interacting with actual patients. In contrast, private non-MBBS doctors knew
the right question to ask only 20 per cent of the time, but achieved the same
level in practice. Private doctors, who are directly accountable to the patient,
make more effort but tend to over-prescribe medicines that are not effective to
please the patient (Das and Hammer, 2005). These problems in delivering
healthcare,especially primary healthcare,are related to bad incentives. When
private providers do not turn up to their clinics they do not get paid. Public
healthcare providers are paid by salary, not monitored by supervisors, cannot
be fired or have pay reduced under any circumstances,and have lucrative
alternative work in the private sector (Hammer et al.,2007).
140 Sources of Growth in the Modern World Economy since 1950
Box 6.3 Barefoot doctors in ChinaBy the 1960s and 1970s the Chinese were achieving better health outcomes than
many countries with much higher incomes. One reason was the strong emphasis
on preventive efforts. In most developing countries government-provided health
care is based on an urban curative hospital-centred system and the majority of
medical professionals are concentrated in the cities, wielding sufficient political
power to resist any shift in emphasis or simply absent themselves from practice
if formally posted to rural areas – remember those absent doctors, nurses and
teachers discussed earlier. After 1968 China popularized a programme first
developed in 1958 in Shanghai. Prior to 1968 intermediate medical schools
graduated doctors after three years and higher-level institutions trained physi-
cians for six or more years. Both types of personnel were highly trained and
expensive and so too scarce to staff China’s several hundred thousand village
cooperative health programmes. An alternative ‘barefoot doctor’ model based
on training of 3 to 6 months began to be promoted. These health workers
provided limited curative services such as post-natal care, advice on boiling
water, vaccinations and some pharmaceuticals. By 1976 there were an estimated
1.5 million such barefoot doctors in post and 85 per cent of villages had a health
clinic staffed by trained barefoot doctors (Lampton, 1978; Riskin, 1991). Life
expectancy in China increased from 36 years in 1950 to 64 years in 1979. The
infant mortality rate in rural China fell from 73 per 1,000 in 1963 to 40 in 1978,
while the average for the other poorest developing countries was 97 per 1,000
(Riskin, 1991; Bramall, 2009). The most valuable lesson from the Chinese
model is that healthcare provision suited to the particular conditions of a devel-
oping country can achieve a significant impact at relatively low cost. The exact
Chinese-style model owed much to the particular conditions of Maoist China,
which would be difficult to replicate. In China during the 1960s and 1970s agri-
cultural land was owned and managed by rural collectives (massive centrally
directed state-owned farms) so it was possible for the local state to allocate the
locality’s labour power to mass health campaigns such as vaccinations when
needed. Few developing countries have the characteristics (strong central state
able to mobilize the rural population and impose its will on elite urban health
groups) which could make the Chinese model feasible (Lampton,1978).