The public/private health care dilemma and an appeal from the nomads of Ashu
by Linda Griffin, Sept 23, 2003

As a translator for the physical therapists on Kham Aid's wheelchair program last year, I was worried that I wouldn't know the Chinese or Tibetan terms for some of the medical conditions we would be dealing with. But as it turned out, neither did most of the patients. "I fell down the stairs ten years ago"…"I was in a road accident"… "I was born like this"… "It hurts here"… "It hurts there"… The translations were simple, but the implications were depressing. The majority of these disabled Tibetans had never seen a doctor - not even for a broken back - because they couldn't afford the fees. And the few who had had medical treatment were not necessarily any better off. One woman in her forties had undergone a botched operation to reset a broken leg after a tractor accident. She was crippled for life and her farming family had lost a precious active member. With the right treatment, our team's doctor said, she should have been walking again in a couple of months.

As director of the medical aid program, I have heard such stories time and again. Most farmers and nomads in Kham simply cannot afford decent health care. This problem is not restricted to Kham: China's whole rural healthcare system is in crisis. The remote clinics which we work with have never been able to provide more than the most basic treatment, but that treatment was at least free in the early Communist decades when they were set up. No more: as China's public services struggle to clear long-standing debts, the cost of health care is spiraling. City entrepreneurs have money, state employees have some basic health insurance. Tibetan farmers and nomads don't, and untold numbers die each year from curable diseases.

Even for those who can afford treatment, rural clinics are ill-equipped to treat serious disease or injury. A trip to the nearest county hospital may involve one or more days' travel on rough roads in areas poorly served by public transport. To get better treatment in Chengdu, the provincial capital, would add several more days on the road and could cost many times the average rural Tibetan family's annual income. It's not even an option.

Besides being beyond the means of the poorest, many government clinics in Kham are badly run. On an unannounced visit, it's not uncommon to find only one junior doctor on duty and equipment rooms locked up, the keys in the pocket of an absent director. Most doctors have had only three years of training at a medical college near Kangding, so their expertise is very limited. Most are Tibetans, but they have usually been posted to remote regions several days' travel away from their own homes, where they have trouble understanding their patients' dialects. They do their best under difficult conditions, but their education (paltry though it is) has given them higher expectations and a taste for urban life, and most hanker after transfers to bigger hospitals.

Private alternatives

It is against this bleak backdrop that a number of privately run charity clinics have sprung up in recent years to provide free or affordable treatment to the poor. The majority are set up by local Tibetan Buddhist leaders. They get their funding from various sources: from the income of their own monasteries, from students in China and occasionally overseas, and from NGOs like Kham Aid. Unlike government facilities, these charity clinics cannot guarantee regular funding for salaries, medicines and other running costs. They survive from month to month, scraping together funds as best they can. Their facilities are usually very basic and doctors' training may be even more limited than that of their counterparts at state hospitals. But the doctors are usually dedicated to the local community, and most crucially the treatment is affordable. Most operate a tiered fee scale, linking payment to patients' means. Unlike state-run facilities, they don't aim to make any profit, so even full payment is much cheaper at the charity clinics.

The Shangye Charity Clinic in Ganzi, where Kham Aid has started a program this year, is bursting at the seams with poor patients. Conditions there are lousy and the doctors cannot treat many illnesses due to lack of equipment and expertise. Meanwhile, up the road, the county hospital has better facilities, more expertise, and fees that poor patients cannot afford. In Rongbatsa, a village outside Ganzi, government and private clinics literally exist side by side. Frustrated with the state system, Doctor Shamba quit his job as director of the village's government clinic and set up his own private clinic right next door, with funds raised by friends and relatives in Europe. A local man, he practices Tibetan as well as Western medicine, which is another attraction of the private clinics - only a few government clinics have traditional medicine.

In an area where there is so much need, it is painful to see such fragmentation of resources. But again and again, I've been told that the government can't or won't join forces with the private charity clinics. No framework for such a collaboration exists, and both sides are somewhat suspicious of each other.

Which leaves Kham Aid with something of a dilemma: do we support public or private clinics? So far we have done both. Last year we donated equipment to some of the most needy government clinics in areas where there are no private alternatives. This year we have funded equipment and repairs at Shangye Rinpoche's clinic, and we are receiving a growing number of requests from other charity clinics. (The most difficult to solve is the perennial need for salaries and running costs, an open-ended commitment which few sponsors are willing or able to take on.) It would be great to see a working public health care system accessible to all in China, but as things stand now these charity clinics are providing a valuable service to poor people in Kham.

Below is an appeal from one such clinic which I visited last month.

Kunphen Charity Clinic (An appeal from Za Kathok Rinpoche)

Kunphen Menkang ('Help-All Clinic') is located in the grasslands of Ashu (Axu), a remote area of Dege County famed as the birthplace of the legendary Tibetan King Gesar. The local Tibetan population are nomadic herders. With little cash income, the average nomad family has no access to good health care.

There is one small government-run clinic in Axu township, but most local nomads prefer Kunphen Clinic for a number of reasons: it is closer to their pastures; treatment is cheaper; the township doctors don't speak the local nomad dialect; traditional Tibetan medicine is not available at the state clinic; and the Kunphen doctors do house- (or rather tent-) calls when necessary. For more serious injury or illness, patients who can afford it must undertake an arduous journey to either Dege or Ganzi. There is no public transport here: patients must travel on horseback, motorbike or by the occasional truck to the main road some 60km away, then try to find a ride onwards. If they are lucky they might get there in a day. "Many die on the way," said Za Kathok Rinpoche, who is trying to raise funds to improve the clinic. The many more who cannot afford the fees in urban hospitals make do with the basic treatment available at Kunphen.

The clinic was set up by two monks from Za Kathok Monastery, both of whom have trained for several years in Tibetan medicine. One of them, Karma Sonam, also studied Western medicine for one year in Dege. They started treating local patients seven or eight years ago, and three years ago they built a small clinic with funds borrowed from a local moneylender. Neither doctor has any salary; they depend on their families for food. They gather medicinal herbs and roots in the mountains and make the Tibetan medicine themselves with a pestle and mortar, an extremely time-consuming process." We spend about three months making enough medicine to last for one year," Dr Karma said. The monk-doctors occasionally travel to Chengdu to purchase other herbs which are not available in Ashu and a limited stock of Western medicine, again with borrowed money.

Treatment costs are kept low, and the monks reduce or waive payment for genuine cases of poverty. ("Everyone knows everyone around here - we know when someone really can't pay" says Karma.) At full cost, they charge only 2-3% more than the wholesale prices of the Western medicines (government clinics charge a lot more), a profit that only allows them to repay the annual interest on their outstanding loans.

The clinic is a single-storey building of rough-hewn stone, with only three rooms. One serves as examining/treatment room and pharmacy, the other two as the doctors' living quarters. Karma hopes to build four small wards outside the clinic, as many people require inpatient treatment. There is no power supply in Ashu, but the clinic has one solar panel which powers a single light bulb in each room.

Kunphen Clinic serves a population of around 60,000 nomads, and the doctors see as many as 20,000 patients per year. "Most come in the winter, when they come down from the higher pastures and camp near the monastery. Also, the cold weather brings more illness. We treat 150 to 200 patients on busy days," said the doctor. Chronic ailments, of which gastric and liver disease are the most common, are usually treated with Tibetan medicine, while one-off illness is treated with Western medicine. As elsewhere in China, frequent injections of glucose solution are administered. Kunphen has neither disposable needles nor adequate sterilizing equipment - needles are just boiled in between use.

The monks are experienced in Tibetan medicine, but with their very limited knowledge of Western medicine, they are essentially acting as pharmacists rather than doctors. Both lack of training and equipment leave them ill qualified to deal with serious injury and illness. Priorities are to improve the basic facilities, hire a fully trained retired doctor from the local township and ensure a regular source of medicines.

Za Kathok Rinpoche, distressed by the plight of the Axu nomads, has set his sights high: "My dream is to build a real modern hospital in this valley, with excellent doctors, operating rooms … and affordable treatment for everyone."

Request for funding

Salary for one extra doctor: 1500rmb/month (US$187/month)

Construction of wards: 8000rmb (US$1000) per one-room ward (includes all building materials, labor and simple furniture); four wards: 32,000rmb (US$4000)

Grinding machine for Tibetan medicine: 5000rmb (US$625) Generator to power the above: 3000rmb (US$375)

High-pressure sterilizer: 600rmb (US$75) and/or disposable syringes: 0.6rmb (7.5 US cents) a piece

Donations large and small are welcome!