After the de-collectivization of agriculture, existing patterns of cooperative medical schemes and community-financed health care broke down. Liberalization in rural health care delivery and private fee-based services supported temporarily by international agencies have not led to improvements in the situation in remote areas and poor areas (Hsiao 2005, Xu 2003, Xinhua 18.3.2006).

Ample research has already been conducted regarding the general situation of health care in the Chinese countryside (see in Western language: Liu Yuanli 2002, 2004, Jackson 2005, Klotzbücher 2006).While quantitative data for the  AR Xinjiang (Xinjiang Uygur Autonomous Region) is available for the province as a whole (Yang Lei et al. 2003, Qin Jiangmei et al. 2003),  the specific health care situation in the pastoral regions of northwest China has been neglected until now (see rare examples Wang Qian et al. 2003, Wei Jibing et al. 2003).  

Therefore, the questions guiding the research of this interdisciplinary project conducted by the University of Vienna and Shihezi University are: What are the pathways to better primary health care for the Kazakh minority in a western region of AR Xinjiang?

What are the special conditions for sustainable health care in this sparsely populated area of  semi-nomadic people?

The Chinese government promulgates new policies for rural areas and a more active role of the state (Zhongfa 2002–13, Guobanfa 2003–3). The claim of political leaders is true: the implementation of state policies in these areas is confronted with great difficulties. With regard to the Chinese case, the scientific community in Western countries (Liu 2002, 2004, Klotzbücher 2006) and in China (Hu Shanlian 2002, Wu Ming 2003: 128ff, Wang Hongman 2003), and recently the Minister of Health (People 3.8.2005, People 4.8.2005, Xinhua 18.3.2006) and think-tanks of the State Council (Wang Liejun 2005) have emphasized the great difficulty in rural health care reforms. Even with national or international funding, many health care projects fail to continue after the initial dissemination phase. The capacity of the central state administration for rebuilding an efficient local health care system is limited: In many regions of China, improving health care is a “one man-show of health administrations units” (“ […] 卫生部门唱独角戏”, Wu/Gao 2000: 13) with very limited resources and personnel. From the central to the township and village levels, the process of implementation becomes increasingly complex and its outcomes more and more uncertain.

However, this “Chinese” experience is not exceptional, but part of a more general phenomenon (Hartman Cohen 2004, Jack/Lewis 2004). In China, as elsewhere, evidence-based research seeks to provide the most worthwhile programs or policies to a designated community, however, “[e]vidence does not make decisions, people do” (Haynes et al. 2002 cited in Dobrow/Guel/Upshur 2004: 210).

Basic assumptions

Building on earlier research in the field of public health (Klotzbücher 2006) and on empirical evidence collected in rural China, our basic assumption is that the problem does not lie in initiating projects, the design of programs, or the quality of policies, but the ways and forms in which these policies and plans are implemented at the local level. Sustainable implementation requires successful integration into the existing structures and a certain compatibility with the actual strategies of the actors. The underlying hypothesis of this project is that building rural health care facilities must rely on the strengths, resources, problem-solving abilities, and governance measures already present and widely accepted. The chances of creating a sustainable program with this bottom-up approach are much greater than with imported solutions designed from outside or from the upper administrative levels (top-down approach).

This approach aims at capacity building. Capacity building is defined as the extent to which communities and community members are aware of their core competences and able to apply them to rural health issues. Sustainable capacity building is a local process of nurturing and building upon the strengths, resources, and problem-solving abilities already present and  enjoying wide acceptance (Robertson/Minkler cited in Crisp et al. 2000: 100, Ebbsen et al. 2004: 88, see also Tang 2005).

Aim

This project intends to explore possibilities of capacity building in health care delivery in the northwestern pastoral regions of China. The key agent for health care delivery in pasture areas of Xinjiang is the pastoral hospital (in Chinese: 牧业医院). The pastoral hospital is a community-oriented, but not village-based health care provider managed at the county level in regions with pasture farming for semi-nomadic pastoralists. The staff of this mobile health station accompanies the nomadic herdsmen and their families on their way to the pasture land even when they leave the villages (I 5/05).

So far, pastoral hospitals do not seem to be capable of solving the problem of health care among the nomadic population as they seem unable to cope with the specific demands from potential patients. Herdsmen mistrust health workers who have only a lower level of education and instead make the long journey to townships or even villages for expensive medical treatment. Or, the implementation of the rural three-tiered health system in county seats, townships, and villages is in line with the central policy, but this concept of a stationary health care delivery does not satisfy the needs of a semi-nomadic mobile population. An existing double structure leads to splitting of already scarce financial and personnel resources and low satisfaction on the part of patients (I 5/05).

Before change can occur in the community, it must first occur within organizations. Better health care delivery, prevention, and health education as well as prepayment schemes need better pastoral hospitals that can act as community-oriented and efficient agents

-        near to the pastoralists and their families,

-        offering cheap prevention and curative health care treatment according to what is needed, accepted, and affordable for herdsmen and their families.

This research project assesses the existing health needs, analyses delivery deficiencies and explores already existing resources and capacities for solving the problems in the villages and among families and tries to rely on these resources in developing models of staff and institutional capacity building with the aim of sustainable health care delivery.

In this context, the following problems must be addressed:

·        How to organize and finance the pastoral hospital and how to define its role in the existing three-tiered rural health care system.

·        How to define the services and forms of health care provision offered by pastoral hospitals.

·        How to adjust the idea of adequate health care delivery to the specific cultural and social conditions of pastoral regions.

·        How to mobilize local resources for selected improvements and render all actors more competent to address and organize prevention and health care delivery.

This project is oriented on providing evidence-based answers to these research questions. It will develop strategies of intervention and adjustment for the pastoral hospital in a cross-sectoral approach focusing on better access, quality, equity, and efficiency in health care delivery organization, and evaluate these steps.

In order to succeed in defining possibilities of capacity building in health care, this project will make use of positive experiences and governance concepts that are widely accepted and efficient in other sectors. Thus, the transferability from other sectors (economic and social sectors) to health care delivery is explored in a cross-sectoral and transdisciplinary approach. We aim to realize, learn from, and enhance these successes in order to better promote health and better organize health care: Based on an analysis of health services, our aim is not to implement new forms of health care delivery, but activate and enhance already existing core competences and awareness within existing health care institutions (institutional capacity). Health care delivery will be upgraded through various forms of training and personnel management, payment and social risk-sharing in health care will be analyzed and adjusted to meet the needs of local residents (staff capacity).

Inter-regional concepts of governance for rural health care

The question of rural health care in the pasture land is not only of major importance for improving the health care situation in a region of high political importance for the Chinese government, it is also a question that shows geographical, political, social, and cultural similarities with other countries in northeast Asia, such as Mongolia, Kazakhstan, and Kyrgyzstan. In later parts of this project, we will focus more on an inter-regional comparison.