Wednesday, July 29, 2009

Teaching at Peking University

One of my former students, DAmjan Denoble has been attending the course I am teaching at Peking University this week, focused on comparing how nations organize and finance health care systems. Damjan writes a blog Here is a cut and paste from his blog from the first day....I am doing it this way because I am struggling with the blogspot software in the way I am having to log in to update my blog.

It has been very interesting to teach this course. There are 90 students from 44 Chinese Universities taking this joint Duke/PKU diploma program....basically some of the top students in China. I will write more of my thoughts on this later.

health (Part 1)
Damjan 1:57 am on July 28, 2009 | 2 Permalink | Reply

Duke University’s Global Health School is in Peking this week teaching a condensed, five day Global Health certificate program to some of China’s best students. The focus of the first week is health inequalities and health insurance financing.

All indicators point to this being a high prestige event. Forty-four Chinese universities have sent up to three of their best students to the Beijing University Health Science Center. The building hosting the event is nary five years old. Built of gorgeous red, Victorian brick (a rare sight in Beijing), internally conditioned, and boasting classrooms fully equipped with the latest audio and projector technologies, it is literally the best that Beijing University has to offer.

The rest of Beijing University Health Science campus – yixue bu – is a bit older, and the majority of the other buildings, as far as I can tell, are done up in a white tile fa├žade so familiar to anyone who has lived in China an appreciable amount of time. The West Gate of the campus is a five minute cab ride from Wudaokou subway station on line 13, and an even shorter hop and skip from Xitucheng station on line 10. I did not know how close it was to the latter, and I did not know that the campus was separate from the main campus of its patron Beijing University institution. Therefore, it took me nearly two hours to find the place, relying solely (and I am not exaggerating) on a single phone call with Donald Taylor, Associate Professor at Duke University, where he basically said the following;

“I don’t know how well you know the Beijing University campus. But we’re in a red brick building. On the fifth floor. Big auditorium place.”

Since it was his first time in Beijing we left it at that, and I was left with three pieces of information. The building I had to find was five floors or bigger. It was constructed of red bricks. And, it was on the main campus. Unbeknownst to me, I was really playing a modified version of the childhood game “Two Truths and a Lie”. The third fact I listed, as you already know after reading this piece, was the unwilling lie.

It took 45 minutes of searching for a five floor, red brick building on main campus, about two dozen stares from puzzled Beida students I had enlisted in helping me find a huangsi zhuantou de jianzhu (or building made of red brick), and a successful Google search for “Beijing University, health, red brick building” to eventually get to the adjoining Health Science campus. Once there I had to choose between two red buildings; trust that the fifth floor location had not changed; and then, once on the fifth floor, follow a North Carolina accented voice to a room full of Chinese students. Trust me, the actual ordeal was even more impressive than I make it seem.

In any case, I know how to get here now. During the next few days I will be putting up the response of the Chinese students to the discussion questions they are asked to examine at the tail end of every lecture period.

I have chosen this as the focus of the piece because, in the near future, many of the students in this room are going to be on the front lines of China’s health reform efforts. Trained in China’s top graduate programs for health management, their voices and opinions are already likely to be an accurate representation of the thinking process and level of knowledge of China’s current health reform leaders.

The way to read through my transcription is simple. For every question posed I have given a series of answers. The group responses are divided by letter. Group A, B, C and so on. Group A’s response has no letter after it.

I. What is the purpose of the Chinese Health System?

1.) Improve health outcomes – to achieve this purpose China has 4 health systems; hospital system, public health system, pharmacy,

2.) Indirect purpose – if we improve out health status we can achieve development of economy and fulfill stability of society and we can achieve sustainable development.

1b.) Figure out a way to balance cost and efficiency

2b.) Promote health education

3b.) Important in building up the community. A sense of the community. Harmony of the community. To make the society more peaceful and more stable.

4b.) Employs a lot of people and so is important to their livelihood

1c.) The ultimate purpose of the Chinese health system is to raise the peoples standard of living.

II. Two things you like about the system? Why?

1.) In 1949 we had very little structure in China and so Mao started the barefoot doctor program.

2.) Dots program – China has been very successful in tackling the dots progr

1b.) Ensures that everyone has an equal chance to share health insurance. For example more and more peasant workers now have health insurance which is taken as 2% of their salary.

1c.) Two main things – The reparation systems for retired workers. There has been great improvement in this area.

2c.) Public health emergency system is much more responsive. Our H1N1 response was much stronger than our response to SARS. Our government controlled this very effectively. It is all due to the surveillance system being employed now. Under this system the government will quickly know if the situation changes.

III. Name two things you want to change/improve? Why?

1.) Primary car service. The general practitioner is very important – they are the bridge between patients and medical institutions. They are the gatekeepers of the system. So, medical resources should be distributed in a more equal way.

2.) We need to get them out to the rural areas.

Don Taylor Response that garnered laughter: “This is a universal problem. If you figure out how to fix that then let the rest of the world know.”

1b.) As everybody knows, it is very difficult to go to see the doctors now. The reason is money –

From the aspect of the providers and the receivers of the health resources.

2b.) Medical students want to go to the best hospitals

3b.) People who are accessing care want to go to the best hospitals. This is a problem because

people with the most serious cases cannot get proper care since the hospitals are overcrowded

with people who are getting sub-standard care

1c.) There are still people in rural china that do not have clean water and clean toilets. Some of them give birth at home. The second thing is that China ha an internal migration problem. China has a population of 140 million rural migrants that have come into urban areas. This population is excluded from urban health services. If one of these individuals gets sick in the city he usually does not have insurance. Even if they do have insurance in their home town it cannot be used in the city.

IV. Name two barriers to achieving changes?

1.) Economic development of China is still in the initial changes while China has the largest population in the world. There is a conflict there that needs to be resolved.

2.) Regions are not equally developed.

3.) Peoples preference – patients prefer clinical practitioners to GPs and medical students want to study how to be private practitioners and not public health experts.

1b.) The cost always contains the cost of the disease cure but also the accompaniments. Doctors often prescribed costly medicines to patients.

2b.) Something about chronic diseases and old people that needs to be better addresses

1c.) Government financing is insufficient. There are many reasons. One is too much bureaucracy. The health ministry does not have control over finances – - – - – - > they have to depend on the finance ministry for money.

2c.) There is no information system which links the rural and the urban areas of the country. Developing information systems between urban and rural counties then cities and towns could share insurance information.

V. Name one strategy to overcoming barriers?

1.) The government should establish their in-state mechanism. For example two doctors who graduate from top colleges but choose to go to public hospitals would be eligible for government awards (probably some sort of financial award).

2.) Education – teachers should emphasize the difference between preventive and clinical treatment. Students should be exposed to the primary hospital early

1b.) If you want the best treatment you have to the best hospitals and get the best treatment. Second it is very expensive to pay for doctors and medicines, especially for patients from rural areas. What has caused this? There are two reasons. First, medical distribution is unfair. China is a big city. Ah. China is a big country. (laughter). We have a big population and most people live in rural areas but they do not get most of the resources.

My strategy is very simple. I think our country should invest more money in rural areas to help build the system. [With more money] they can attract more doctors and build more doctors. This will make it more convenient for rural patients access care outside of the city. My second strategy is to further educate patients about health problems so that they can learn how to take care of themselves better.

Donald Taylor comment that garnered laughter: What’s interesting about this group [Group B] is that you put almost everything within the responsibility of the health system.

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