CHAPTER 10

THE CASE OF CHILE

The causes of the underdevelopment of Chile, and the concomitant maldistribution of health resources, are the cultural and technological dependency on the developed countries and the underuse and improper use of the existing capital by the lumpenbourgeoisie and its foreign counterparts (1). These also are the causes of the underdevelopment seen in much of the Third World. Bourgeois sociologists and economists, and the development agencies of the metropolitan countries would have us believe that the underdevelopment of countries like Chile is due to the scarcity of technology, the right values, capital and resources in the underdeveloped country and the lack of diffusion of capital, technology and values from the developed countries to all areas of the underdeveloped country. Chile, like many another underdeveloped country, is rich in natural and human resources as well as capital.

The underdevelopment of health services in Chile before the Allende popular front government was due to the inequitable distribution of economic and political power between the different classes in Chile. The following description of the class system in Chile was given by the Popular Action Unity Movement (MAPU), one of the coalition parties in Allende’s Unidad Popular Government.

The upper class consists of the wealthy urban (monopolistic and non-monopolistic) bourgeoisie and the agrarian bourgeoisie; the middle class consists of the professionals, the white collar workers, civil servants, the petit bourgeoisie, and middle-ranking officers of the armed forces; the working class includes the workers in the small and large industries and the subproletariat; the peasantry includes farm workers and sharecroppers(2). The power of the upper classes (the lumpenbourgeoisie (3)) is dependent on the power of the bourgeoisie in the metropolitan countries. The middle classes in Chile lack the independent power of the middle classes in the industrialized metropolitan countries and are, here, dependent on the power of the lumpenbourgeoisie. The top 10 per cent of the population controls 60 per cent of the wealth of the country, and determines the pattern of underdevelopment; the working class and the peasantry constitute 65 per cent of the population but own only 12 per cent of the wealth (4).

This picture is reflected in the country’s health care delivery system where the state’s ‘National Health Service' covers the poor, the unemployed, the working class and the peasantry (70 per cent of the population). Voluntary health insurance covers the middle class (22 per cent of the population) and private fee-for-service medicine covers the lumpenbourgeoisie (8 per cent of the population). In 1968-1969, the top 30 per cent of the population consumed 60 per cent of the country’s health expenditures, whilst the rest of the population (70 per cent) consumed only 40 per cent of these expenditures, and the differences in the consumption of health resources as between the classes is increasing rather than decreasing. This has led to a situation where family expenditures for health services in the lower classes are a tenth of the amount spent by the upper classes (5).

The History of the Health service in Chile

Health as a right was written into the Chilean constitution in 1925, but little more was done, partly as a result of the Depression in the world economy in the thirties. During World War II, however, the demand for Chile’s products increased and the ruling elite and their allies in the metropolitan countries saw an opportunity for the increased exploitation of the nation’s resources through a form of industrialization. For this, a healthy industrial workforce was required. In 1952, a ‘ National Health Service’ was introduced. The statute establishing the National Health Service stated that a major aim of the health service was to produce a healthy and productive labour force; a prime objective was to guide the development of the child and the young, and the maintenance of the adults for their full capacity as present and future producers.

The incipient industrialization in the 1940s was followed by increasing inequality between social classes, social unrest and repression. As had happened previously in the development of other industrial societies, the stick of repression was accompanied by the carrot of social security and health insurance legislation when the existing social order felt threatened. In Chile, Dr Allende, a Socialist Party member of the Chilean Senate, sponsored the law establishing the National Health Service in 1952. The new health service became an important source of income for 90 per cent of the physicians who worked in it on a part-time or full-time basis. The upper and middle classes continued to be serviced in the private sector on a fee-for-service basis.

As the health costs rocketed in the 1960s and physicians feared that their private patients would be forced into the National Health Service, a health insurance plan (SERMENA) was created in 1968. This provided a cover for both hospitalization and ambulatory care while maintaining the fee-for-service method of payment to physicians. The situation in the health sector now reflected the class structure of Chilean society in that the National Health Service took care of the poor, the industrial workers, the peasants and the unemployed (all constituting 70 per cent of the population), the voluntary health insurance scheme took care of the middle class and a small proportion of the elite (constituting 22 per cent of the population), whilst the lumpenbourgeoisie continued to make direct monetary payments for their health care.

THE MALDISTRIBUTION OF HEALTH RESOURCES

There is also a geographic maldistributin of health resources in Chile (6). The country is long and narrow and it is 75 per cent urban, with 30 per cent of the total population living in the capital, Santiago. The personal expenditures for health services (including both ambulatory and hospital care) in Santiago are over four times those in the rural areas. Santiago has over 60 per cent of all physicians and 50 per cent of all dentists. In the urban areas 80 per cent of the water supply and 65 per cent of the sewerage system are considered adequate, whilst the corresponding figures for the rural areas are 20 per cent and 9 per cent respectively.

In Chile, as in most other underdeveloped countries, the lumpenbourgeoisie control most of the wealth, income and property in society. In the health sector, consequently, resources are distributed according to consuming power (upper class consumer power) rather than producing power, and medical education is Flexnerian (emphasizing curative medicine) and urban-based, with the medical students coming mainly from the professional and lumpenbourgeoisie classes.

The influence of the lumpenbourgeoisie over the organs of the state is such that even the public sector comes to serve their needs. The consequences of this are that the health services are oriented towards specialized, hospital-based medicine as opposed to community medicine; urban technologically intensive medicine in contrast to rural, labour-intensive medicine; curative medicine as different from preventive medicine; and personal health services as opposed to environmental health services. All of which is inappropriate in a country where malnutrition and the infectious diseases are the main causes of mortality and morbidity.

The lumpenbourgeoisie have an interest in the latest scientific medicine and in the super-specialities, such as open-heart surgery units, coronary care units and organ transplants. This diverts much needed resources from the production of health services aimed at the care of the many. In a country where 38 per cent of the population is under 15 years of age and with a type of morbidity caused by enviromental and nutritional deficiencies, surgery still represents the top speciality by percentage of physicians, and paediatrics and public health remain the lowest categories.

THE ALLENDE YEARS

“.......with Allende, the ragged ones govern” was a song that was popular amongst the enemies of the Chilean revolution (7), during the Allende years. The Unidad Popular (U.P.) government under President Allende came to power after the elections of 1970. It was a coalition government that included the Socialist Party, the Communist Party, the Radical Party, the United Popular Action Movement (MAPU) and the Christian Left Party. Health policy was decided by the Cabinet which was dominated by the Socialists and the Communists, and led by President Allende, a physician by profession. Allende himself had for long been involved in the developments of the health services in Chile both as a member of the Senate for the Socialist Party and as Minister of Public Health in a 1938 Popular Front governemnt. The Allende government was committed to the integration and democratization of the different branches of the health services and the placing of greater emphasis on ambualtory care and preventive services.

Under previous administrations, the National Health Service in Chile had become centralized, bureaucratic and hospital-oriented, with nearly 50 per cent of all National Health Service expenditures going to hospitals. Health care was delivered at three levels: primary care delivered through health centres, secondary care delivered, through community hospitals, and super-speciality tertiary care delivered-through regional centre hospitals and units.

The Allende government began by allocating more resources towards the primary care centres. Physicians working in the NHS had to spend a third of the time in the health centres. All physicians had to spend an increased period (5 years) in a health centre after qualification, or at the end of their residency programmes. The health centres, themselves, were kept open till late in the evening, or, in the case of Santiago, were kept open 24 hours a day, utilizing final year medical students. Preventive services (immunization, vaccination, prenatal care) were emphasized as part of the usual services of the health centres. The usual distribution, of half a litre of milk per day to children under the age of five, was extended to include children of upto 15 years of age. These measures, although not popular with the majority of physicians, were popular with the majority of the population and resulted in a large increase in the consumption of ambulatory services, especially amongst children.

As a result of demands, in the 1960s, by working class political parties, for more participation in social and economic areas, a previous Chilean administration created the Community Health Councils with the remit to advise the directors (appointed by the central government) of the appropriate institutions in the primary, secondary and tertiary care levels. In the event, they were not very effective, and were regarded by the working class as a co-opting mechanism to legitimate the decisions of the bourgeoisie.

Committed to the democratization of the health institutions, the Allende government created the executive committees which were the top administrative authorities in each institution in the health service. The membership of an executive committee was comprised thus: one-third of the members were elected by community organisations and trade unions, another third were elected by the workers and employees of that particular institution, and the final third were appointed by local and central government authorities. The executive committees of the health centres elected the, executive committees of the community hospitals, and these, in turn, elected the executive committees of the regional hospitals.

The democratization of the health service was welcomed by an increasingly politicised population, though not by the civil service and the medical profession. Other examples of community participation were the Councils for Distribution of Food and Price Controls, to assist in the distribution process and avert a black market, and workers’ control of the enterprises in the public sector. When the owners of factories went on strike in 1972, the factories were taken over and managed by the workers and the communities. As the movements of the workers and of the communities gained momentum, the government hesitated and backed down in its commitment to popular control. It is widely believed that this was partly responsible for the fall of the Allende government (8).

Allende was also hesitant in his commitment to create one national health service through the integration of the National Health Service and the voluntary health insurance scheme (Sermena). Opposition to this programme came from the lumpenbourgeoisie and the middle classes who feared that they would have to share limited health resources with the rest of the population. The medical profession opposed this measure on ideological grounds. They also feared the loss, of their economic and professional power.

One year after the Unidad Popular government took office, industrial production went up to full capacity from 75 per cent capacity, unemployment went down to 3.8 per cent from 6 per cent, workers received a 20-30 per cent increase in real wages, the percentage of the national income in wages went up to 60.7 per cent from 51 per cent, and inflation went down to 22 per cent from 26.5 per cent.

However, many adverse factors mitigated the successes of the Allende years. The increase in imported commodities and the fall in the price of copper, Chile’s main foreign-exchange earner, resulted in a rapidly worsening “balance”, of payments. On top of this, there was an economic blockade of the country. When Allende nationalised the U.S.-dominated mining industry, the U.S. pressured international lending institutions to deny new credits to the Chilean economy (although the Chilean armed forces remained the main receipients in Latin America of U.S. aid for training officers). When no other department of the government could obtain international credit, the Chilean military received credit to buy supersonic F5E jets and the U.S. granted to the Chilean military a total of $45.5 million in aid in 1971-1974, double the amount donated in the previous four years (9).

The economic blockade of Chile was operated by the U.S. foreign aid programmes, the Inter-American Development-Bank, the U.S. Export Import Bank, the World Bank, and U.S. private banking institutions. This left the government without credit to purchase foodstuffs, machinery and equipment; and also to pay off the national debt inherited from previous governments. The government was subverted by political strikes organised by the lumpenbourgeoisie, such as the truck owners’ strike that interfered with the distribution of food.

These factors gave the lumpenbourgeoisie and the middle classes (such as the medical profession) time to organise the opposition and later paved the way for a military take-over. The Chilean Medical Association, which had expelled President Allende, a founder member, in the summer of 1973, was the first professional organisation to send a telegram of support to the junta when it took over the government on September 11, 1973. The plotting, in fact, had begun towards the end of 1972, and involved military leaders, the transport owners, professionals (including the Chilean Medical Association), the Chilean Chamber of Commerce and representatives of national and international economic interests.

THE EFFECTS OF THE COUNTER-REVOLUTION

The advances made during the years of the Allende Administration, both within and without the health sector, were undone by the counter-revolutionaries under General Pinochet. Within the health sector: an Army colonel was appointed Minister of Health and the treasurer of the Chilean Medical Association was appointed Director-General of the National Health Service. The integration of the NHS with the voluntary health insurance scheme was abandoned. Outwith the health sector, most of the nationalised industries were returned to their previous owners, and the owners of the remainder were generously compensated. Foreign investment was encouraged with generous inducements. Almost immediately after the military coup, the World Bank, the Inter-American Bank and the Latin American Development Bank made generous loans to the military dictatorship that they had persistently refused to the Allende democratic government. Further massive credits were approved by the Nixon administration.

Also, within the health sector, institutional democracy was discontinued; outside the health sector, workers’ control of the management of factories was discontinued, trade unions banned and their leaders jailed, and working class-based parties outlawed. Furthermore, the amount of money available to the health centres was reduced, and that available to the hospitals increased. The number of hours worked by the physicians in the health centres and the number of hours during which the centres were kept open were reduced. The milk distribution programme was abandoned. The workers and peasants began to find life hard again, but the stores themselves were full of expensive consumer goods for the middle classes and the lumpenbourgeoisie. Finally, all opposition was outlawed.

The Chilean Medical Association provided the police authorities with the names of those physicians and health workers who did not join the physicians’ strike against the Allende government; as a result, these workers were victimised (10). A campaign of repression was commenced against the public health movement which had supported the Allende Administration. The country’s only school of public health had its budget slashed by three-fourths. 82 out of its 110 faculty members were dismissed or imprisoned or both. All medical schools and universities were placed under military control. In all, 21 physicians were shot, 85 imprisoned and many, many more dismissed.

The Chilean experience demonstrated the fact that, in that country, as indeed in most of the underdeveloped, economically dependent Third World, current political structures militate against any opportunity to bring about change that would benefit all of the population, and not just the elite. The lumpenbourgeoisie and their foreign counterparts dominate those political structures which maintain unjust political, social and economic privileges. They feel that any concession to a movement that might entail a lessening of their privileges would escalate and lead to a loss of all their privileges.

The Chilean experience also proved that a process of gradualism, with the postponement of outright decisions, reduces the opportunities for real change in society as it allows time for the massive opposition of the national and international interests to organise. No one understood this more than the Chilean workers and peasants when they urged the Allende government to proceed with haste with the proposed reforms after the first unsuccessful military coup on June 29, 1973 had raised the level of political awareness.

Health Services in Cuba

STATISTICS

Statistics relating to the period before 1959 were incomplete and, therefore, highly unreliable. Since 1965, high priority has been given to establishing a reliable system of data gathering to cover the whole population.

Prior to 1959, one third of the Cuban population and 60 per cent of the rural population suffered from malnutrition. The percentage of malnutrition was higher amongst children than amongst adults, and 80 per cent of the children in rural areas were undernourished. On the other hand, “Cubans now probably all have enough to eat [although] just enough. And in the country..........the very poor peasants must be fed better and more regularly than before the revolution; and nearly everyone has better meals than they did before the terrible years of the Depression which lasted so long in Cuba” (16).

There has been a marked decrease in the mortality resulting from water borne diseases, such as gastroenteritis and other diarrhoeal diseass, with the mortality figures falling in the period 1957-1967 from 42.5 to 20.1 per 100,000 of population. The first three causes of mortality were now heart disease, cancer and cardio-vascular conditions (as it is in the U.S.). Changes in the socioeconomic development of Cuba have resulted in a change in the mortality and morbidity patterns.

HEALTH SERVICES

The health services in Cuba are run by the state and are free, whether, they are preventive or curative, enviromental or personal, medical or social. Drugs are supplied practically free of charge. Staff are paid according to profession, experience and training. The Cuban health services are organised into seven health provinces for administrative purposes, each province holding approximately one and a quarter million people. Each province is divided into several regions of approximately one-quarter million people, each region into several areas of approximately 30,000 people and each area into several sectors of 3,000 - 5,000 people each.

The levels of care rendered are as follows:
Sectorial units provide some supportive primary care services. Health centres (or polyclinics) operate at the area level and provide primary care, general medical services and ambulatory secondary services. Each health centre has several sectorial units. Regional hospital centres provide secondary or speciality care services. Provincial hospital centres provide tertiary care or super-speciality services. There is a continuous flow of patients from the periphery (the area) to the centre (the province), and a flow of specialised and supportive personnel and resources from the centre to the periphery. Curative and preventive medicine, enviromental and personal health services, and medical and social services are integrated at the area, regional and provincial levels.

THE HEALTH CENTRE

The health centre, non-existent before 1959, is the smallest administrative unit providing health services and is the point of entry into the health services system. There were, in the seventies, 268 health centres. Their size is related to the size and density of the population served; the largest type of health centre has maternal, child care and observation beds and may then constitute a rural hospital. The health centres supervise and administer the sectorial units which are staffed by paramedical personnel (an auxiliary public health nurse and an assistant technical sanitarian). The health centres provide clinical (curative and preventive) services in internal medicine, paediatrics, obstetrics-gynaecology, and dentistry; enviromental health services; public health and community services; and finally, social services. Each of these four different services is provided by a different team comprising primary care specialists, specialized nurses and auxiliary nurses. The three types of clinicians based in each health centre are general practitioners (who were in solo general practice before 1959); physicians serving their 2-year period of compulsory service in the rural health centre after their medical training, and functioning as primary care specialists (part of their time is spent in hospitals); and primary, secondary and tertiary care specialists.

Supportive secondary and tertiary care services are available in the health centres on a referral basis, provided by medical specialists attached to the health centre and from the regional and provincial hospitals. There is a great utilization at the health centre of nurses, nurse assistants and auxiliary personnel. The nurses have more clinical responsibility than their counterparts in the U.S. and routinely administer intravenous injections and make house calls. Physicians do not make house calls in Cuba. Public health nurses carry out clinical immunizations, supervise health education, and keep a registry of all children and pregnant women in the community. The role of the social worker is to guide patients in their use of the social and rehabilitation services. The auxiliary technical sanitarian, working under the supervision of the full-time director of the health centre and the regional chief of environmental services, is responsible for the operation of the water supply and the sewerage services.

THE REGIONAL HOSPITAL CENTRE

In the seventies, there were 38 regional hospital centres in the country, each with 250 to 300 beds. Services here include those in the four basic specialities, viz., paediatrics, internal medicine, obstetrics-gynaecology and dentistry, as well as urology, ophthalmology, ear, nose and throat, dermatology, psychiatry, orthopaedics, traumatology, cardiology, angiology, clinical laboratory and radiology services, public health laboratories, blood banks, and tuberculosis clinics. With the exception of some services in the super-specialities, the services offered at the regional centre are in-patient services, out-patient services being provided at the health centres. All hospital clinicians from the regional and provincial centres spend two to three outpatient sessions per week at a health centre, one session of which is devoted to preventive services.

THE PROVINCIAL HOSPITAL CENTRE

This provides tertiary facilities such as allergology, neurology, neuro-surgery, nephrology, haematology, oncology, virology, occupational medicine laboratories, sports medicine and rehabilitative medicine. Some provincial centres are associated with various special institutions such as a large acute bed hospital, a large obstetricalgynaecological hospital, a psychiatric hospital, blood banks, tuberculosis clinics or rehabilitation units. The clinicians who work in the provincial hospitals also work part-time in the health centres. Besides these centres, there are large national institutes which serve the whole country, such as the National Psychiatric Hospitals in Havana. Research is centralized, and there are national research institutes for each speciality; this permits the maximum utilization of scarce resources. Researchers have also to work part-time in either the provincial or regional hospitals, or in the health centres.

Following the revolution, hospital services were, as has been shown, centralized. Small uneconomical hospital units, especially in the urban areas, were closed, in the interests of economy. Thus while the total number of hospitals was reduced, the average size and capacity of the remaining hospitals was increased and new hospitals were built. Of the nearly 42,000 hospital beds existing in 1969, 63 per cent were constructed after 1958. The process of regional equalization gave high priority to the rural and indigent areas and reduced regional disparities. Of the 236 new health centres that were built in the decade 1959-1969, over half were built in rural areas where none existed before 1958.

The health services were re-oriented from the hospital to the community. To achieve the maximal utilization of scarce resources, hospital care was centralized at the provincial and regional centres, and ambulatory care was decentralized from the hospital out-patient departments to the increasing number of health centres. The health centres offered ambulatory care to all communities in the country. As. a result of the process of regional equalization, there was an increase in the utilization of both the hospital and health centre services, with the greatest increases amongst services for children and services in the poorer rural areas. Service in all centres, polyclinics and hospitals was free. There were no class distinctions in access to private and open wards; the use of single-bed rooms depended solely on the patient’s medical condition. (17)

STAFFING IN THE HEALTH SERVICES

Many new physicians were trained to replace the 3,000 physicians who fled the island after the revolution. The government encouraged university students to choose medicine as a career, and, as a result of the new open-admission policies, large numbers of women, who previously would have chosen nursing or teaching as a career, took up medicine. Furthermore, more attention was given to the training of medical and dental assistants and to the upgrading of nurses who could assume greater clinical responsibilities under supervision. Physicians, especially those from teaching institutions, were encouraged to participate in the planning and administration of health services, even at ministerial level. Efforts were also made to increase the recruitment of auxiliary personnel, to train them and to upgrade their status. These included auxiliary nurses. X-ray technicians, laboratory technicians, auxiliary technical sanitarians and dental assistants Before the revolution there was no training for any of these.

THE TRAINING OF PHYSICIANS

Medical training in Cuba now consists of six years in medical school. The first two years are devoted to the basic sciences which include, in addition, epidemiology, statistics and social medicine. The next three years are spent in clinical training whilst the sixth and final year is spent in internship. The format of medical teaching was changed in 1968 such that the teaching, which was formerly done by departments (e.g. paediatrics, obstetrics) is now done by systems (e.g. circulatory system, nervous system), thus avoiding the duplication that was inherent in the traditional method. The internship that a student undertakes is related to the residency programme that he will be undertaking. The internship and residency programmes are regulated and administered by the Ministry of Health. During the fourth, fifth and sixth years of medical training, medical students must work in the sugar cane camps where they are responsible, with the help of a nurse and an auxiliary technical sanitarian, for all health services for approximately 2000 sugar cane workers. The fifth year medical student and the intern attend two sessions a week at the health centres, where they work under supervision.

After his internship, the new physician works for two years in the rural medical service, in a rural health centre or hospital. All clinical residents have to spend three sessions a week at the health centres or polyclinics. The residencies vary from two years (public health) to three or four years, and lead to the certification of a second degree specialist. After at least 5 years practice, and appropriate publications, experience and continuing educational periods, a peer review committee may confer third degree certification.

A new co-ordinated curriculum and other developments after 1968 appeared to produce a new kind of physician in Cuba. The Cuban medical curriculum is amongst the most community-oriented of any in the world today. The teaching of epidemiology and social medicine was increasingly done by clinicians working in the clinical departments with support from the epidemiologists in the department of epidemiology. The community orientation of the new physicians has been strengthened by the emphasis on social motivation that is apparent in all education in Cuba today.

Within the Ministry of Health is a National Teaching Unit that functions as the School for Public Health. Its public health residencies train epidemiologists, sanitarians, nutritionists and health service administrators. The National Teaching Unit is the authority responsible for the training of paramedical and auxiliary personnel through the provincial teaching units (for paramedical personnel) and regional teaching units (for training auxiliary personnel).

A characteristic of the educational programmes for the training of Cuban health professionals is that of mobility, both vertical and horizontal. A graduate of the auxiliary nurse programme, for example, may, after a year’s experience, take two years of additional training in a provincial school and become a general nurse. At the medical schools, students are able to shift to the biological sciences or veterinary medicine, since a number of the courses are co-ordinated and interchangeable.

THE PLANNING PROCESS IN CUBA

Final decision-making power in Cuba rests with the Communist Party and the mass organisations, while planning and administration are the functions of government. The smallest unit within the Communist Party is a productive unit which is any unit that employs workers, such as a factory or university. In 1969, the Communist Party had 70,000 members. Members of the Party are elected by the workers of the productive units. The Communist Party members of the executive committees of the productive units elect the sectors’ executive committes, who, in their turn, elect the regional executive committees. These elect the six provincial executive committees, who, finally, elect the 100 members of the Central Executive Committee, the top authority within the Communist Party.

Under the aegis of the leadership of the Communist Party, the mass organisations participate in the decision-making process. The larger of these organisations are the Committees for the Defence of the Revolution, the Federation of Cuban Women, the Association of Small Farmers, and the Trade Unions. Members of the mass organisations assist in the immunization campaigns, the fight against flies and mosquitos, the cleaning and repair of streets, the construction of schools and parks, the campaigns for eliminating illiteracy, the creation of child care centres, the integration of women into the labour force and the sponsoring of special agricultural programmes. The trade unions and the farmers’ association protect and defend the rights of their members, and participate in campaigns related to rural health services and occupational health.

The National Planning Office is the top planning agency in the country and consists of the technical staff from the political organisations. At the provincial and regional levels, co-ordination of the different plans is done by the Institute of Physical Planning and Regional Development which has a similar relationship to provincial and regional political bodies.

In the health sector, the top administrative planning and supervisory agency is the Ministry of Health which has also provincial and regional offices. The Ministry is divided into two vice-Ministries: Hygiene and Epidemiology, and Medical Care and Teaching. In addition, there is a Division of Planning and Evaluation. At the regional level, the director of the health centre and the director of the regional hospital are both accountable to the regional director of health services, and the health centre is not administratively dependent on the hospital. Each institution (hospital or health centre) is administered by an administrative executive committee, headed by the director of the institution who is also the top administrative authority, and composed of the heads of the different clinical, paramedical, and auxiliary services, and representatives of the employees and of the local membership of the Communist Party.

Parallel to the administrative authority at each level, area, regional, provincial and national, are the People’s Commissions on Health which are the political and decision-making bodies and which participate actively in implementing programmes and health service plans at the local and national level. At each level, the Commission is chaired by the director of each administrative unit and comprises representatives of the mass organisations led by the Communist Party. At the area level, the Commissions mobilize the local population to implement the health centre’s programmes, and assist in street-cleaning, immunizations and control of infectious diseases, voluntary blood donations and health registration of the entire population. All the inhabitants of an area must be registered at a health centre and undergo regular health examinations and immunizations.

In addition, the mass organizations have assisted in specific health programmes, such as projects on health education, enviromental upgrading, the control of mosquitos, day care centres, occupational medicine, food safety and control, the control of tuberculosis and occupational rural health. People’s health commissions exist at every level to assist the director of health at that level. These commissions elect the people’s health commission for the level next above them and so on till, at the national level, there is the National Commission on People’s Health.

The following are some examples of the results of the efforts of the health commissions (18):

-    A 50 per cent decrease in the mortality rate for gastroenteritis in children (1959 1968) through sanitary improvements, improved water and food supply, public health education and much improved availability of clinical and hospital services.

-    Eradication of polio (1963) within a comprehensive programme of periodic immunizations almost totally organised by mass organisations.

-    Eradication of malaria (1967) through aggressive case-finding and patient follow-up in endemic areas, and neighbourhood attention to mosquito control.

-    Improved care of the expectant mother through a pregnancy census, prenatal visits and maternity homes near rural obstetric services to guarantee an institutional birth.

-    Early cancer detection programmes for women (1967), the most comprehensive programme of its kind in the world.

-    Control of tuberculosis through BCG vaccination, health education, aggressive case-finding, ambulatory care from a polyclinic (health centre) rather than from segregated services, patient follow-up and social services for dependent

-    Control of leprosy (using the same means as for tuberculosis) with emphasis on health education of both lay and professional people to combat the centuries-old stigma of incurability, contagion and “offensive” disfigurement.

PLANNING

Each vice-ministry has advisory planning task forces, one for each speciality or department, that are primarily composed of professors and chairmen from the main departments of the medical schools who are appointed by the Ministry and considered to be top authorities in each sector. This structure of the planning process is repeated at provincial and regional levels. The task forces secure participation from the other members of the medical profession and develop norms and procedures to be followed at every level of administration. These norms and procedures are mostly clinical in nature (e.g. how to treat diabetes in children), and are reviewed every three years. Using the national norms and procedures as guide-lines, the advisory planning task forces at the national level prepare various programmes for each sector. The Division of Planning and Evaluation of the Ministry of Health co-ordinates the various sectorial programmes and allocates resources to each from the overall resources provided. After ministerial approval, the plans and programmes generated by the task forces are implemented by the administration at provincial, regional and area levels. The people’s commissions on health help to implement the programmes and also involve the entire population in the health programmes.

The mobilization and participation of the public explains the success the country has had in controlling epidemics. For example, during a polio epidemic in 1970, more than 80 per cent of Cuban children under 15 years of age (nearly 2 1/2 million) were vaccinated in under 24 hours. The cost of these services is borne by the earnings from the government’s control of industry and agriculture. Small sums have to be paid for out of hospital drugs, for certain dental services and eyeglasses. (The pharmacies and stores are, of course, operated by the government). Drugs for tuberculosis, venereal disease, and maternity care are free (19).

The ultimate effect is that the preparation of plans in the health sector is centralized at the level of the Ministry with a heavy professional imput, and implementation is decentralized at the local level with the hearty participation of the local population. The medical profession advises and decides on the priorities within the health sector, but final authority and control rest with the political bodies.

When a conflict arises within the health sector, it is resolved by the political body, at the central level, increasingly in favour of public preferences. The reasons for this are many. The privileges enjoyed by the medical profession have been re-defined. There is also now a better educated and more aware public which demands participation. A change in the type of morbidity in Cuba has affected the decision-making process in the health sector; as the prevalent pattern of morbidity changes from one of acute illnesses to one of chronic diseases, the management strategy of the morbid conditions changes from one of (acute) cure to one of (chronic) care, when, with the social and medical implications, the public calls for broader participation and more open control of the decision-making processes.

In summary, it can be said that public health campaigns in the underdeveloped countries of the world cannot succeed unless there is massive public participation in their implementation. This is especially true in the eradication of infectious diseases. Furthermore, Cuba, a small poor country, subject to a strict economic blockade, succeeded in providing comprehensive health services to the whole population without the involvement of direct payments, as a result of the guiding philosophy of equalization in health care, and the redistribution of health resources. The Cubans have shown that, contrary to conventional wisdom, the absence of comprehensive health services coverage in most underdeveloped countries is not due to the lack of health and other resources, but to the maldistribution of resources, both within and outwith the health sector, as a result of the concentration of political, economic and social power in the hands of a small elite.

In Cuba, the redistribution of resources followed a substantial redistribution of the power of pre-eminent groups and classes and their redefinition. This was a necessary pre-condition of the country’s commitment to health care as a basic and fundamental right, rather than as a commodity to be subject to a substantial determination by the commercial market. The ultimate question is how much of a nation’s resources will be channelled into the public sector - for health care, education, housing or any other need so that the service is available at a reasonable level, without regard to personal wealth or social status.

LIBERATION

In August 1950, the first National Health Conference was convened, and Chairman Mao Zedong called for unity between modern doctors and the traditional healers. Chairman Mao saw an important role for traditional healers in the protection of the health of the people in modern China. In the early years of the new state, a patriotic health campaign, guided by sanitary workers, saw millions of all kinds of people eliminating the four pests of the land, viz., flies, rats, bedbugs and mosquitos. A permanent part of the war against disease, this campaign was closely integrated with the hygiene and sanitary work of the mobile medical teams which followed.

In the initial period, post Liberation, the main health efforts were for logistic reasons concentrated in the urban areas, although effort was expended in several directions to remedy this. For the training of many more doctors, new medical schools with their teaching hospitals were built in the cities, and, by the late sixties, China was probably turning out more medical workers than any other country in the world. With the rapid development of industry and the consequent increase in the urban population, the number of urban hospital beds had increased more than tenfold.

The large scale collectivisation of agriculture and the formation of People’s Communes in the rural areas resulted in a series of major political, social and economic changes which, in turn, fostered the creation of an efficient system of social security and welfare services, with medical clinics and preventive services. So solid and rugged was the base of the socio-economic structure that it easily survived the serious widespread national calamities that befell the country in the sixties, viz., drought, followed by floods and poor harvests. An equitable system of distribution ensured that no one starved and that everyone was adequately clothed and protected against the elements.

With agriculture then recognised as the foundation of the national economy, industry was re-oriented to serve the needs of the countryside. This involved electrification, the manufacture of chemical fertilizer and agricultural tools, the construction of gigantic resovoirs to minimize the effects of drought and floods alike, and the production of essential consumer goods. The orientation of the health service towards the countryside in the middle sixties led to the formation of mobile medical teams (21).

The mobile medical team that Dr Horn described comprised 107 nurses, laboratory workers, administrators and doctors of all specialities and levels of seniority from a hospital in Peking. The team served 12 People’s Communes with a total population of about 80,000 persons. The team was divided into 3 medical brigades, each of which was based on a central clinic and served four Communes. The central clinic itself was responsible for smaller clinics in the production teams. The production team, which had a membership of several hundred people, was the smallest sub-division of a People’s Commune.

People on the same production team lived close to one another in small villages and formed the basic social unit in the countryside. The production brigade was formed by the combination of several production teams and had wide responsibilities with regard to health, transportation and the grinding and storing of grain. The Commune was the lowest level of formal state power and was composed of from ten to thirty production brigades. It was responsible for overall planning, education, health and social services, and the operation of small factories that produced goods for the Commune and for distribution further afield (22).

Doctors in the small clinics regularly visited villages and were available for emergency calls. They lived with the villagers and when they were travelling round the outlying villages they would stay with the peasants and share their food and shelter. Once a week they joined with the peasants in manual labour in the fields. All the members of the mobile medical teams were volunteers with the right balance between newly qualified and experienced doctors. The period of service with the mobile teams was one year. The workers in the mobile teams received eight days home leave every two months with free travel. They kept their normal hospital salaries throughout.

Prior to joining a mobile medical team in the countryside, workers attended a preparatory course of training. In the general medical mobile teams, there were also, according to need, specialised mobile medical teams, such as an ear, nose and throat team, a dental team, and a birth control team.

The tasks of the mobile medical team were sixfold. The mobile medical team was, firstly, to provide preventive and therapeutic services in its area of operations. Preventive work was given priority, with all children being given their primary and ‘booster’ immunizing doses by travelling inoculation teams. The population was encouraged to become actively involved in its own health care. By the late sixties, smallpox, typhoid, diptheria, polio and whooping cough had virtually disappeared from the Chinese countryside. Later, children were immunized against measles and, during epidemics, injections were given against encephalitis and infectious meningitis. Oral BCG vaccine was given for protection against tuberculosis.

Other aspects of preventive work consisted of the prevention of water-borne diseases by making drinking water safe and by the safe disposal of human and animal excreta. Delousing teams equipped with sprayers and parasiticidal solution dealt with the problem of lice. In goitrous districts, an iodine compound was added to table salt. The therapeutic work of the mobile medical teams was carried out in the central clinics, in the small village clinics, and in the homes of the sick villagers. In the central clinic, major surgery was performed. In the smaller village clinic, there were facilities for midwifery and minor surgery. There was also a smaller pharmacy and patients were seen by the health staff at any time of the day or night. The staff of the small village clinic consisted of three or four doctors from the mobile medical team and a few traditional doctors. Low fees were charged and paid into a common fund from which the staff drew their salaries. The large central base hospital of the mobile medical team (in the large town or city, e.g. Peking) subsidized the salaries of the mobile medical team which remained unchanged during their sojourn in the countryside. As a result of the new socialist consciousness of the health workers, a rural health service was improvised at little expense during the initial stages of building up the country.

A therapeutic service was rendered in the villagers’ own homes. Members of the mobile medical team who were stationed in the cottage clinics visited every village in the neighbourhood once or twice weekly. Team members carried a supply of medicines from which they dispensed, on the spot, as and when required. Initially, team members performed only minor surgical operations, but, later, with experience, they performed major emergency operations and even major non-emergency operations in the villagers’ own cottages with perfectly acceptable post-operative infection rates.

The second task of the mobile medical team was to train auxiliary medical personnel from amongst the local people. The objective everywhere was to train one peasant doctor for each production brigade, one voluntary sanitary worker for each production team and enough midwives to ensure that every peasant woman giving birth is helped by a person of some professional competence. With some 70,000 People’s Communes in the country, and every Commune divided into production brigades, which are in turn subdivided into production teams, the intention clearly had been to train hundreds of thousands of medical workers.

The third task of the general mobile medical teams was to help implement the Party’s policy of planned parenthood in the countryside. Villagers were given educational sessions on birth control side by side with lessons on night-soil dispersal, fly control and food protection. Talks were illustrated by means of brightly-lit coloured lantern slides. The ideas were accepted once the support of the peasants and of the women’s organisations had been gained. The means of contraception were provided free by the state through specialized family planning mobile teams. In the middle and late sixties, there were widespread trials of the contraceptive pill and of the intrauterine device.

The fourth task of the general mobile medical teams was to raise the level of medical care in the countryside with the co-operation of the people. Prior to the mobilization of the general mobile medical teams, a central clinic, for example, which might have been opened by a county government in the early fifties, would consist of a pharmacist and a few traditional and other middle grade doctors. The arrival of the specialists in the mobile medical teams was of great benefit to the local area as the newly arrived and previously resident medical staff exchanged information with each other. The old central clinics were converted, with the help of the local people, into small modern rural hospitals with accommodation for in-patients, an operating room, an out-patient department, a laboratory where biochemical and other blood tests could be carried out, and a library of medical books and journals. Refresher courses in the nearest University town were arranged for the original staff of the clinic.

The fifth task of the general mobile medical team was to assist in the preventive health activities of the Patriotic Health Campaigns, through which the mobile teams linked directly with the villagers. The original activities of the Patriotic Health Campaigns were the elimination of flies, bed-bugs, rats and mosquitos. Encouraged by the mobile medical teams, Patriotic Health Campaigns began to engage in lice elimination, water control, food protection, the safe disposal of night-soil, and simple methods - to install running water systems and bath houses.

The sixth task for the general mobile medical teams was to help the people of the countryside think about, and fit better into, the new society, and to become more effective in building socialism. A racist, imperialist or capitalist society “...........fosters the conviction that it is a law of nature that some should live off the labour of others, that some should be rich and some poor, that some should own factories and hire others to work in them, that black people should toil to keep white people in luxury, that the driving force in society should be self-interest” (23).

The ideological remoulding that was necessary after Liberation in China was especially difficult for those who had previously been accustomed to leading a soft life and enjoying special privileges. Ideological remoulding is not an easy process that can be accomplished by reading books, by meditation, by a whole lot of good intentions, or by staying in the countryside for a year or two. It is a long process and necessitates international solidarity with all working people to transform the world. The great majority of the members of the general mobile medical teams benefited immensely from their contact with the peasants. The doctors lost their selfishness, their competitiveness and their feelings of superiority. They were now keen to serve their country and their countrymen and -women to the best of their ability.

THE STORY OFTHE BAREFOOT DOCTOR IN CHINA

Much has been written about the revolution in health care delivery that was brought about by the large scale training of peasant doctors that some space will now be devoted to the development of the system of health care by the peasant ‘barefoot’ doctor. The barefoot doctors were indigenous rural personnel who participated in agricultural production and at the same time delivered health care. They were trained in short term classes and through practice by the general medical mobile teams from the large cities, such as Peking and Shanghai from 1958 onwards as part of the ‘Great Leap Forward’. The training of barefoot doctors received a boost as a result of Chairman Mao Zedong’s “Directive of June 26th.”, in which he declared, in 1965, that full health care delivery must be implemented in the rural areas of the People’s Republic of China (24).

Following this directive, the number of barefoot doctors increased throughout the country, with the result that, by the early seventies, there were about one million of them, playing an indispensable role in health care in the countryside. The word ‘barefoot’ was used to emphasize that he was a peasant, rather than to describe his lack of footwear. All barefoot doctors, in fact, wore shoes. The Chinese themselves defined a barefoot doctor thus: “A ‘barefoot doctor’ is a peasant who has had basic medical training and gives treatment without leaving productive (i.e.productive agricultural) work. He gets the name because, in the south, peasants work barefooted in the rice paddies” (25).

The barefoot doctor was a peasant who performed some medical duties rather than a health worker who did some agricultural work. During the planting and harvesting seasons, almost all of his time was spent in farming work; at other times a considerable part of his time was spent in health work, particularly in enviromental control and preventive medicine. In this regard, the barefoot doctors were different from the feldshers of the rural Soviet Union and from the medical assistants in certain African countries, who were essentially full-time health workers and were differentiated from the people they served in more ways than one. A barefoot doctor received the usual wages of an agricultural worker. He earned his work points just like any other worker, except that his work points derived from agricultural work and health work. Like any other commune worker, he shared equally in the distribution of the produce and in the cash from the sale of the produce.

TRAINING

Prospective barefoot doctors were chosen by their future patients for their political orthodoxy and their genuine commitment towards serving their fellowmen and women. The barefoot doctors felt that it was an honour to be so chosen. As with most other occupations in socialist China, the qualifications required for the job emphasized valuable and necessary practical skills rather than the duration or type of training. Formal training was undertaken either in a commune or in a county hospital, and was evenly divided between theoretical and practical work. The training consisted of three or four-month periods in successive years, interspersed with on-the-job supervision and guidance, to a single three- to six-month period of training followed by a variable period , of on-the-job supervised experience.

The overall goal of the government was to give the barefoot doctors an adequate, but short, training in order that they could return to their communes to “serve the people”. The aim was to have one barefoot doctor per 1,000 of the population. In the initial period most of the barefoot doctors were in their twenties and early thirties, although a few of the women barefoot doctors were much older. Most barefoot doctors had received middle school education, but a few had only primary school education, and fewer still had had no formal education. The incentive to learn came from the students’ recognition of their future responsibilities rather than from examinations, grades, or competition amongst the students. Each student, on the other hand, was expected to help fellow students who may have been slower at learning the material or the techniques.

Athough the details of the barefoot doctors’ duties varied from commune to commune, they had standard responsibilities for enviromental sanitation, health education, immunizations, first-aid, and aspects of personal primary care and post-illness follow-up. The barefoot doctor was responsible for the delegation of duties relating to the proper collection, treatment, storage, and use of human faeces as fertiliser. He was responsible, together with his health workers, for directing campaigns against such pests as flies, cockroaches, fleas, or snails. The homes of members of the communes were visited regularly and sprayed with insecticides.

The barefoot doctor and the health workers under his supervision were responsible for the immunization of the families in the production brigade and for the keeping of detailed immunization records for each child. Immunizations against diptheria, pertussis, poliomyelitis, measles, smallpox, meningococcal meningitis and Japanese B encephalitis were routinely given. The barefoot doctor was available for medical emergencies, and he treated colds, bronchitis, gastrointestinal disorders, measles and minor injuries. The auxiliary health worker assisted the barefoot doctor and was trained to apply dressings for minor injuries and to give medications for headaches, colds and fever. All major problems were referred to the commune health station.

The barefoot doctors immunized all the brigade’s children from the ages of one to seven; the records of the immunizations were kept in the health station. The barefoot doctors were responsible for educating the brigade women about family planning and for providing them with contraceptives. They planted and collected medicinal herbs, and prepared oral and injectable medications. The brigade midwife, a woman, received a training very much similar to that of the barefoot doctor. She provided prenatal care, performed uncomplicated deliveries and gave health education, with special attention to education in birth control methods.

In his medical bag, the barefoot doctor carried medications ranging from traditional herbs, through aspirin and antacids, to penicillin and chlorpromazine, as well as equipment such as alcohol, gentian violet, bandages, forceps, syringes, clinical thermometers, and acupuncture needles. The doctors showed a detailed knowledge of the properties of the medications they dispensed, together with their indications, contraindications and adverse reactions. Health care was accessible for, and appropriate to, the problems encountered, with referral for the more complicated problems. The barefoot doctor was, more importantly, known and trusted by his fellow workers.

The health centre for a production brigade (about 1800-2000 people) was usually a one-room building furnished with a table, chairs, an examining table and a medicine cabinet. Four barefoot doctors usually cared for brigade members. In addition, there would be one health worker for each production team. The barefoot doctors rotated their duties, so that whilst there was always one on duty in the health station, the others would be visiting the production teams or performing agricultural work. The health workers were responsible for immunizations and for educating the women about birth control.

Large communes had their own hospital facilities to which the production brigade health stations referred patients. The China-Rumania Friendship People’s Commune in the southwestern suburbs of Peking was described by the Sidels(26) as serving 46,000 commune residents in 1971. The staff consisted of 25 barefoot doctors, two Chinese traditional doctors and 15 nurses in addition to technicians, administrators, and a cook. There were no cleaning staff; all the staff helped with the cleaning. The hospital had sections for surgery, ENT, internal medicine, traditional medicine, gynaecology, public health, radiology, a laboratory, emergencies, in-patients, a pharmacy that dispensed Western-type scientific as well as traditional medicines, a factory that produced machines and a supply service. The funds for running the hospital were raised from the registration fee that all patients had to pay, and from sums of money contributed by the commune. The doctors were on a one-year rotation from a District Hospital in Peking, and they worked in the fields for one day in the week. If a traditional doctor saw a patient who needed surgery, that patient would then be transferred to the surgical department.

County hospitals are located in the towns and serve the people of the area, as well as patients referred from the commune hospitals. The Sidels describe the hospital for Shunyi County which is a part of the Peking municipality, north-east of the city proper. It had a staff of 104 men and 114 women to run services for the 450,000 members of the 19 communes in the county. 143 members of the staff were medical workers, - 48 doctors, 63 nurses, 32 pharmacists and technicians. In addition to the county hospital, there were seven commune hospitals and twelve commune clinics that provided medical care in the county. In total, 676 medical workers (not including barefoot doctors and health workers) served the population of the county: 312 doctors, 65 nurses, and 299 pharmacists and technicians.

The revolutionary committee of the county hospital was composed of some of the members of the hospital staff . The chairman of the committee was a Party cadre; of the 11 members, 5 were full-time and 6 part-time, and 8 were men and 3 women. The full-time members were the chairman, and the 3 vice-chairmen in charge of professional work, administration, and public health respectively. The 6 part-time members were doctors, nurses, and workers in the hospital. When planning the medical work of the hospital, the committee paid heed to the opinions of the poor and lower-middle peasants and workers. Funds from the hospital came from the county financial department and the hospital usually received the funds requested.

After Liberation, the new Chinese government placed a high priority on making health care available to its people, and especially the delivery of preventive medicine and of medical care to those who previously had the least access to those benefits. Medical personnel were used to their fullest potential. The delivery of medical care was tailored not only to suit the needs of the individual but also to fit into the overall development of the new society. In order to understand the success a country has achieved in a specific health delivery area, such as the increase in life expectancy, or the lowering of mortality rates, it is necessary to comprehend the changes that have occurred in other related sectors of health such as general educational levels or the distribution of physicians (27). De Miguel suggests that the reform of the health services and their organisation can only begin by a change of the whole political structure of a country, especially in authoritarian regimes (28).

New and New(29) suggest that the barefoot doctors were a success only because of the changes in policy in a number of significant areas. Traditional Chinese medicines and treatments, herbs and the use of acupuncture, were again being used extensively. The length of formal education was shortened. Certain licensing procedures for health workers were removed, and students were admitted to higher education based on their correct ideological positions, and after they had worked a number of years. All this was part of the levelling process that was going on in Chinese society. Most communes instituted a healthy co-operative plan whereby individuals paid a certain amount, matched by the commune. Each commune and urban neighbourhood had access to health stations, community health clinics, small in-patient hospitals and medical centres with supporting personnel at every level of care. All the different sectors of health care were linked along national lines. The barefoot doctors were linked to other health institutions and the commune itself was linked to the larger society.

There was flexibility in the requirements, training and function of the barefoot doctors.The central government saw to it that resources were used to the best effect. Theflexible approach was accomplished through a tight organisation of all governmentand residential units. Control over the allocation of personnel allowed fastermobilization of all persons to carry out any central or local directives. Single purposededication - such as mobilizing 90,000 peasants to complete an irrigation system forone commune in 18 days - can only be accomplished through a flexible approach anda central directive which leads to an immediate mobilization of manpower. In the newChina, every effort was made to actively engage every citizen, so that everyone feltjointly accountable for the well-being or ills of society (30).

Lu states: “In order to understand the self conception and behaviour of the peoplein present Chinese society............., it is necessary to know how the Chineseperceive their success or failure in fulfilling the social expectations in the performanceof their new social roles........ The transformation of the individual, the cultivationof “a new person”......... is one of the objectives of the Cultural Revolution in China.It is recognised that the development of a new “self” among the individuals isindispensable to the building of a new society and at the same time [it] is a pre-conditionfor the development of a new “self” “(31).

Chin suggests that an individual’s health behaviour is integrated with his politicalbehaviour:“In China, health behaviour is more accurately described as health conduct. Theolder connotation in English of the word ‘conduct’ meaning ‘behaviour’ is appropriatehere because health acts are ‘political’. For China and the ‘New Man’, no act isdevoid of political factors, which define the purposes and direction of society. Thus,health conduct is moral-political conduct laced together by the cognition, ideologies,actions and spirit of the socialist state and of the socialist citizen” (32).

SUMMARY

Socialist Chile, Cuba and China exhibited characteristics in the development of their health services that challenge some of the assumptions prevalent among health service planners in the developing world. One of the assumptions is that it is impossible to provide health services to entire populations in developing countries due to their indisputable scarcity of resources. The lack of health service coverage of the whole population is attributable not so much to the scarcity of resources in all sectors, but to the poor distribution of those resources within and outwith the health sector (33).

Both China and Cuba, with all their problems, are providing health care to all their people. As a result of their commitment to social and regional equalization, China and Cuba redistributed both their old and new health resources. All the old inequalities were minimized and erased: the inequalities between social classes, between cities and rural areas, and between regions. But the redistribution of resources alone was not sufficient. Redistribution could not in itself generate new resources. In the provision of health services, both countries relied on physicians, and, more importantly, on paramedical and auxiliary personnel. There is an answer here for those countries with shortages in medical manpower. The national leadership in China as well as in Cuba recognized that people were a resource and encouraged massive popular participation in the health campaigns, convinced that the mass of ordinary people are able, given the requisite power, knowledge and motivation, to tackle successfully highly complex problems (34).

The popular participation is part of overall socio-economic development. As Navarro says: “.....the value of the Chinese and Cuban experiences, with their strengths and weaknesses, lies not so much in their direct applicability to other enviroments both Chinese and Cuban health planners would agree on the desirability for each country to develop its own system -but in the relevance of some of their imaginative and resourceful experiments to other countries, both developed and developing” (35).

REFERENCES

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2. JOHNSON, D.L.(Ed.). “The Chilean Road to Socialism”. Anchor Press, Garden City, New York. 1973. Chapter 10.
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14. Ibid.
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19. ROEMER, Milton I. “Political ideology and health care: Hospital patterns in the Philippines and Cuba”. Op. Cit. p 491.
20. HORN, J.S. “Away With All Pests”. Hamlyn Publishing Group, London. 1969. p 124.
21. Ibid, pp 129-146.
22. SIDEL, Victor W. and SIDEL, Ruth. “Serve the People”. Josiah Macy Foundation, New York. 1973. p 77.
23. HORN, J.S. “Away With All Pests”. Op. Cit. p 143.
24. NEW, Peter Kong-Ming and New, Mary Louie. “Health Care in the People’s Republic of China: The barefoot doctor”, in ‘Inquiry’, Supplement to Volume XII, No. 2, ,June 1975. pp 103-113.
25. SIDEL and SIDEL. “Serve The People”. Op. Cit. p 80.
26. Ibid. pp 90-94.
27. ELLING, Ray H. and KERR, Henry. “Selection of contrasting national health systems for in-depth study”, in ‘Inquiry’ (Supplement), Vol. 12, June 1975. p 25.
28. DE MIGUEL, Jesus. “A framework for the study of national health systems’, in ‘ Inquiry’, Vol. 12, (Supplement) June 1975. p 10.
29. NEW and NEW. “Health care in the People’s Republic of China: The barefoot doctor”. Op. Cit. pp 106-109.
30. NEW, P.K., HESSLER, R.M. and CATER, P.B. “Consumer control and public accountability”, in ‘Anthropological Quarterly', Vol. 46, July 1973. pp 196-213.
31. LU, Y.C. “Social values and psychiatric ideology in revolutionary China”, quoted in ‘Health care in the People’s Republic of China: The barefoor doctor’ by NEW and NEW. Op. Cit. p 111.
32. Ibid. Quoted.
33. NAVARRO, Vicente. “Editorial: Health and health serv