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Contact Us Spring 2001; Volume 2, Number 1
Health Highlights
 
Health Care in Tibet: Clinical and Policy Perspectives (Cont.)
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Many people, however, are not yet enrolled in the CMS system that has been implemented within the last year. Moreover, unless a person is elderly, disabled, poor, orphaned, or has a family member that served in the military, everyone is expected to pay. For those people living in the larger cities, enrollment will not be difficult and education about the new health system will be possible. However, in the rural areas, however, implementation of this system will be difficult. In many rural areas, people have more than eight children and will not be able to afford to enroll the entire family. It will also be difficult to educate the people in the villages about how the system works and what they will get in return for their money.

As a result, most people cannot afford basic medical care at present. Patients wait until they are quite sick before they seek medical attention, and at this point, care becomes prohibitively expensive. For city dwellers, services and medications are available but often not affordable. In the rural areas, patients too sick to be treated by the township or village doctor have to find affordable transportation to the closest county or prefectural health facility. Tibetan transportation, however, is unreliable, difficult to find, and often unaffordable. Once at the hospital, most villagers will not be able to pay the required 1,000RMB deposit, not to mention the final cost for care and medications.

Accessibility

As indicated above, access to health care is possible in the cities, but in the rural areas is most difficult. Patients who require care beyond that which is provided at the local level are often carried to cities on yaks or in vehicles that are passing by. It is often much too expensive for these individuals to afford transportation, let alone the bills they will acquire when they arrive at the city hospitals.

Equity

The system, mainly as a result of accessibility issues, is clearly inequitable. Those poeple that can pay for more and have the means to be transported to better facilities clearly have access to better health care. This holds true for the diagnosis and treatment of pulmonary diseases. The diagnosis of TB, asthma and cancer is under-diagnosed everywhere in Tibet, but especially in the rural areas. At the village and township levels, the doctors do not have the facilities or the ability to recognize these respiratory diseases. And if they do happen to make proper dianoses, they have very few means to adequately treat their patients.

Problems and Recommendations
 
Problems to Address

There are a vast number of problems in the Tibetan health care system that are preventing citizens from obtaining adequate medical care, especially for the treatment of pulmonary diseases. Changes in the overall structure of the system as well as in the policies that govern this structure are needed to provide sufficient medical services. In addition, changes at the clinical level are critical to improving patient care. The following is a focused list of problems that deserve immediate attention.

  1. Basic standards of cleanliness and asepsis are not met.
  2. Training of doctors is not consistent and is not adequate at the township and village levels.
  3. Health care is not affordable for many Tibetans.
  4. Quality health care is not accessible to most rural Tibetans.
  5. TB remains a significant problem in Tibet, including its diagnosis, treatment and containment.
  6. There is a lack of the basic medical supplies needed to treat routine pulmonary diseases, specifically x-ray machines, ventilators, nebulizers and inhalers.
  7. A lack of patient educatioi leads to poor patient compliance.
Recommendations

Under ideal circumstances the most salient issues could be addressed simultaneously. With limited time, money and resources, however, not all of the problems I've discussed will likely be eliminated in the near future. The following is a list of recommendations that are needed to help bring better health care to Tibet.

  1. Implement standards of cleanliness and asepsis: Guidelines should be drawn up by a group of physicians. Ideally, this group should consist of both Chinese and Tibetan doctors from all different levels and types of health care facilities. They should draw on the standards used by Western countries. Once standards are established, they should be distributed to all physicians. To ensure that the minimum standards are being met, the government should do yearly inspections.
  2. Improve Physician Education and Training:
    • Basic: A minimum number of years of study in a medical school should be required for all doctors, including township doctors. For those that want to go on to practice in hospitals, an internship should be mandatory.
    • Technical: Physicians need to be trained in how and when to use medical supplies. Seminars should be created to educate practicing physicians on how to use basic medical technology.
    • Pulmonary diseases: In addition, most doctors need to be educated on the treatment and diagnosis of pulmonary diseases. I recommend that seminars be set up by either the Chinese government or NGOs to teach the proper ways to diagnose and treat the most common pulmonary diseases in Tibet. Funding could be obtained from corporate grants, the government, and, in small part, from the participating doctors themselves.
    • Patient education: A national campaign should be developed to:
      1. Encourage Tibetans to join the CMS system.
      2. Encourage patients to see their local doctor early in their illness.
      3. Encourage hand washing.
      4. Discourage smoking.
      5. Discourage spitting.
      6. Encourage disease prevention.
      7. Warn people of the risks of communicable diseases.
  3. Increase Affordability: With the implementation of the CMS system, it is possible that with outside funding, all Tibetans could afford health care. Grants provided from large corporations and government agencies could be filtered through NGOs. Staff members could go out into the villages and bring the villagers to their CMS center. Here, the villagers could sign up, funded by outside financing, and be educated as to what medical facilities they now have at their disposal.
  4. Improve Accessibility: For those who live in the city, health care is accessible. In rural areas, however, transportation to better facilities is unreliable and unaffordable. I propose that each township be affiliated with a county or prefectural hospital. A schedule of transportation can be arranged so that on a weekly or bi-weekly basis a vehicle will go between the township and the hospital exchanging delivery and pick up of specimens and patients. A nominal fee could be charged per patient to help cover costs. The hospitals could also contribute, as they will be generating increased revenue from the patients and lab tests they receive.
  5. Focus on Tuberculosis: There are several measures, often overlapping with those recommended for the health care system overall, that could be implemented that would help to better contain and treat this disease, including screening, identification and Registration, treatment, education, follow-up, and incentives to increase compliance.
  6. Distribute Supplies: To better treat all pulmonary diseases, asthma and lung cancer specifically, the following supplies need to be distributed:
    1. Inhalers (Ventolin and Beclamethasone) need to be distributed to all medical facilities including the townships.
    2. Nebulizers need to be distributed to all hospitals in the prefectures and counties.
    3. At least one mechanical ventilator should be available in each hospital in the prefecture and county levels.
    4. Every hospital at the county and prefecture level should have a working x-ray machine.
    5. Funding: Some drugs and equipment can be donated from health facilities in other countries that are updating systems. Donations from companies that make the equipment and drugs can also be obtained. Funding for equipment and drugs can come from corporate grants and the government.
  7. Increase Screening: Three screening programs, in particular, should be implemented:
    1. Asthma: Screen all children that enter primary and secondary school by physical exam. Every person under the age of 20 should be screened when he is registered for the CMS.
    2. Lung Cancer: Promote screening chest x-rays for all high-risk persons (smokers, occupational exposure to carcinogens) over the age of 45.
    3. TB: Purified Protein Derivative (PPD) testing.
Conclusion

Since the Chinese Cultural Revolution, Tibet, like other parts of China, has been changing rapidly. The health care system is one area where these changes are very apparent, and where the system is currently in a state of disorganized flux. As one might expect, a shift of this measure is often fraught with difficulties, predictable and otherwise. However, when a component of society so fundamental as health is affected, steps must be taken to minimize harm and encourage rapid change that will benefit the people. There is no doubt that the intention of the Chinese government is to bring Tibet closer to Western Medicine and thereby improve the overall health status of the country. But during this time of transition, the Tibetan health care system is functioning poorly.

Progress has been made in some areas, but improvements are badly need in other areas. The new system of financing through the CMS should, to some extent, help resolve some of the basic issues of affordability and equity. Yet, the issue of deficient physician education and training, is not being addressed. Without some serious consideration of this critical issue, which I see as most critical of all, health care in Tibet will not improve. An uneducated doctor is as ignorant as an uninformed patient, and the combination is lethal. For improvement to occur, it is imperative the medical and public health communities recognize the extent of this problem and find solutions that will impact not only Tibet, but also other communities and nations who are facing some of the very same problems.

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