop yields may slow improvements in nutrition. China's health workers see population growth as a major obstacle to continued improvements in the standard of living. Since 1949 the population has doubled; now one billion people live in China. If the rate of population growth does not slow, the progress in health made since the revolution may be slowed. Strict incentives to limit family size may prevent threatened worsening of food and housing shortages if zero population growth occurs by the year 2000. POPULAR PARTICIPATION IN HEALTH IN CHINA One of the principles of health work in China has been the "mass line." This concept holds that the people working together with motivation and knowledge of basic skills can make great advances in health despite shortages of technology and professional medical workers. During the Great Proletarian Health Movement millions of people mobilized to eliminate the four pests: flies, rats, mosquitoes, and sparrows. (Sparrows received a reprieve because they are not a major source of disease.) The people involved in this public health campaign used simple techniques to eliminate the pests and their breeding grounds. Mass campaigns such as this helped to eliminate major sources of disease and provided a vehicle for health education. Intensive effort by many compensated for the health resources that China lacked. As infectious disease has become less prevalent, emphasis on the mass line has decreased. Integration of technology into the health system and professional training now receive relatively more effort.8 Despite this shift in policy, the people remain China's greatest health resource. China's urban municipalities are subdivided into districts, and these districts contain several neighborhoods (also called streets or urban communes). Each neighborhood has about 50,000 residents. Lane committees, which represent 1,500 to 5,000 people, are the basic political units of the neighborhoods. Lane committees organize primary medical care as well as other public health and social welfare functions. Lane committees select the residents who receive training to be medical workers at the "lane health station." At the health station the medical workers do immunizations, treat minor complaints, and teach people about nutrition, disease prevention, and contraception. The Health Station is visited 392 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 74, NO. 4, 1982

by a physician once or twice a week; the medical worker provides primary medical care the rest of the time. The lane committee ensures that pregnant women receive prenatal care and that children have periodic health maintenance. Health initiatives planned by the lane committee and medical workers include sanitation, pest control, and campaigns to encourage the use of contraceptives. Chinese workers generally receive primary health care at their work place. The workers participate in the management of factory health services through their trade unions. In Harbin, a northeastern industrial center, the hospital for chronic diseases of workers has a patient committee that investigates complaints about the care. These problems are referred to the trade union, which administers the hospital, for resolution. Health services in rural areas are the responsibility of commune production teams and brigades. Communes are self-governing politico-economic units with 5,000 to 50,000 residents. They are divided into 10 to 30 production brigades, each of which contains several production teams. Production brigades operate small health clinics similar in function to the lane health stations. The medical workers in the health stations are elected by the members of the brigade. The lay medical workers and their neighbors plan and carry out health programs for the brigade. Throughout China, posters remind people that maintaining good health is part of their responsibility to society. In the lanes, factories, and production brigades, people meet to discuss health issues. At these public meetings an individual who failed to have his children immunized or who created a sanitation problem might be publically criticized. People who need assistance with a health problem can often get the help they need from their production brigade, trade union, or lane committee. POPULAR PARTICIPATION IN HEALTH-CUBA The Committees for the Defense of the Revolution (CDR) were established in Cuba during the years after the revolution. Originally they organized neighborhood patrols to protect residents from counterrevolutionary sabotage. CDRs, located throughout urban and rural Cuba, now have important health responsibilities. They organize community health activities such as immunization, sanitation, and health education. They play an important role in case finding for the local health providers. One CDR in Havana proudly displays a chart that shows several CDRs in that section of the city as having the best record of blood donation, another task of the organization. Most Cuban adults participate in CDR activities. The Federation of Cuban Women (FMC), to which more than 75 percent of Cuban women belong, sponsors women's health activities. The FMC organizes health education programs about contraceptives, and it coordinates Cuba's day-care programs for the children of working mothers. Polyclinics are the primary health units of the Cuban health system. The Ministry of Public Health has taken several steps during the past five years to upgrade the quality of health services at these polyclinics. They recognized that many people chose to receive health care episodically in municipal hospital emergency rooms. People preferred the emergency room because that was where the best trained physicians worked. Many polyclinics, especially those in rural areas, had physicians with only one year of postdoctoral training. They were fulfilling their one year of required clinical service before starting residency training. Patients did not see the same physician each time they went to the polyclinic, but they were no worse off seeing a different physician each time they went to the emergency room. The reorganization of primary care services is called Medicine in the Community. Since the inception of the program in 1977, pediatric, internal medicine, and obstetricgynecology residents spend part of their time working in the polyclinics. Each municipality will have at least one teaching polyclinic associated with a hospital based residency program. Clinical faculty at the polyclinics organize conferences for the residents and supervise their work. The fact that specialists train at the polyclinics has helped to improve the polyclinic's image. Primary care teams have been established at all polyclinics so that patients see the same physician each time they visit. Each primary care team (internist, pediatrician, obstetrician-gynecologist, nurse, and dentist) has a geographic sector of the polyclinic catchment area for which they have responsibility. These sectors have from 3,000 to 5,000 residents. Within each sector are several FMCs and CDRs. Frequently, representatives of the FMC and CDR, the polyclinic administration, and members of the health care team meet to discuss the health needs of the sector. The pri- JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 74, NO. 4,1982 393

mary care team's work area has maps of the sector with stick pins indicating cases of tuberculosis, low birth weight, diarrheal disease, and other health problems. These maps graphically remind the team of its responsibility for the health care of a specific community. Their contacts with the community organizations ensures that the health care team stays in touch with the needs of the sector. A team with a social worker, a hygenist, an epidemiologist, and a psychiatrist serves the entire polyclinic catchment area. They help the primary care teams and community representatives to plan health programs to address the needs of the.sectors. Without the participation of the people in China's Great Patriotic Health Movement or the work of the Cuban CDRs and FMCs, some of the striking successes of these countries' health systems, such as the virtual elimination of syphilis in China or the almost complete immunization of Cuban children a- gainst polio, would have been impossible. PLANNING FOR HEALTH Two levels of health planning can be identified in China and Cuba. Strategic health planning defines problems, allocates resources, establishes goals, and evaluates progress towards the goals. Tactical planning develops specific programs to achieve health goals. In both countries national or provincial authorities do the general or strategic planning. Local health facilities and community organizations work together to do the tactical planning. Both nations had a concentration of health resources in urban areas before their revolutions. The strategic health planners identified this problem and promoted construction of new health facilities in rural areas and assignment of health practitioners to rural areas. Central planning also identified and quantified health problems such as low birth weight, poor nutrition, and high incidence of communicable disease. Goals for improvement were set centrally, but community organizations such as lane committees, production brigades, or CDRs developed and carried out specific plans to reach the goals. Reliance on the local organizations to plan and to execute activities encourages community participation by placing day-to-day operation of health programs in the hands of those people who will be using the programs. It allows the community some degrees of freedom to set priorities and to tailor programs to meet their own needs. Allocating resources, identifying problems, and setting goals centrally encourages equal distribution of resources and availability of services throughout the country. The structure of health service reporting and accountability in Cuba supports central strategic planning and local control of health and other institutions.9 The administrators of a municipal hospital or polyclinic report to the Municipal Assembly of Popular Power, which consists of delegates elected from districts throughout the municipality. Anyone, Communist Party member or not, may run for election to the assembly. The delegates are elected by secret ballot, and by law there must be at least two candidates from every district. Delegates represent about 1,000 people. They meet frequently with their constituents to discuss decisions made by the Municipal Assembly and to hear the needs of the people in the district. The Standing Committee and the Health Committee of the Municipal Assembly oversee administrative decisions concerning programs, personnel, and day-to-day policy in the polyclinics and hospitals in the municipality. The polyclinics and hospitals in the municipality also report to the provincial Ministry of Health on the progress being made towards meeting provincial and national health goals. In Cuba, the Ministries of Health are primarily strategic planning and norm setting agencies. They provide the technical support and advice that the health facility may need to plan its activities. The Municipal Popular Power Assembly and the Provincial Popular Power Assembly control the administration of health services. Goals are set nationally, but local interests retain control of the day-to-day function of health facilities. China, with its huge population, does most of its strategic health planning in the provinces. Provincial health departments collect data and set specific targets. The national ministry sets only broad goals for health. For example, a national health goal is to slow the rate of population growth. Seeking to slow the rate of population growth, China wishes, at the same time, to preserve the cultural heritage of its national minority groups. Tibetan and Mongolian ethnic groups are the -largest of these minorities. Provinces and regions with large national minority populations have less stringent population control programs. Centralized norm setting and strategic planning with local con- 394 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 74, NO. 4,1982

trol of health services administration and tactical planning in Cuba and China contrast with the health planning system in the United States. Within one area there may be health services that rely on any one of several levels of government-federal, state, or local-for their mandate, strategic planning, and evaluation. Some health services do not do any strategic health planning or evaluation. The health services may be accountable to one of the levels of government, a board of directors, a community board, or to no one for their dayto-day operations. Administrative responsibility may not be in the same hands as those responsible for planning and evaluation. Not infrequently, the administrators and planners work under different sets of assumptions and incentives. The United States did not have a written statement of health goals until 1979.10 In view of the fact that health care costs account for about one tenth of the gross national product, it is amazing that nothing has ever been written stating what we hoped to get for the money. The Health Systems Agencies, which are an attempt to let local community representatives plan health services, may not survive the current administration. LESSONS FROM CHINA AND CUBA China and Cuba demonstrate that significant progress can be made in spite of scarce resources. Certain areas of the United States demonstrate that a relative abundance of medical resources do not guarantee good health statistics. This suggests that planning for a more equitable distribution of medical and other resources in a society has a positive effect on health. Making health a collective effort enhances the work of the health care system. In China and Cuba, community organization around health has been successful at promoting primary and preventive health services -and health education. Popular participation, local control of health services administration, and central strategic planning are closely linked concepts. Local control and administration of health services can facilitate popular participation by providing mechanisms in which people can become involved to improve their health. In the absence of central strategic health planning, national problems such as maldistribution of health workers may go unaddressed. Local planners sometimes fail to identify health problems because they look at a small part of the national health picture or because they lack the tools to collect and analyze the data. In both nations the functions of the central government are to train health workers, to build health facilities, to ensure that health resources are fairly distributed, to collect health data, and to set and evaluate progress towards goals. These are the very functions that our federal government now seeks to cut back. China and Cuba have successfully addressed the health problems associated with underdevelopment. Now, as we observe their response to their newly emerging health problems-cardiovascular disease, accidents, chronic lung disease, and malignancy-we can learn new approaches to these problems for our own communities. Acknowledgements My thanks to Ms. Sue Forte, Mr. Walter Isaacs, Mr. John O'Connor, and Ms. Ann Umemoto for their helpful suggestions in the preparation of this manuscript. Literature Cited 1. Roemer Ml. Health development and political policy: The lesson of Cuba. J Health Polit Policy Law 1980; 4:570-8. 2. Report of the Director, Quadrennial, 1974-1977. Washington DC, Pan American Health Organization, 1978. 3. Informe Anual, 1979. Havana, Ministry of Public Health, 1980, pp 14, 32. 4. Sidel VW, Sidel R. Serve the People: Observations on Medicine in the People's Republic of China. Boston: Beacon Press, 1973. 5. Horn JS. Away With All Pests. An English Surgeon in People's China, 1954-1969. New York: Monthly Review Press, 1969. 6. Sidel VW, Sidel R. The delivery of medical care in China. Sci Am 1974; 230:19-27. 7. Dubos R. Mann Adapting. New Haven: Yale University Press, 1965, pp 163-76. 8. Blendon RJ. Public Health versus personal medical care: The dilemma of post-mao China. N Engl J Med 1981; 304:981-4. 9. Navarro V. Worker's and community participation and democratic control in Cuba. Int J Health Serv 1980; 10:197-216. 10. US Department of Health and Human Services, Public Health Service. Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention, 1979. Washington DC: US Government Printing Office, 1979. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 74, NO. 4,1982 395