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China Perspectives 2016/4

SPECIAL FEATURE

The Health System and Access to Healthcare in China

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China Perspectives 2016/4

Special Feature

Editorial Page 3

Carine Milcent

The Lost Generation: “Barefoot Doctors” in Post-reform China Page 7

Jiong Tu

ABSTRACT: In the 1960s and 1970s, China’s barefoot doctor system was acclaimed worldwide for providing inexpensive and equally accessible medical care for rural populations. In the 1980s, with the advent of market reform, the barefoot doctor system came to an end. Many barefoot doctors either became private doctors or gave up medical practice. More than three decades have passed since this dramatic change, and barefoot doctors seem to have been forgotten. However, the legacy of the barefoot doctor system is still felt in the hardship of aging former barefoot doctors who now find themselves pensionless. Based on ethnographic research in a county in Sichuan Province from 2011 to 2012, this article explores the experience of a group of former barefoot doctors to observe their transition in post-reform China, and their struggle for payment, pension, and status in recent years. It records the change these doctors experienced from barefoot doctors working under very difficult conditions in the collective era, to individual doctors in the market era who struggle with qualification requirements, market competition, and selfsupport, to the newly ambiguous status of village doctors, who constitute an important part of the primary health care network but are still marginalised in the health care system.
KEYWORDS: barefoot doctors, payment, pension, health care, rural China.

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The Hippocratic Dilemmas: Guanxi and Professional Work in Hospital Care in China Page 19

Longwen FuCheris Shun-Ching Chan

ABSTRACT: Patients mobilising guanxi (interpersonal relations) to gain access to hospital care is prevalent in post-Mao China. Yet few studies have centred on how medical professionals deal with guanxi patients. Based on ethnographic research and applying an analytical frame of Chinese guanxi developed by Fei Xiaotong (1992 [1948]) and Cheris Shun-Ching Chan (2009), this article examines the dilemmas that Chinese physicians face in weighing professional standards versus guanxi. We divide the patients into three general categories: patients without any guanxi, patients with weak to moderate ties with physicians, and patients with strong ties with physicians. We find that physicians face few dilemmas when they interact with patients without guanxi. They largely adhere to their professional code of practice and generally display dominance over the patients. When interacting with patients with weak to moderate ties, however, physicians are caught in a dilemma between fulfilling renqing (interpersonal obligation) and adhering to a professional code of practice. They manage this dilemma through dramaturgical strategies such as information-sharing, emotional work, and face-giving. When interacting with patients with whom they have strong ties, however, affection and the sense of asymmetric obligation may take precedence over professional codes. Physicians deal with this dilemma through a different set of strategies, such as information-control, emotional avoidance, and altruistic care. Our analysis reveals the impacts of guanxi on medical professionals and the moral dilemmas they face in a guanxi-dominant societal context. It offers direction for possible policy reforms to mitigate the problem.
KEYWORDS: China, guanxi, medical professional, moral dilemma, hospital care.

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Health Insurance Reforms and Health Policies in Rural China Page 29

Martine AudibertXiaoxian HuangXiezhe HuangfuJacky MathonnatAurore PélissierLaurène Petitfour

ABSTRACT: Since the early 2000s, the Chinese government has undertaken a series of reforms in the health sector. Among these, the three most important have been concerned with medical insurance, hospital administration, and pharmaceutical policies. The aims of these reforms were to extend health insurance coverage, to increase the activities and the efficiency of the health establishments, and to improve patient care. This article focuses on two components of these reforms: the development of health insurance in rural areas and the policy on essential medicines in conjunction with hospital reforms. Our longstanding co-operation with a research team from Weifang University and with the Weifang Health Bureau allowed us to follow these reforms and collect data (primary source) from a sample of township hospitals from Weifang Prefecture. Those data allowed us to study their effects on health facilities’ level of activity and efficiency. This article provides an overview of studies we carried out on these issues over the period from 2000 to 2012. Our analyses were mainly based on non-parametric models (Data Envelopment Analysis, Malmquist Index, and partial frontiers) and impact analyses, coupled with interviews with hospital staff and medical authorities. Results show that the development of health insurance in rural areas had a positive effect in greatly increasing the activities of the hospitals covered by our study. On the other hand, it did not have a positive influence on their efficiency, which declined in the period concerned. This result is to be explained by the fact that, even though staff activity increased, it remained low, since the observed increase in activity was not sufficient to make up for the parallel increase in staff numbers. Similarly, reforms in the hospital and pharmaceutical sectors had no effect on the township hospitals of our survey. In fact, in order to compensate for the observed reduction of hospital resources following the introduction of the reforms, on the one hand the government increased the subsidies allocated to township hospitals, and on the other hand the hospitals strongly innovated in sophisticated and expensive care, to the benefit of a relatively small number of patients. Therefore, there were some very positive steps forward, but they still call for a more nuanced assessment of the effects of the reforms.
KEYWORDS: Technical efficiency, non-parametric approach, Malmquist Index, township hospitals, health insurance, hospital and pharmaceutical reforms, China, Weifang Prefecture.

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Evolution of the Health System: Inefficiency, Violence, and Digital Healthcare Page 39

Carine Milcent

ABSTRACT: China’s public health system has gone through a number of development stages. This paper aims at showing how, from its inception as a hierarchical system, the healthcare system then lost its structure, to finally give birth to a focalised system where the first point of entry in the treatment process has become the hospital, in particular the healthcare establishments that offer the most reliable standards of care. These days, the widely-acknowledged inefficiencies of the healthcare system have led to a climate of violence between medical staff and their patients, caused by the overwhelming demand that hospitals must bear, the ambiguous status of public establishments, financial benefits and other perks for medical staff, as well as the medical staff’s civil servant status, and the implications thereof. Policies to foster the development of primary health centres are struggling to gain traction, while digital healthcare offers promising solutions and is developing fast.
KEYWORDS: healthcare system, hospital, inefficiency, violence, digital healthcare.

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Healthcare Service in Hong Kong and its Challenges: The Role of Health Professionals within a Social Model of Health Page 51

Veronika Schoeb

ABSTRACT: The Hong Kong Special Administrative Region combines a British colonial history within a Chinese cultural context and offers its population a dual system with a comprehensive and efficient public health care system in tandem with private hospitals and practitioners. Multiple challenges are looming: increasing demand for health services due to an aging population, staff shortages at all levels, and an underdeveloped primary healthcare system. Health is determined by multiple factors and is defined as a state of complete physical, mental, and social well-being. In recent years, the medical model of health focusing on pathology and disease has been considered insufficient, and a social model of health has been proposed, relying on a more holistic and broad definition of health. Rather than focusing on individual responsibility for health, the social model emphasises collective responsibility for health. This paper analyses the challenges facing Hong Kong in view of the social model of health. The discussion provides some reflections on medical dominance, the reasons behind limited primary care services, and what steps could be recommended to deliver healthcare services in Hong Kong in line with a more holistic view of health.
KEYWORDS: social determinants of health, healthcare delivery, access, healthcare system, Hong Kong, health professionals.

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Articles

“Do You Hear the People Sing” “Lift Your Umbrella”? Understanding Hong Kong’s Pro-democratic Umbrella Movement through YouTube Music Videos Page 59

Tim Rühlig

ABSTRACT: Around the world, music serves as an important element of mobilisation for social movements. Singing songs is not only a peaceful protest technique but also helps to construct a protest identity locating and relating the social movement to its political and social environment. Most importantly, a social movement is to a significant extent remembered through its music, and this determines its future impact on local (contentious) politics. Against this backdrop, this article seeks to understand Hong Kong’s Umbrella Movement through four YouTube music videos, analysing the lyrics, music, and video imagery in order to carve out core elements and values of the Umbrella Movement. Especially given the importance of Hong Kong’s identity as a “global” city with a cosmopolitan culture and past, the peaceful nature of the movement and the rise of a xenophobic localism in the shape of sarcasm are emphasised.
KEYWORDS: Hong Kong, Umbrella Movement, music, songs, protest art, mobilisation of tradition.

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Living in the City: The Identity Strategies of Schoolchildren in an Urban Setting Confronted by the Stigma of Being “Children of Nongmingong” Page 69

Zhou Mingchao

ABSTRACT: Based on an ethnographic survey in a primary school for the children of rural migrant workers in Hangzhou, this study examines the effects of the process of stigmatisation and the forms of internalisation associated with the “nongmingong” status of their parents. It also looks at how some of these “children of nongmingong” who go to school in the city are able to reverse this stigma. In particular, the study analyses the identity strategies deployed by students aged between ten and fourteen to deal with the stigma of their place of abode, by drawing a distinction between individual strategies (when they are alone with the investigator) and group strategies (in the presence of their peers at school).
KEYWORDS: stigmatisation, socialisation, urban segregation, children of rural migrant workers, Hangzhou.

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CEFC News Analyis

Whom to Trust When Sick? The Wei Zexi Incident, the Chinese Internet, and the Healthcare System in China Page 79

Anthony H. F. Li

Review Essay

Alain Badiou and the Multiple Meanings of the “Cultural Revolution” Page 85

Xiaoquan Chu

ABSTRACT: Alain Badiou’s work L’Hypothèse communiste (The Communist hypothesis) presents the “Cultural Revolution” in China as a necessary and commendable stage on the way towards the realisation of the Communist ideal. Badiou’s analysis of this event completely neglects what really happened to the Chinese during this period and shows a curious willingness on the part of the author to take literally the discourses produced by the official propaganda of the day.
KEYWORDS: Cultural Revolution, Badiou.

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Book Reviews

Stein Ringen, The Perfect Dictatorship: China in the 21st Century Page 90

David Bartel

François Gipouloux (ed.), China’s Urban Century: Governance, Environment and Socio-Economic Imperatives Page 92

Nicolas Douay

He Jiahong, Back From the Dead: Wrongful Convictions and Criminal Justice in China Page 93

Stanley Lubman

David Shambaugh, China’s Future Page 94

Alexandre de Saint-Denis

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