Mark Strand, PhD, CPH, Professor, North Dakota State University discusses how the nonprofit Evergreen has worked in close partnership with the Shanxi Province Health Bureau in China since 1994, focusing on training and health system strengthening at the CCIH 2018 conference.

1. “NGO Collaboration with the
China Ministry of Health: Striving
for Health for All”
CCIH Conference
Power of Partnership:
Working Together to
Serve the Kingdom
Mark A. Strand, PhD
2018

2. Brief History of China
Healthcare System
 Mission hospitals
 CBPR pre-liberation – James Yen, Yale grad, worked with
YMCA to apply Christian principles to community
development; Dingxian Experiment, 1926-37 (Rural
reconstruction movement)
 Communist system – Barefoot doctors, 1968-1981
 80 % of urban residents covered by work units
 90% of rural residents were covered by cooperative health
plans
 Privatized system -- 1981-2003
 National health care model – 2003-present
“看病难，看病贵”

3. Declining Gov’t Support for
Health

4. Li et al. Health Insurance In China: After Declining In The 1990s, Coverage Rates
Rebounded To Near-Universal Levels By 2011. Health Affairs 2017;36:1452-1460.

5. UHC Definition
 All individuals and communities receive the health
services they need without suffering financial hardship.
It includes the full spectrum of essential, quality health
services, from health promotion to prevention,
treatment, rehabilitation, and palliative care.
 Measure: Maximal proportion of the population can
access essential quality health services.
 Measure: Minimize the proportion of the population that
spends a large amount of household income on health.
http://www.who.int/mediacentre/factsheets/fs395/en/
George. AJPH 2016;106(5):830-831.

6. World Health Organization’s
UHC “Cube Diagram”
Boerma et al. Monitoring Progress towards Universal Health Coverage at Country and Global Levels.
PLoS Med, 2014;11(9): e1001731.

7. Meng et al, The Lancet, 2015;386:1484-92.
Urban Employee Based
Medical Insurance
职工医保
Urban Basic Medical
Insurance
居民医保
Rural New Cooperative
Medical Scheme
新农合

8. Background on Evergreen
 Started in Shanxi Province China in 1993
 Providing public benefit services for the common
people, for the purpose of showing forth the
credibility of Christ
 Initial invitation involved medical collaboration
 Site visits with provincial public health bureau
 Team of 5-10 expatriate medical professionals
and the same local

9. 1994 Evergreen in Rural NCMS
 Evergreen committed to developing rural health care in
1995.
 We begin working in 1995 in FP (Chinese Capitol Medical
University)

10. Meng and Xu, Bulletin of the World Health Organization 2014;92:447-451.
Xinhua News. China vows to make greater contributions to global health governance.
5/27/2018. http://www.xinhuanet.com/english/2018-05/27/c_137210024.htm

11. NCMS (Rural) Results
 The scheme has reduced out of pocket
expenses, and the risk of financial ruin as
a result of a health crisis.
 Increased patient volume.
 But fewer specialized services and drug
sales have reduced overall income in rural
clinics.
BMJ Online First

12. 2003 Evergreen in Urban CHS
 2004 began Integrated Community Development Project
in cooperation with a private Community Health Center.
The focus was on systematic management of chronic
disease and community-based health education. At the
time, there was no govt support for such work.
 Tianjin visit in 2005
 April 2007 launched a 10,000 person outreach
 As the government-mandated model began to take
shape, they increasingly looked to this work as a pilot
project. Thus, it became something of a template for
others learn from.

13. China Healthcare Reform
 On February 21 of 2006, the State Council setup a dead-
line: “by 2010, cities at district or above level and cities
at county level with sufficient condition should complete
a comprehensive community healthcare system.” To
support this aim, a national leadership group was formed
under the State Council and seven government agencies
provided supporting policies.
 The recent plan on health system reform, approved by
the State Council on March 17 of 2009, is a road map
toward a more equitable health system.
Li and Yu. Health Policy 99 (2011) 167–173

14. Evergreen Medical Team Model

15. Challenges for China
 Transitioning from a medical to a CH perspective
 Clinical work with weak connection to community health
outreach
 Govt motivated, so it has support, but under compulsion
 Community participation is limited, but the argument is
made that urgency precludes community involvement.
Will this threaten the sustainability and depth of the
model in the years to come?
 China’s ability to openly embrace a daunting challenge is
impressive.
 Through political will, and the talents of 1000s of flexible
Chinese medical workers, it is coming to pass.

16. Challenges (cont)
 Funding for CHCs hasn’t increased much since it
was founded in 2007.
 Primary care docs have weak capacity.
 The underserved – rural migrants (18%) and
minorities (8.41%) are neglected.
Wei et al.Journal of Health Services Research & Policy, 2015;20(3):162–169.

17. Challenges in Collaboration with
Government Agencies
 Urgency and form compromises quality.
 Health records lack “meaningful use,”
mostly for surveillance and CDM reporting,
but not used in routine clinical care.
 Annual health exams are to fill quotas.

18.  Maternal and Child Health Partnership– Monitoring and
Evaluation, report to their established system
 Family Medicine Education – introduction of outpatient
medical records
 Community Health Service – establishment of
community-based PHC system, Monitoring and
Evaluation
 Chronic disease management program
 Supporting other FBO’s in China
Evergreen Promoting Best
Practices

19. Health Systems
 Significant gap
 Little accountability
 What are some example nations?
Weak
Government
System
Large NGO Systems

20. Health Systems
 Large gap, limited communication
 NGOs struggle for space
 NGOs serve a small population
 Limited NGO impact Big Government
Small and
weak NGO

21. Health Systems
 Government is strong, and responsible
 NGOs are small but effective
 For responsibility and sustained impact
NGOs in strong overlap with government
Large, Responsible
Government
Small but
strong NGO
Serving population
Impacting the
system

22. http://www.social-protection.org/gimi/gess/RessourcePDF.action?ressource.ressourceId=48277

23. Prerequisites for UHC
 Strong central government
 Growing economy with sufficient tax
base
 Uniform medical education system

24. Conclusions
 Universal Health Coverage, delivered through
Primary HealthCare, is the pressing need
globally.
 Under challenging circumstances, and periods of
misdirected efforts, China has steadily moved
toward Universal Health Coverage.
 One way faith-based organizations can serve the
kingdom perspective is by partnering to support
the establishment of healthy healthcare systems.

25. Publications (n=24)
 Yin ZN, Perry J, Duan XQ, He MZ, Johnson R, Feng YL, and Strand MA. Cultural adaptation of an evidence-based lifestyle
intervention for diabetes prevention for Chinese women at risk for diabetes: Results of a randomized trial. Accepted to
International Health December 21, 2017. In press.
 Strand MA, Liu SF, Wang P, Perry J, and Gu XX. Metabolic syndrome as a predictor of incident chronic disease in middle
aged Chinese persons. Global Journal of Health Education and Promotion, 2016;17(3):88-102.
 Strand MA, Yin ZN, He MZ and Perry J. Pathway to Health (PATH): A Lifestyle Intervention to Prevent Diabetes in High-risk
Chinese Women. World Guide to IDF BRIDGES 2015 Brussels, Belgium: International Diabetes Federation, 2015.
 Strand MA, Huseth-Zosel A, He MZ and Perry J. Menopause and the risk of metabolic syndrome among middle-aged
Chinese women. Family Medicine and Community Health 2015;3(1):15-22.
 Strand, M.A., Perry, JL, Wang, P, Liu, SF, and Lynn, Henry. Risk factors for metabolic syndrome in a cohort study in a
north China urban middle-aged population. Asia-Pacific Journal of Public Health. 2015;27(2):N255-NP265.
 Strand MA, Will T, Gu XX, and Perry J. A descriptive study of the progression of the metabolic syndrome in middle aged
Chinese persons. The International Quarterly of Community Health Education. 2015; 35(2):163-176.
 Huseth-Zosel A, Strand MA and Perry J. Socioeconomic differences in the menopausal experience of Chinese women. Post
Reproductive Health. 2014;20(3):98-103.
 Strand, MA and Fischer, PR. An appraisal of China’s progress toward the Millennium Development Goals as they relate to
children. Paediatrics and International Child Health. 2014;34(3):156-164.
 Strand, M.A. Zhao, Y, and Zhang, T. Evaluation of the effectiveness of an intervention on 615 hypertensive patients.
(Chinese) Journal of Community Health, 2012;10(18):82-83.
 Strand, M.A., Perry, JL, Wang, P. The association of metabolic syndrome with alcohol consumption among urban Chinese.
Journal of World Health and Population. 2012;13(4):5-14.
 Strand, MA, Duan, XQ, Johnson, R, Li, YQ. Social determinants of delayed diagnosis of tuberculosis in a North China urban
setting. International Quarterly of Community Health Education, 2011; 31(3):279-289.
 Strand, M.A., Perry, JL, Wang, P, Liu, SF. Prenatal and early childhood exposure to malnutrition and the development of
Metabolic Syndrome. Chinese Preventive Medicine 2010; 11(9):894-897.

26. Publications (n=24) (cont.)
 Strand, M.A., Perry, JL, Wang, P, Liu, SF. 2010 presence of metabolic syndrome and related correlates among 44-52 year
persons in Shanxi Province Jinzhong City. (Chinese) China Journal of Public Health; 2010, 26.
 Strand, M.A., Perry, J., Guo, J.Z., Zhao, J.P., Janes, C. Doing the month: Rickets and post-partum convalescence in rural
China. Midwifery 2009; 25(5): 588-596
 Strand, M. A., Perry, J., Zhao, J.P., Fischer, P.R., Yang, J.P. and Li, S.H. Severe vitamin D-deficiency and the health of
north China children. Maternal and Child Health Journal. 2009; 13(1):144-150.
 Strand, MA, Wang, XB, Duan, XQ, Lee, K, Wang, A, Li, YQ, Ni JX, Cheng GM. Presence and awareness of infectious
disease among Chinese migrant workers. International Quarterly of Community Health Education, 2007; 26(4):379-395.
 Jin MM, Zhao JP, Xi WP, Yang JP, Zhang PY, Li SH, Strand MA Perry J, Guo JZ. Prevalence of vitamin D deficiency rickets
and associated correlations. (Chinese) Maternal and Child Health Care of China Jilin, China, 2007; 22(16):2217-18.
 Fischer PR, Thacher TD, Strand, M. A., Kirmani S, Tebben PJ. Pediatric bone disease: A decade of discovery. Submitted
to Minnesota Medicine April 2007, pp 36-37.
 Strand, M.A., Perry, J., Jin, M.M., Tracer, D.P., Fischer, P.R., et al. Diagnosis of Rickets and Reassessing its Prevalence
Among Rural Children in Northern China. Pediatrics International 2007; 49(2):202-209.
 Thacher, T.D., Fischer, P.R., Strand, M.A., and Pettifor, J.M.. Nutritional rickets around the world: causes and future
directions. Annals of Tropical Paediatrics. 2006; 26(1):1-16. As of 2/8/16, the most frequently cited paper in the history of
the journal (journal name has since been change to Paediatrics and International Child Health).
 Strand, M. A., Peng, G.X., Zhang, P.Y., and G. Lee Preventing rickets in locally appropriate ways: A case report from North
China. International Quarterly of Community Health Education, 2003; 21(4):297-322.
 Strand, M. A. and Chen, A.I. Rural health care in north China in an era of rapid economic change. The Yale-China Health
Journal 2002; 1:11-24.
 Strand, M. A., Chen, Y, et al. (1999). Child's health collaboration between Western Family Practice physicians and county-
level maternal and child health workers. General Practitioner 1999; 8(4): 167-8.
 Strand, M. A., A. Chen, et al. Training up Family Practice doctors with creative-thinking skills. China Academic Medicine
Outstanding Selected Essays. Chinese Medical Society, Beijing, China Technological Literature Publisher. 2001; 2:511-516.