Perspectives
Profile Yan Guo: shaping China’s public health policy The past two decades have seen China transformed in innumerable ways, but the country’s overhaul of its primary care system and rapid improvements in child and maternal health have been particularly profound. As Professor of Public Health at Peking University Health Science Center’s School of Public Health, Yan Guo has long been at the heart of efforts to shake up primary care and rural health in China, leading research into everything from the benefits of health education to the cultural barriers to improving maternal and child health. And far from being a purely academic pursuit, Guo’s research is informed by her strong connection with the communities she works with. Guo graduated from high school in the early 1970s, amid the tumult of the Cultural Revolution. The country’s universities had closed, and like many of her peers Guo was sent from her small hometown in Hebei province near Beijing to work in the countryside. “Because my grandfather was a doctor, I was nominated to be a barefoot doctor in my rural community”, she says. After 9 months of training at a county health centre, Guo went back to her community to “follow what Chairman Mao told us: to serve the people’s heart and soul”, she says. At that time barefoot doctors were the backbone of the Chinese primary care system. “It was a unique experience, and I think that time was a great opportunity to get close to the people”, says Guo, but when the Cultural Revolution drew to a close, she was one of many barefoot doctors who decided to take the entrance exam to the newly reopened universities. At school Guo had always imagined going to university to study mathematics or physics, but her time as a barefoot doctor turned her on to medicine and public health. She graduated from Beijing Medical University in 1982, and was immediately offered a position as a lecturer at the university’s School of Public Health. At that time China’s open-door policy had started to transform Chinese society, including academia. The medical curriculum that Guo had studied based on the Soviet model was replaced with a new one founded on western teaching methods that introduced concepts like health economics and social medicine to the School of Public Health. “I didn’t learn anything about those new fields when I was a student, but I had to teach those courses”, she laughs. It wasn’t long before Guo was up to speed, and by the early 1990s she had started to build an ambitious programme of research at the School of Public Health that focused on China’s primary health-care system. “China had very good primary health-care teaching in the 1950s, but by the time of the open-door economic reforms there was no financial support for primary care at the community level”, Guo explains. “When I was a barefoot doctor there was no overprescription, but when the doctors www.thelancet.com Vol 384 August 30, 2014
had to earn money for themselves their behaviour changed and there was overprescription”, she says. Guo’s evaluations of the primary care system brought to light many of these issues, and helped bring about sweeping changes over the next two decades. In 2000 Guo had the opportunity to travel to the USA to study for a master’s degree in international health at Tulane University in New Orleans, and on her return to Beijing her research focus switched to maternal and child health. “In the early 2000s in China there were big disparities in maternal and child mortality rates between the urban and the rural, between the east and the west. If you looked at the western part of China, in remote areas, the rates were two or three times higher than in the eastern part of China, so disparities and health inequities in China were a huge challenge”, explains Guo. By analysing the causes of those disparities, and evaluating the government projects that sought to address them, Guo’s research has been instrumental in shaping China’s progress towards achieving Millennium Development Goals 4 and 5. For example, she explains, “we found that almost half of the maternal deaths in the western part of China happened at home or on the way to hospital. So we asked people why they didn’t go to hospital. The first reason was that they didn’t have money. The second reason was that they didn’t think they needed to go to hospital to give birth, and the third reason was that hospital was too far away. After that the Chinese Government developed a strategy, including putting a lot of money towards providing free services for hospital delivery, to deal with those kind of disparities. And we are going to follow up those strategies to evaluate whether they are a success or not”, she says. “Recent years have shown that the gap between urban and rural maternal mortality rates has decreased and almost disappeared”, says Guo. “That’s big progress, but it’s not been easy.” Having cut her teeth in global health as one of the Commissioners of WHO’s Commission on Social Determinants of Health, which reported in 2008, and more recently with The Lancet’s Global Health 2035 Commission, Guo is now planning to devote part of the next phase of her career to working out how to translate China’s successes in tackling maternal and child health to other countries where progress has been slower. “There are definitely several unique things about China that are maybe not easy to translate to other developing countries, but there are some things like health financing, service delivery, techniques in primary health care, I think those are the types of experience we can share with other countries”, she says.
David Holmes 737
Profile Yan Guo: shaping China’s public health policy The past two decades have seen China transformed in innumerable ways, but the country’s overhaul of its primary care system and rapid improvements in child and maternal health have been particularly profound. As Professor of Public Health at Peking University Health Science Center’s School of Public Health, Yan Guo has long been at the heart of efforts to shake up primary care and rural health in China, leading research into everything from the benefits of health education to the cultural barriers to improving maternal and child health. And far from being a purely academic pursuit, Guo’s research is informed by her strong connection with the communities she works with. Guo graduated from high school in the early 1970s, amid the tumult of the Cultural Revolution. The country’s universities had closed, and like many of her peers Guo was sent from her small hometown in Hebei province near Beijing to work in the countryside. “Because my grandfather was a doctor, I was nominated to be a barefoot doctor in my rural community”, she says. After 9 months of training at a county health centre, Guo went back to her community to “follow what Chairman Mao told us: to serve the people’s heart and soul”, she says. At that time barefoot doctors were the backbone of the Chinese primary care system. “It was a unique experience, and I think that time was a great opportunity to get close to the people”, says Guo, but when the Cultural Revolution drew to a close, she was one of many barefoot doctors who decided to take the entrance exam to the newly reopened universities. At school Guo had always imagined going to university to study mathematics or physics, but her time as a barefoot doctor turned her on to medicine and public health. She graduated from Beijing Medical University in 1982, and was immediately offered a position as a lecturer at the university’s School of Public Health. At that time China’s open-door policy had started to transform Chinese society, including academia. The medical curriculum that Guo had studied based on the Soviet model was replaced with a new one founded on western teaching methods that introduced concepts like health economics and social medicine to the School of Public Health. “I didn’t learn anything about those new fields when I was a student, but I had to teach those courses”, she laughs. It wasn’t long before Guo was up to speed, and by the early 1990s she had started to build an ambitious programme of research at the School of Public Health that focused on China’s primary health-care system. “China had very good primary health-care teaching in the 1950s, but by the time of the open-door economic reforms there was no financial support for primary care at the community level”, Guo explains. “When I was a barefoot doctor there was no overprescription, but when the doctors www.thelancet.com Vol 384 August 30, 2014
had to earn money for themselves their behaviour changed and there was overprescription”, she says. Guo’s evaluations of the primary care system brought to light many of these issues, and helped bring about sweeping changes over the next two decades. In 2000 Guo had the opportunity to travel to the USA to study for a master’s degree in international health at Tulane University in New Orleans, and on her return to Beijing her research focus switched to maternal and child health. “In the early 2000s in China there were big disparities in maternal and child mortality rates between the urban and the rural, between the east and the west. If you looked at the western part of China, in remote areas, the rates were two or three times higher than in the eastern part of China, so disparities and health inequities in China were a huge challenge”, explains Guo. By analysing the causes of those disparities, and evaluating the government projects that sought to address them, Guo’s research has been instrumental in shaping China’s progress towards achieving Millennium Development Goals 4 and 5. For example, she explains, “we found that almost half of the maternal deaths in the western part of China happened at home or on the way to hospital. So we asked people why they didn’t go to hospital. The first reason was that they didn’t have money. The second reason was that they didn’t think they needed to go to hospital to give birth, and the third reason was that hospital was too far away. After that the Chinese Government developed a strategy, including putting a lot of money towards providing free services for hospital delivery, to deal with those kind of disparities. And we are going to follow up those strategies to evaluate whether they are a success or not”, she says. “Recent years have shown that the gap between urban and rural maternal mortality rates has decreased and almost disappeared”, says Guo. “That’s big progress, but it’s not been easy.” Having cut her teeth in global health as one of the Commissioners of WHO’s Commission on Social Determinants of Health, which reported in 2008, and more recently with The Lancet’s Global Health 2035 Commission, Guo is now planning to devote part of the next phase of her career to working out how to translate China’s successes in tackling maternal and child health to other countries where progress has been slower. “There are definitely several unique things about China that are maybe not easy to translate to other developing countries, but there are some things like health financing, service delivery, techniques in primary health care, I think those are the types of experience we can share with other countries”, she says.
David Holmes 737
