The Ministry Of Public Health Health And Social Care Essay

Nevertheless, while this decision clearly favored those under the Labor Insurance Regulations, the ‘three have-nots’ and especially the majority of peasants were totally destitute. In fact, the reality that many people benefited from the economic reform did not indicated that there were plenty of those remained plain poor. Besides, the reality that people owned family, means of making a living did not put them in a position to pay for the high hospitalization fees. Till 1987, only a few hospitals operated by the Ministry of Civil Affairs network offered fee remission for the poorer self-pay patients while many of others did not (Pearson, 1995). In other word, the shift of core funding by the Ministry of Civil Affairs obviously stimulated the upgrading of mental health hospitals, which was pleasant for those affordable, however, they were on the expense of poor and long-term-ill patients.

In 1988, in order to bring the correspondence and consistence with the emphasis placed on the obligation of state to provide work, and the responsibility of all citizens to boom up the productivity (Cui, 1988), the Minister of Civil Affairs declared that "great efforts must be made for the development of factories employing the handicapped, including those having mental illness." This also contributed to the initial formation of three-level coordinating committees providing after care and homecare support for those mental ill. However, influenced by the stigma and fear of persons with mental illness, those factories that supposed to offer the opportunity and welfare would rather employ those with physical disability than mentally disordered.

The Role of Ministry of Public Health

Lin (1985) confirmed in his book that there was actually no office or officer in the Ministry of Public Health responsible for mental health, most of the resources in the ministry contributed to seven areas according to a professor from Beijing at that time: child, community, psychosocial aspects, geriatric, forensic, epilepsy, and education (Pearson, 1995). Accordingly, in terms of mental health, the Ministry of Public Health as a general rule runs hospitals dealing largely with who are acutely ill, and is responsible for governing those chronic care hospitals.

The Role of Ministry of Public Security

The mental health policy in the PRC is relatively special as it is infected as a tool for public security and political control. This relates to the role of Ministry of Public Security, which is responsible for forensic hospitalization of those defined as dangerous to the society. This made the mental health policy in the People’s Republic of China distinct with many other western countries, influenced by the strong emphasize of the Party for social control and social stabilization (Pearson, 1996; Pearson, 1995; Phillips, 1998; Ran, 2005). Since the 1980s, there has been construction of a network of new police psychiatric hospitals, Ankangs (安康 – Peace and Happiness) hospitals. These hospitals primarily provided service to people suffering from mental illness and other forensic problems. Till the mid of 1990s, the Ministry of Public Security is responsible for 3.1% of the total mental health services from all the governmental ministries (Tian, Pearson, & Wang, 1994).

The Ankang Hospital has two properties: one fitted by the Criminal Law of the People’s Republic of China as the medical institution that the Chinese government hospitalizes those mental illness patients with harmful damage but no criminal responsibility; the other corned in the Police Law of the People’s Republic of China as the appointed place for the mentally-ill that harm or will potentially do harm for the public or individual security. According to The Meeting Minutes of the First National Meeting for the Psychosis Governance Management by Ministry of Public Security (《全國公安機關第一次精神病管治工作會議紀要》), the Ankang Hospitals governed by the Ministry of Public Security have the responsibilities to receive the mental illness patients that harm the social stability after the psychiatric-judicial authentication. This action was further verified as a special legally-supported administrative coercive measure by the Criminal Law in the National Ankang Hospital Meeting in 2010.

In the current administrative environment, it is extremely difficult to ensure the quality and availability of mental health services. The sources of funding, administrative structure, access to medical graduates and other trained personnel, and mandated clinical standards (if any) of the different types of hospitals and community services vary tremendously. There is little coordination between the different types of institutions and there is no national development plan for the provision and regulation of mental health services. At present, supervision of the quality of services is sporadic or in the case of cooperative and private institutions non-existent. Even when a ministry mandates regular inspections of its mental health facilities, the quality of care is usually defined in terms of the level of available equipment and standards of cleanliness, not in terms of an assessment of clinical outcomes.

The Role of China Disabled Persons’ Federation (CDPF)

China Disabled Persons’ Federation (CDPF) was established by Deng Pufang, the older son of China’s Paramount Leader, Deng Xiaoping. He was thrown out of the window from the third floor by Red Guard during the Cultural Revolution (1966 – 1976) and confined to the wheelchair later then. In 1984, the China Welfare Fund for the Disabled was founded; it then turned to the China Disabled Persons’ Federation (CDPF) in 1988. Before that, the first national survey of people with disability was held in 1987, paving the way for the legislation and future plan for disabled person in 1990s.

After the negotiation between many senior psychiatrists and Deng, mental illness was finally agreed to be included as one of the groups of people suffering a disability (Tian et al., 1994). Since then, China Disabled Persons’ Federation (CDPF) has been acted as the leading association for initiating and organizing the supporting programs for helping the mental health patients, this is more prominent in 1990s and the present with the development of internet promotion.

Three Levels of Coordinating Committees and the Party-dominated Management

Since 1980s, the three levels of mental health coordinating committees – municipality, district, and neighborhood – have been structured for contributing to the overall after-care support for people with mental illness (Pearson, 1988). The Municipal Hospitals were supposed to provide trainings for the retired workers involved and for paramedical staff. The district and neighborhood organizations helped run occupational therapy stations for those patients who were either unable for ordinary work or unnecessary to be in the psychiatric hospitals anymore. They are staffed by retired workers who volunteer for the job. According to Xia (1985), in Shanghai each station is expected to be self supporting but with sufficient work for each patient to take home a small wage for the six hours a day, 6 days a week of work. In 1981, there were 120 such occupational therapy stations taking care of 2,740 patients.

In an authoritarian country like the People’s Republic of China, authority relations were rigid and hierarchical. This is also true for China’s hospitals, especially those in the municipalities. There were few formal consultation channels with staff and little room for innovation or changes unless introduced either from the management team or by outside forces. Hence, the structure of hospitals is largely depended on the top-down imposition of official policies.

In terms of individual power, there were five most important people in the hospital hierarchy (Pearson, 1995): the Party Secretary, the Medical Superintendent, the Medical Director, the Deputy Medical Superintendent, and the Administrative Director (who was also a doctor, and in 1989 was promoted to become Medical Superintendent). Unlike the case in Western hospitals, the most influential and powerful person in the hospital was the Party Secretary, which was the case in any Chinese organizations or State-owned enterprises. All professional and administrative matters were subject to Party dogma and discipline.

Concerning the decision making procedure, just like the Chinese Communist Party owns the paramount power at the national level, it is also supposed to be equal within each sub-levels, no matter it is a government department, a factory, village, towns, or districts (Madsen, 1984). Whenever there is disagreement between the unit manger and the Party Secretary of that unit, the latter possesses the power to prevail and interfere in any aspect of the business of that unit. In the Municipal Hospitals for instance, the Party Secretary can advocate more political education of the patients and doctors, or he could order the doctors to change his initial treatment scheme.

While this Party-dominated management had been decreased gradually, especially when the seventh plenary session of the Twelfth National Party Central Committee held in 1987 adopted the policy that the functions of the Party and government at all levels be separated (Beijing Review, 1987), some Party Secretaries still defined themselves as the major power in the hospital, covering the management of discipline, security and administration. After the Tiananmen incidents in 1989, the Party-dominated structure reverted to its previous position, ignoring the previous aim for separation of powers. To the present, there are still Party unit embedded in the hospitals for guiding and supervising the Party education and implementation.

Reconsidering the Reform and Model of Mental Health System from 1990s to present

Starting from 1999, a series of policy researches were carried out to study the situation of mental health services in China (See Appendix 2). These studies revealed the real situation, inadequacies, and challenges of the demand and supply of mental health services. It was the first group of formal national systematic studies done in the PRC in articulating the supply, utility, cost, and expenditure of various types of mental health services as well as availability and qualification of mental health workers in China. Based on the results, the China Mental Health Work Plan (2002—2010) was issued by the Central government in 2012. It includes various gals and targets for the future development from 2002 to 2010. In this chapter, the basic background for the mental health situation provided by those researches will be summarized, and the challenges and reforms since the 1990s to the present will be discussed. Generally speaking, the mental health policy in PRC is still immature and highly diversified among various regions in China.

China Disabled Persons’ Federation (CDPF) and the Progress of Mental Health Policy

China Disabled Persons’ Federation (CDPF) has been continuously dedicating to the mental health services support since its establishment in 1988. Two years later, the ‘Deng Pufang connection’, composed by several senior psychiatrists and Deng himself, led to the formation of the Chinese Rehabilitation and Research Association for the Mentally Disabled in 1990. This association is subsumed under the Chinese Rehabilitation and Research Association for the Disabled, so it is in turn belonged to China Disabled Persons’ Federation (CDPF). When the 1991 Law (Article 8) officially recognized China Disabled Persons’ Federation (CDPF) to "represent the interests of disabled persons, protect their lawful rights and interests, educate disabled persons and provide service for disabled persons", it was for the first time those interested in influencing the mental health services gaining the channel for them to legitimately act out, being able to express vies and develop pressure group tactics, though such initiatives still had long way to go. While these developments were quite new, they did provide to some extent the foundation for optimism.

The influence of China Disabled Persons’ Federation (CDPF) on mental health policy could be visible then in the Eighth Five Year Plan for Disabled Persons 1991 –1995, in which the Paragraph 2:4 clearly includes a specific provision for an experimental service delivery project for people with a mental illness. 32 cities (urban) and 32 counties (rural) were to be selected for the provision of a comprehensive range of treatment and rehabilitation facilities on an experimental basis (Pearson & Phillips, 1994).

In 1992, China Disabled Persons’ Federation (CDPF) emanated a document circulated at the Second National Psychiatric Rehabilitation Meeting held in Chengdu to give more details on the coordinating works of CDPF, including the cooperation between the local offices of the China Disabled Persons’ Federation (CDPF) and governmental representatives of Ministry of Civil Affairs, Public Health, and Public Security on the one side, and the network between the Federation and local street level organizations, mental health institutions in villages and towns for setting up the work therapy station to provide some occupation, recreation, and medical supervision for the mental-ill. Besides, two general principles were recommended. First, for those mildly ill or the status have already turned to stable, ‘back to the community’ should be suggested for the benefit of their future development. Second, for those still imprisoned at home by their families, ‘don’t lock patients up’ should be strongly promoted by all-level organizations for the sake of protecting their rights and chances to be treated equally and psychologically. However, while these ideas were discussed to be good in the consensus at the Second National Psychiatric Rehabilitation Meeting, problems concerning the financial shortage and the unsupportive attitude of cadres and general public were fatal to the actual implementation. Therefore, this scheme has only taken off in few areas where suggested facilities and services were already in existence (Pearson & Phillips, 1994).

The Supply, Utility, and Costs of Mental Health Services

The Supply

According to the study of Zhu (2002), there were altogether 96 mental health organizations in China. Inherited from the previous tradition, various ministries provide hospitals for targeted groups. The Ministry of Public Health for severe and long-term patients, and it was the major (58.51%) supplier of mental health services in PRC. The Ministry of Civil Affairs mainly supported the ‘Three-nos’, it operated as the second large provider of mental health services. The Ministry of Public Security supervised patients with criminal records and violent disposition, the Ministry of Military helped the military armies and their family members. Besides, since the economic reform, there has been more and more mental health services provided by the privately run mental hospitals, ranking the third for services providing (19.4%) (Zhu, Zhang et al., 2002).

The distribution of mental health services varied among regions and provinces. The eastern part of China, with more populations and commercialization, contained nearly one third (31.1%) of the total organizations, while the south western region owned less than one tenth (8.5%) of the sum (Zhu, Zhang et al., 2002). For province, remote areas like Tibet had no mental health organizations, Qinghai and Ningxia contained only 1 and 3 organizations. However, eastern provinces like Hebei and Shandong owned 111 and 106 organizations respectively.

In 2002, there were about 1.3 billion of the population in PRC and only 134, 000 psychiatric beds available in different provinces, which means for every ten thousand people, there were around 1.03 psychiatric beds available (Zhu, He, & Zhang, 2002). This lagged far behind the well-developed countries where there are 10 psychiatric beds per ten thousand persons. Within different regions, the North Eastern Region, though not containing the largest population, had the highest ratio of psychiatric bed (2.01/10,000) (Zhu et al., 2002; Zhu, Zhang et al., 2002), and Shanghai had the highest ratio (6.7/10,000) among other areas while Tibet had the least (0).

The Fund and Income

According to the study of Zhek et al. (2003), the income and fund varied largely among different organizations in rural areas, town, cities, and capital cities in each province (See Appendix 3). In general, nearly all mental hospitals in all levels had to strive for at least two thirds of their income by themselves in their service delivery. In terms of funding, the mental health hospitals in capital cities got the largest share and percentages of funding from the government, while those in the rural areas received the smallest amount. This led to the problem that psychiatric hospitals in well developed and populated cities earned their income with the most ease, while those in less developed areas met difficulties earning their incomes including governmental funding. As a result, a vicious cycle was formed where developed areas owned more opportunities to utilize advanced machines and professional psychiatrists while undeveloped ones lack the attraction and power for better services.

Gradual Reforms till the present

Centralized Mental Health Planning

Facing the huge demand but very limited supply of mental health services in PRC, a much more centralized, comprehensive, and efficient mental health policy was extremely requested. In 2002, the three leading governmental ministries including Ministry of Public Health, Ministry of Civil Affairs, and Ministry of Public Security together with the China Federation of Disabled People (CFDP) formulated and published an important guiding document, China Mental Health Work Plan (2002-2010). This served as the main mental health policy directing the mental health services from 2002 to 2010, and it had large influence on shaping the policies within those years.

In this document, it estimated that there were around sixteen million persons with mental illness that necessitate long-term treatment and rehabilitation, thirty million adolescents with behavioral and emotional problems, six million persons with epilepsy and numerous elderly persons with mental health problems like Alzheimer’s disease (中國殘疾人聯合會, 2002). It set the overall goal and focus of future development during the period as primary prevention, integration of treatment and rehabilitation, intensive intervention, wide coverage and centralized legislation and policy. To make it more precise, five focuses and aims were addressed. Firstly, to establish a mental health system, organizational management, and coordinating mechanism under the leadership of government, cooperation of various ministries, and participation of social groups. Second, to stimulate the process of formulating related mental health laws, regulations, and policies, forming a mental health security system coping with the current national economy and social development. Thirdly, to strengthen the promotion and education of mental health, improving the recognition of importance for mental health work, improving the mental health level of the people. The fourth one was to consolidate the intervention for those with severe mental illness, improving the treatment and rehabilitation services and preventing the increasing trend of mental health illness. The last goal was to build a comprehensive mental health service system and network, consummating the existing function and improving the quality and ability of mental health team to basically meet the need of the masses.

Under the above guidance, mental health has been gradually included in the national public health reform program. Since October 2003, there had been many applications of specialized public health projects supported by the Ministry of Public Health for the investment and funding from the Ministry of Finance. After a serious selection, a delegation led by Guihua Xu (Vice Director of China Centre for Disease Control) and three psychiatrists from Peking University Institute of Mental Health, visited Melbourne to study a suitable and practical model for the PRC, ending with a suggestion of the patient-centered approach that was community-based, seamless, function-oriented and multi-disciplinary (Liu et al., 2011). In September 2004, the program for mental health service reform, as the only non-communicable disease program, was included in the China’s national public health plan, representing a major historical milestone for China when mental health became officially included into public health.

In the late 2004, the mental health reform, named the 686 Program after the government funding of 6.86 million RMB, was formally approved by the Ministry of Finance and soon put into practice. By early 2005, sixty demonstration sites, locating in one urban and one rural area in each of 30 provinces, were established, covering around 43 million people. The plan attempted to extend aspects of care that were found to be reasonably successful in the PRC (Zhang, Yan, & Phillips, 1994). These sites initially helped with the two-level training model from nation-level to the provincial-level, in order to build up a capable mental health workforce. This was something that the Chinese authorities had not carried out for several years (Lin & Eisenberg, 1985).

One year later, with the help of the National Continuing Management and Intervention Program for Psychoses, an intervention and treatment program was incorporated in the 686 Program for providing continuous care for four types of mental illness patients: schizophrenia, bipolar disorder, delusional disorder, and schizoaffective disorder. As a result, in 2009, a total of 34,861 facilities participated in this program, including 44 provincial hospitals, 92 municipal hospitals, 168 district/county-level hospitals, 986 urban community health centers, 2,748 urban community health stations, 1,136 township clinics, 11,480 village clinics, 5,660 urban neighborhood committees and 12,547 village committees (Liu et al., 2011).

689 Program not only enhanced the mental health professional training and treatment approaches, it also stimulated policy reforms, followed by five vital national polices on mental health: the Guiding Compendium on Development of National Mental Health Work System (aimed to improve inter-ministerial coordination); the Government Work Report (when the mental illness was first addressed in the annual report of the Central Government); the Short-term Strategy of Health System Reform (psychiatric hospitals should be included in the overall aim at improving public health service capacity building); the Opinions on Improving Gradual Equity of Basic Public Health Services (in which the management of mental illness was included as one of nine national basic public health service domains); and the Working Criteria on Management of Psychoses (in which responsibility of different sectors in the management of mental illness were defined and classified).

Satisfied with the outcomes of previous reforms while still accounting the unappeasable demand of mental health services, the four agencies – Ministry of Public Health, Ministry of Civil Affairs, Ministry of Public Security, and China Disabled Persons’ Federation – again jointly drafted the China Mental Health Work Plan (2012 -2015) and issued for public opinion in 2012. In this document, five goals, which were similar with the previous plan from 2002-2010, were set more specifically in detail (中華人民共和國衛生部, 2012).

Decentralized Authority under the Western Influence and Financial Requirement

Although there have been persistent efforts of the government and Party to improve the comprehensiveness and effectiveness of mental health policy, at the same time, the government in fact has correspondingly decreased its commitment to provide the health services, especially in terms of funding and insurance. Influenced by the economic liberalism of pragmatic reformers, mental health services have inclined towards economically self-sufficient (Phillips, 1998). This can be significantly reflected in the virtual elimination of the rural cooperative medical insurance system that previously provided basic medical care to the majority of China’s huge rural population (Gu, Bloom, & Tang, 1993). As the reforms continue, the decentralized authority, self-determination and individualism had indirect but powerful effects on the provision of social welfare and mental health in various regions. For instance, the allocation of funding for health resources will be more susceptible to local influence peddling: powerful urban centers gradually gained an increasing proportion of the available resources and mental health services; whereas those less influential localities would receive a decreasing proportion of available government funds.

Besides, the distribution of mental health services were largely by the policies promoting increased self-determination and job mobility. Under the intensive emphasis on financial benefit, there have been less and less people mobilized by the local cadres to participate in neighborhood mutual help programs. This change will undermine the continued viability of the previously innovative ‘guardianship networks’, sheltered workshops, and operational centers that support the community mental health care through volunteering (Pearson, 1992a). In terms of vocational factors, as more medical and nursing students got the chance for choosing their jobs, fewer become psychiatrists and psychiatric nurses for the low salary and low status of psychiatric and psychological works compared to other medical specialties, not to mention the clinical social workers for mental illness persons.

As a result of less governmental commitment and psychiatric professions, the drift influenced by Western individualism caused a gradual shift in the focus or caring responsibilities of the mentally ill to the family. However, the governmental-sponsored health insurance had been decreased on the one hand; on the other, trapped with the stigma of mental illness as dangerous sources, more families are reluctant to re-accept mentally ill relatives back home after an acute hospitalization. Besides, as the Chinese Mental Health Law is still under evaluation, currently the decision to hospitalize the mental illness patients lied on the will of their families and their consultation with local psychiatrists, which caused the frequent cases for hospitalization by forces in the PRC these years (Phillips, 1998).

Conclusion: Challenges and Prospective for Future Reform

Deriving from the gradual development of mental health policies in China since the initiation till the present discussed in the previous three chapters, it could be concluded that contemporarily under the influence of a mixture of Communist ideology, the mental health policy in the People’s Republic of China is still a top-down, government or to some extent Party-controlled arrangement. After the Cultural Revolution, several flaws were recognized by the Chinese government and it started planning and implementing vigorously in the policies to promote mental health prevention, treatment, rehabilitation, and education, despite the original intention behind as social stability emphasized by the Chinese Communist Party. Since the Open Door and Economic Reform in 1978, China adopted a market economic and began to privatize its health care system – introducing private practice and health care insurance, for instance. Hence, the system has been leading off the trend of decentralization. Confined by the magnitude and the complexity of the mental health problems as well as the changing situation, this trend in consequence ended with several problems and challenges of the mental health policy in the People’s Republic of China, including the political structure, cultural stigmatization, and economic restriction. This chapter will go deep to analyze these problems and challenges, and it will examine the potential prospective for the future mental health policy reform.

Challenges

Political Structuring Problems

Political influence and Party infiltration pose the preponderant problem for the mental health policy in the People’s Republic of China. Since the initiation of this policy, the two factors have been continuously guided the three periods of evolution of mental health policy and services till the present. During the first stage, under the impact of Russian political ideology, the Pavlovian theory began to be the dominant principle for those initiators of psychiatrics in the PRC, while the Western side theories, like Freudian, were regarded as the product of the evil capitalism and strongly opposed. In the second duration, especially during the Cultural Revolution, mental health was distorted into a political tool to lock up and punish those holding Anti-Maoist ideology, capitalists, and scholars, categorizing them diverged from the Maoism leadership and forcing them to be hospitalized or receive political education intensively. Political coercion led by the Red Guard at the end caused several destructive consequences to the Chinese society. Within the third period, with the trend of Open Door and Economic Reform, although either the anti-Western psychology attitude and the previous compulsive political education curtailed, and the country has realized the importance of planned and comprehensive mental health policy, the Chinese Communist Party, leveraged the credentials of better social stability, implicitly infiltrated the policy making and political structure of the mental health facilities as well as services, this can be reflected in the administrative structure and power of the hospitals, the benefits of the vested interests, and the promotion slogan of mental health services. Therefore, to some extent, while the central government giving the efforts to the mental health policy, the end of the series of trials goes back to the goal for maintaining the social order and social stability so that the Chinese Communist Party could be eventually benefited.

Apart from these, as discussed before, the "three men leading groups" (Ministry of Civil Affairs, Ministry of Public Health, Ministry of Public Security) has technically turned to "four men leading groups" (adding the China Disabled Person’s Federation) according to the statement from the Legislation on the Protection of the Disabled (1991) since the beginning of 1990s. The coordination among them was rather inefficient and inattentive due to the absence of central authority to execute the certain power for the integration of mental health policies and provision of services by these various ministries. Consequently, the mental health systems and inpatient care in one region may be easily discontinued, while even for each ministry, the administration of its responsible psychiatric hospital could be at the national, provincial, municipal, county, or enterprise level (Phillips, 1994).

Cultural Stigmatization

In fact, before the initiation of official mental health policy since the establishment of People’s Republic of China, the stigma towards people with mental illness was already existed. As a result of this deep-rooted stereotype, several widespread believes that magnify the aftermaths of mental illness emerged, some associated with fork proverbs: the belief that people with mental illness are frequently violent or destructive (jing shen bing ren jun can bao 精神病人均殘暴); the belief that the illness comes from the immoral behavior by the individual, his families, or his ancestors which is hereditary (qian bei zuo lie hou bei shou 前輩作劣後輩受 or you qi fu bi you qi zi 有其父必有其子); the belief that the illness brings along some bad ‘fate’ caused by spirits and ghosts (gui shen fu ti 鬼神附體); and the belief that the illness itself is contagious, and that would spread to the surrounding people as well. Just as Phillips (1998) stated that during his stay in Shashi psychiatric hospitals, some of the psychiatric nurses held the fear that they would indirectly "carry" the mental illness through the patient services. These long-existed cultural and social stigmas clearly ended in inefficient or to some extent distorted mental health policy compared that in the West.

First, as both the stigma and in real occasions reveal that people with severe mental illness cause the disruption of social order and fail to abide by the principle of social harmony as promoted by the Chinese Communist Party; they are considered as serious transgressions of social norms in the Chinese worldview. Accordingly, the Chinese government believes that the need to maintain order and control is one of the main priorities of its mental health policy (Pearson, 1996; Ran, 2002; Ran, 2005; On the one hand, it is concerned as acting along with the best for the patients; and on the other, it is a governmental response for social disorder. Reflecting in the Chinese mental health policy, the human rights of mental illness patients and the quality of mental health services for every person who needs the services are seriously impaired.

Second, in terms of the providers of mental health services, the stigma also existed in many psychiatric professionals. Psychiatric graduates, as discussed in previous chapters, are reluctant to choose related jobs for mainly three reasons: low social status, which they would bear the rumors from the neighbors that they could carry the mental disorder soon when working for the group of people; low job salaries, due to the minor role of psychiatry in PRC especially comparing with other branches of medicine; and in fact their own fears of people with mental illness. This reluctance results in an acute shortage of mental health care professionals, as indicated by a population ratio of 1 per 100,000 (Xiang, Ran, & Li, 1994), and psychiatric hospitals continuously lose professionals with higher levels of education, training, and expertise. Moreover, in fact, many governmental officials, party members or psychiatric hospital administers do associate the above stigma towards mentally ill (Phillips, 1994; Phillips, 1998). Together with the historical tradition that it is the duty of the family to take care of their ill relatives, the Chinese government has been formulating several laws and regulations prescribing family obligations (Leung, 1997), leading the misunderstanding that it is only the family should take care of them. Accordingly, they neglect the factors that efficient mental health services do need the mental health policy to establish, support, investigate, and supervise. The government then considers transforming psychiatric facilities into "public health institutions" where staffs are regarded as "paracivil servants". This may make the discipline of psychiatry less attractive.

The third consequence concerned with the receivers and targets of mental health policy. Widespread stigma towards mental illness turned to one of the main obstacles for the group of people to become an independent member of society. While there is a crucial problem of unemployment in China, especially in the state- ad collectively-owned enterprises (Leung, 1995), among them 67% are disabled and are not financially independent (Pearson & Phillips, 1994), they have to rely on their family support. Many of the mentally-ill are jobless, and thus without the channel for social welfare benefits, including health insurance, housing, subsidized schooling, and retirement benefits. When the Chinese communities express their unwillingness to accept half-way houses or other residential services that provide minimal direct supervision of mental illness patients in the community, many of them become homeless.

What is more, the rule of gaining "face" — others’ perceptions of one’s power and influence — as the credit for obtaining benefits from those who pursuits profit or power is deeply ingrained in the Chinese culture and society (Hwang, 1987). However, under this principle, people with mental illness, who are not possible for reciprocating such favors, will be so or later socially isolated as other utilitarian people are unwilling to interact with them. This cause them more diverged from the society unless there is any socially or politically powerful figures who would like to defend them.

At the present, with more exposure to and communication with the Western psychiatric and psychological ideas, the stigma of contagiousness and moral deficiency associated with mental illness may change. However, fears about their potential for violence and distrust of their ability to reciprocate in normal social exchange network will remain. Unless these skeptical and categorical stereotypes within the Chinese people recede, the mental health policy in the PRC could not be fully efficient.

Economic Restriction

Funding became a major dilemma for the mental health policy in PRC, especially after the economic reform since 1978, leading to the trend of decentralization for funding matters. The central government allocates money to fund organizations, technical support groups, and training programs needed at the national level as discussed in the previous chapters. At the same time, since 1980s, most of the funding, suggested by the Ministry of Public Health, is expected to be found locally. However, many fund-raising organizations, such as the Community Chest, Rotary, and Round Table, charities that are familiar and popular sources of non-government funding for deserving projects in Western societies, are pretty rare in the PRC (Pearson, 1996). Therefore, most local governments or mental health facilities confronted a main obstacle that they could not find alternative funding to support their mental health services and system.

As a result of this mental health policy, the rural areas will be largely suffered for lacking of enough funding for psychiatric hospitals and facilities, which under the Chinese psychiatric ideology of "hospital first" are considered as the dominant role of the mental health services (Ran, 2005). Thus, the distribution of available resources between the urban and the rural areas is highly unbalanced (Xiang et al., 1994).

Economic restriction can be also reflected in the reducing or almost non-existed national health insurance system in which mental health treatment is guaranteed to all. Previously, for most of the urban citizens, the costs of hospitalization, including those in psychiatric hospitals, could be substantially covered by the health insurance or welfare that was provided through their workplace or danwei (Chow, 1991) such as the state-finance retirement benefits. In rural areas, peasants were supposed to be benefited from the communally financed insurance system. These were the two systems existed to support people in urban and rural areas.

However, guided by the Party’s ideology to promote more productivity and self-reliance, especially those words from Deng like "science and technology are the primary productive forces" (科學技術是第一生產) or "Development is the fundamental principle" (發展才是硬道理), the occupational reform was started in the 1980s, the communally financed insurance system in the rural areas and insurance systems in urban areas were curtailed (Pearson, 1995). Currently, many mental illness or mental disorder patients have to face the full costs of hospital treatment while at the same time, the hospital fees are rising year by year (Pang & Kao, 1992).

The restriction also rooted from the economic reform in 1978, before that, all mental health services were under the system of economic planning as it was considered within the context of an orderly socialist society with stable family life that was supported by the state (Yang, 1995). After the reform, the economic expansion stimulated the rapid expansion of health sector resources. However, this was not as beneficial as it should be, particularly in poor rural areas (Gu, Tang, & Cao, 1995), where the financial base of the working-brigade and the ability to provide sufficient health insurance or welfare safety net in villages were dissolved (G. Liu, Liu, & Meng, 1994). In urban areas, the enterprise reform also shrank or varied the health care benefit of its workers (Hu, Ong, Lin, & Li, 1999). At the same time, the government’s commitment has been gradually minimized (Lee, 1993). Altogether, this economic reform largely towards privatization had great effect on the funding and welfare for both urban and rural areas.

Prospective

After the analysis, the following suggestions may be the prospective for possible changes of mental health policy in the People’s Republic of China. First, political domination should be separated from the provision of mental health policy, although they would argue that the main goal for them to exist is corresponded with the Party’s emphasis on social stability. Unless the mental health services are not regarded as one of the health welfare that people have the rights to enjoy, mental health policy with political ideology legacy will stay inefficient.

Second, the Chinese National Mental Health Law, which was passed in October 2012 and will be implemented in May, 2013, should be investigated under different groups including the governmental ministries, psychiatric professionals, mass media, and residents from both rural and urban areas. Without a vigorous legislation in the nationwide, mental health policy and regulation varied in different regions are inattentive.

Third, government officials need to pay more recognition to mental health services, avoiding the prejudices that stigmatize mental-ill patients in Chinese society. It should be noticed that in a country with highly centralized government structure such as the PRC, mental health policy does need strong and continuous support from governments at all levels. Without this, the mental health sector would find it hard to fulfill the services and management. In addition, as the Western influence gradually increase, the concept of civil society has been popularized. So the government needs to be more aware of the importance of non-governmental organizations and their potential role in integrating various social resources and providing valuable supplementary services for the mentally ill in various places to enhance their recovery and rehabilitation, though in PRC non-governmental organizations specialized in mental health is not yet known.

Fourth, the four national "leading groups" (Ministry of Civil Affairs, Ministry of Public Health, Ministry of Public Security) should gain more power to coordinate mental health policy and services provision, possibly through setting up a special national department in charge of the leadership responsibility. This is crucial for the Communist China as the "Red Head" official documents are usually more influential.

Fifth, the national health insurance and welfare system ought to be reformed and consummated as soon as possible with the help of both the state and local power, not only in the urban areas, but also for the peasants in rural areas that are not affordable for the increasing hospital fees. Lastly, psychiatric professionals should be given higher social status and received at least equal salary as their counterparts.

Implications of PRC’s Mental Health Policy Reform for International Prospective

On the one hand, as one of the modern authoritarian governments, the PRC obviously reveals how the mental health policy in such kind of governance is formulated and implemented through a Party-prominent direction and top-down approach, which fulfills the political and party interest more than the welfare of people. Besides, there is a continuously preference of the government to explore a Chinese characteristic way of mental health policy and services when comparing with the prevailed Western style since the initiation to the present. Officials keep emphasizing the special national situation of the PRC and the according policies which are set to customize our own demand, but of cause the mental health services supplies and supports, as discussed before, are far lagged behind the huge need of the people.

On the other, shaped by the intense globalization trend and international advocacy. The progress of mental health policy in the PRC is quite consistent with the recommendations in recent years by the WHO and supporting agencies. Since 2001, the WHO (2001) has been emphasized the community-based services for mental illness patients, which was then strengthened by a series of exercises such as the development of the Mental Health Gap Activity Programme (mhGAP) under the WHO (2008), the call for scaling up mental health services for the mentally disordered by the Lancet Group (Lancet Global Mental Health Group et al., 2007), and the activities of the World Psychiatry Association (Maj, 2009; Maj, 2010) guided by the recent publications in the World Psychiatry (Ng, Herrman, & Chiu, 2009; Thornicroft & Alem, 2010).

Clearly, a review of the efforts in the 686 Program and other decentralized policies suggest the important tendency of the mental health policy in the PRC towards internationally advocated standards in mental health services provision and projection. However, as one of the many Low- and Middle-Income Countries (LAMIC), mental health services in the PRC still have a long way to go to reach the target and requirement of community mental health provision that really benefits different levels of patients comprehensively. Moreover, dissemination of the locally driven researches which provide precious information for policy makers faces the dilemma of poor representation of publications in China within the mainstream psychiatric journals (Patel & Sumathipala, 2001; Saxena, Paraje, & Sharan, 2006). This is the problem shared by most of the LAMIC that none of them in the Asian and African regions have representative psychiatric journal in the main international databases (Kieling, Herrman, & Patel, 2009; Mari, Patel, & Kieling, 2010). Accordingly, the further development calls for more transparent and professional voices, either domestic or international, for policy decision makers.

Limitations

There are several limitations of this study. First, most of the resources are secondary, although they come from professionals in this area, some bias and deviations in writing will result in subjective information that remain in this thesis after my serious judgment. Second, examine the mental health policy in China with official documents will cause the doubt of reliability, as many information are not that transparent, sources in the public documents main have been revised and maintain little gap between the real statistics and the refined tone. Thirdly, more empirical studies like interviews with current politicians are highly recommended but omitted in this study due to the limited time and space. These may weaken the explanatory power of my study, but I am convinced that the political-dominated and Party-prominent feature of the mental health policy in the People’s Republic of China concluded in this research is a useful perspective to examine the nature and transformation of mental health policy of China at the present and in the future. Therefore, the following studies request further and in-depth research in this area.

Remaining Questions

On Oct 26, 2012, the PRC passed its first Mental Health Law, regulating the rights of decision of involuntary hospitalization for the mental illness patients, handling the final decision to the professional psychiatrist. This initiated the discussion and debate within patients, their relatives, lawyers, and media concerning whether this action will practically protect the rights of the mentally-ill and whether it is an official government response to the social pressure for efficient mental health policy and demanding mental health services (Xinhua, 2012). While the real implementation of this law will wait until May, 2013, it is hard to predict to what extent the Law will be a beginning for better mental health policy of the PRC. Actually, the situation is blended with complexities when it comes to special practices. Mental health policy in the PRC has been an instrument for politics, rather than the health welfare of the people. I would argue that this nature and trend will still go on in the future formulation and practice of mental health policy. Without a thorough institutional reform within the political system, mental health will remain overlooked when comparing with more socially and internationally influential factors such as national economy and defense. Then, how could the central government respond to the huge demand and unprofessional workers while there is increasing number of examples that hamper the social stability and harmony that it continuously emphasizes? Would, or could, it follow the steps of Western formula to establish a comprehensive mental health system in the near future? What kinds of factors the government should compromise with its interests and make more efforts? How to solve the disparity of mental health policies and services at the present? These would become crucial and critical problems for central-local, and government-people relations.

These are all questions demanding future research. I do hope that the findings of this study contribute a clearer understanding of the nature and challenges of the mental health policy in the People’s Republic of China. If this work fulfills its purpose, it will then alert researches to emphasize not only the psychiatric or psychological logic, but the political impetus behind reform policy in the future. Changes in the political structure, institutional arrangements of the Party, and economic developments all matter. I hope this study will provide the basis for more informed discussion as the PRC moves to the next stage of institutional building and health reform, which can significantly suit the demands of people with mental illness with good and enough services. However, to build up a comprehensive and efficient mental health system in the PRC will still be a long way to go.

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Appendix

Appendix 1

Resources: United Nations Department of Economic and Social Affairs. (2005). Unlocking the human potential for public sector performance: World public sector report 2005. New York: United Nations Department of Economic and Social Affairs.

Appendix 2

Studies on National Mental Health Services in China from 1999 to 2002

Related Studies

Research Focus

Research Methodology

Subjects

Zhu, Zhang & He (2002)

Demand and Need of Mental Health Service in terms of:

The distribution of professional agencies and organizations.

The distribution and utility of psychiatric beds

Literature Review and Archives on:

The information, materials, and findings gathered in the Third National Conference on Mental Health Work.

The recent information obtained in different websites of related organizations and services

Agencies in China

China Statistics Report

31 provinces in China

969 mental health organizations in China

Zhu, He & Zhang (2002a)

Zhu, He, & Zhang (2002b)

The Current Situations of Mental Health Personnel

Literature Review and Archives on the information, materials and findings gathered in the Third National Conference on Mental Health Work

Altogether around 30,000 mental health personnel in 13 provinces with around 8,584 medical practitioners and 16,000 psychiatric nurses

He, Zhu & Zhang (2002a)

The Utility of Services in:

Outpatient clinics

Mental hospitals

Use of Structured Questionnaire

36 mental health services agencies and units

He, Zhu & Zhang (2002b)

He, Zhu & Zhang (2002c)

The Training of Mental Health Professionals

Use of Structured Questionnaire

36 mental health services agencies and units

He, Zhu & Zhang (2002d)

The Qualification of Mental Health Professionals

Use of Structured Questionnaire

36 mental health services agencies and units with 176 mental health professionals

Zhek, Zhui, Lu & Zhang (2003)

The Cost and Expenditure of Mental Health Service

Use of Structured Questionnaires and Literature Archives by Ministries of Civil Affairs, Public Health, and Public Security, China Federation of Disabled Persons

662 mental health organizations

Source: reorganized from Yip, K. S. (2007). Mental health service in the People's Republic of China: Current status and future developments. New York: Nova Science Publishers, p.45.