Chinese public health system during the Mao Zedong period was based on a sound primary healthcare strategy. On the spot basic healthcare was provided to rural families who lived in communes and villages.

With the launch of the cultural revolution in 1965, Mao expanded the idea of “health for the masses” beyond infectious diseases like the famous big belly or the schistosomiasis, which affected Chinese in the early days in a big way. This gave birth to the idea of barefoot doctors in China and they played a crucial role in eliminating many of the diseases in rural areas soon after the cultural revolution.

The World Health Organisation (WHO) had commended the barefoot doctors and they even encouraged many developing countries,  to experiment with the idea of community health workers.

Current crisis
But in recent times, with massive urbanisation and mass migration of rural people to urban areas, the healthcare system for rural people has suffered a lot in China. With the collapse of healthcare provided by barefoot doctors, the Chinese Communist Party has started paying close attention to the increasing cost of healthcare in rural areas. Healthcare insurance has been made mandatory without the provision of basic healthcare in the village.

Even then, more than 60 per cent of those in dire poverty have been driven to that stage by rising medical expenses. Rural health insurance premiums are being deducted from the grain price the Chinese farmers get. But, since rural hospitals are catching up with city style hospitals to keep prescribing unnecessary X-rays and lab investigations, it adds to the cost of treatment to rural inhabitants. The poor would not be able to pay even for the treatments let alone the tests.

The 150 million rural population, which are behind the plough in rural China, are enjoying neither the benefits accorded to those who have stayed back nor the big subsidies enjoyed by the city born counterparts. In 2004, WHO described the “launch of the new medical system during a rapid population shift as the equivalent of launching a ship with a radically new design at the height of a typhoon. This ship is not weathering well”. (The Economist Oct 13,2007.)

The majority of rural ailments could have been treated by the barefoot doctors of the early days without fanfare. Rural China is still home to 60 per cent of the country’s 1.3 billion people but agriculture’s contribution to GDP has fallen from more than a quarter in 1990 to less than 12 per cent today. The Chinese  government’s spending on agriculture and rural welfare as a proportion of total spending has similarly fallen from 8-11 per cent in the 90’s to 7-8 per cent in this decade.

Indian situation
India is not far behind China in neglecting its rural health care. As per WHO figures, some 117,000 women died in child birth in India in 2005. In a study done by WHO in six Indian states it was revealed that health costs push people into high indebtedness. Some 12 per cent had to sell their assets to meet health expenses and 43 per cent had to resort to loans.

Over the years our Traditional Birth Attendants (TBAs), Community Health workers, in the villages could have saved many lives. But we keep changing our public health priorities and keep floating new populist schemes like the Rural Health Missions, which create more layers and more functionaries in the already overcrowded rural public health system. A properly and continuously trained TBA in a village and updated with good delivery practices can save many mothers from delivery-deaths than a rural or urban hospital can possibly do.

Despite the massive World Bank aided Reproductive Child Health Programme, deliveries done in rural hospitals have not touched even 40 per cent. Our rural mothers are reluctant to deliver in a rural hospital because of the lack of customer care and satisfaction. But, even city hospitals like those in Mumbai are not free from malpractices.

In a recent case the Mumbai High Court has warned hospitals against cruel practice of holding back the body of a patient – demanding lakhs of rupees from the family before returning it. In public health, care begins with the patient. But in private health money comes before the patient. We need more public health than private care!