New hope for the women of Tibet:
Sciences of healing, Sowa Rigpa and Community Health Workers
This is the fourth of four blogs on the number of Tibetan women dying in childbirth, at a rate equivalent to some of the poorest places on earth, and what can be done.
The first blog took up two common arguments why little can be done. The “efficiency argument” of the economists is that a developing country such as China can at best afford centralised, urban health services, not extension services in remote areas. The first and second blogs looked more closely at strengths and weaknesses of traditional Tibetan attitudes to women, birth, death, cleanliness and pollution; to ask if these are the obstacles to improving the appalling maternal mortality rate (MMR).
The other master narrative that warrants a fresh look is the efficiency argument, which on economic grounds, concentrates investment in centralised locations where factor endowments are concentrated. In this argument, it will never be economically viable to deliver effective health care outside an urban hub, not only because of economies of scale but also because of the scarcity of trained staff, who are unwilling to work in remote areas.
This standard argument needs unpacking, partly because new technologies can overcome the spoke-and-hub logic of centralisation; and because the modern exchange economy is not the only way of working in Tibet.
The key to reducing MMR is by reducing post-partum haemorrhage (PPH), which can often be risk-assessed well in advance of labour, and the danger period for PPH. There is opportunity for alternative approaches that emphasize prevention, early diagnosis and remedial measures that do not require routine medicalization of pregnancy, or hospitalization as the default setting for delivery. Tibetan culture is a use economy, not an exchange economy. Sowa rigpa practitioners are usually not paid for diagnosis, dietary, behavioural and mental advice, because sowa rigpa is intrinsic to Buddhism, one of the tantras. Buddhist mind training exhorts practitioners to heal for the sake of healing, not for personal advantage or profit. A classic slogan of the lojong cycle of mind training is: “Don’t put exchange value on things.”
It is part of Buddhist tradition to emphasize not only acting compassionately, but also with a motivation uninflected by self-interest. Intention matters greatly. China’s for-profit medical clinics distort treatment options, skewing doctor’s behaviour towards overuse of expensive and unnecessary antibiotics, injectable medications, and other biomedicines that may be unnecessary or actually harmful.
From the perspective of Tibetan patients, the institutional pressure on professionals to make money from patients means replacing trust in the disinterested advice of the amchi with a sceptical questioning of the concealed agendas of the clinician. The transition in Tibet from amchi to clinic doctor; from use economy to exchange economy; from generosity to calculation; introduces complexity, ambiguity and distortion, with many perverse iatrogenic outcomes.
The Rural Cooperative Medical Scheme (RCMS) was meant to reduce costs of both inpatient and outpatient treatment, especially the catastrophic costs of catastrophic illness, and the recent successes of RCMS, as it has become more comprehensive in quite remote areas, has also done much to restore trust. However, recent reviews of how this scheme functions in practice suggest that government financing of the RCMS does little to reduce costs to users, and that most of the reimbursement is offset by a rapid rise in medical expenses. There is also consistent evidence that the availability of reimbursements by the RCMS has greatly increased the rate of Caesarian section births, whether or not they were medically necessary. This intensifies the medicalization of pregnancy, and further marginalises sowa rigpa and its amchi practitioners.
Traditional Tibetan doctors, especially the female minority, can be trained in early diagnosis, and as birth attendants, building on their skills in early diagnosis of imbalances, through direct intersubjective pulse readings , without the mediation of instruments. This seems a more promising prospect than creating a new vocation of birth attendants, as if Tibetan tradition has no strengths to build on. Rural Tibetans continue to trust their amchis, who are often the only healers who are accessible. However, biomedicine is alluringly new, even in remote areas of Tibet. It is not only physical distance from an urban clinic that makes the amchi the preferred source of health services. Even with the funding newly available under the RCMS, urban hospitals still raise much of their funding and staff salaries from patients, which heavily skews treatment towards injections and the overprescribing of the most powerful of biomedicines, whether this is in the patient’s interests or not. Further, cost-recovery and profit-making clinics and hospitals usually require upfront payment even before admitting a patient to the ward; and common prejudices about “dirty nomads” make it hard for a prospective patient to even get in the door unless one has “connections”. For these reasons rural Tibetans are reluctant to go near a hospital unless absolutely necessary.
MODERN EFFICIENCY EXTENDED IN OUTREACH TO REMOTE POPULATIONS
Because of these constraints, the few small scale NGO initiatives to reduce MMR have not only trained community health workers as skilled birth attendants, but have also operated a clinic functioning not as an exchange value for-profit, but as a use-value service that took care to avoid excessive reliance on biomedicines of doubtful relevance. These experiments have demonstrated that doctors also need incentivisation to refrain from over-prescribing. While the results of this pilot project are impressive, this model is hard to replicate or upscale, unless it is adopted officially, as it requires of staff a high level of dedication, and considerable external support. Fortunately, official adoption of this incentivised model may come soon.
This trial, over nine operational years in the remote Surmang area, did demonstrate many of the less evident reasons why MMR in Tibet remains so stubbornly high. Even if clinics and hospitals were closer to where Tibetans live, other obstacles remain, and are hard to overcome in the current neoliberal model with Chinese characteristics. This is clear in the assessment of the experimental Surmang clinic by researchers from the Institute of Population Studies at prestigious Peking University. The Surmang model paid medical staff well enough to live without having to make money from prescribing and administering expensive drugs. Health service provision was free, undistorted by the need to overprescribe as a primary source of income.
The Peking University assessors report: “A number of community health workers trained by Surmang charity clinic have become a vital force in providing health services to the local community. While providing free health care services, Surmang charity clinic actively set up a practical operating model in line with the reality in the remote areas, such as practical and feasible management model, methods for training health care staff, and health education for local residents, which has achieved positive effect. “
”The survey discovered that therapeutic methods used by Surmang charity clinic are largely different from those used in public, primary medical institutions, by Tibetan doctors and village-doctors. Doctors in Surmang charity clinic generally resort to the fewest medical measures. Around 40% of the visiting patients are given just health education instead of drugs. The principle for drug use is: minimize the use of multi-drugs, and avoid intravenous injection when possible. In public, primary medical institution, after inquiry about the symptoms, doctors usually prescribe medication as treatment. In using western drugs, over half are injections, of which 90% are intravenous injections. Doctors sometimes sell drugs without any analysis.”
“In medical services, doctors are both the agents of patients and the ones to maximize their own interests. The interests of patients may conflict with those interests of doctors. If the providers are profitable, there will certainly be conflicts between the two groups. The reason for doctors in Surmang charity clinic to achieve high efficiency and good effects in this non-profit clinic lies in the stimulation to win good reputation. Doctors of the clinic accumulate a wealth of experience by serving local patients and win good reputation. Moreover, they don’t need to consider how to compete in the market for patients. All of these factors encourage the doctors to choose the best treatment programs according to the specific conditions of patients, so as to maximally avoid irrational and nonstandard behaviors.” 
The Surmang clinic saw itself as a replicable prototype that could be done elsewhere in Tibet. It could be an exemplary benchmark if the source of its’ strengths are understood. The Beijing-based evaluators have little to say about the core values on which the prototype was built, which are distinctively Tibetan Buddhist. The Tibetan doctors and staff shared with their international project inception team a shared experience of the inner strength generated my mind training in the Tibetan tradition. One aspect of that is what Tibetans call “sacred outlook”, which holds all others in positive regard. The ethos of community service, and a use value economy, pervades the Surmang model, which motivated its staff not with foreign-funded high salaries, but with a classic Tibetan Buddhist cultivation of active compassion for all.
While this use-value model remains deeply embedded in Tibetan culture, where it is widely-recognised and respected, is it practically able to achieve results in reducing maternal mortality? A 2013 review of the Surmang model suggests that, once it focussed specifically on MMR, by training community health workers (CHWs), much was achieved: “The CHW program represented a shift in focus for the Surmang Foundation from an ambulatory clinic operation largely serving male patients to a community-based care model supporting and recognizing the maternal and child health care needs of area women. The primary goal for the CHW program since its inception in 2006 has been to reduce both maternal and infant mortality rates in the Surmang Township catchment area of Qinghai Province, China. the CHWs are interviewed each summer to determine the number of antenatal visits, numbers and nature of births attended, referrals to clinic for pre/postnatal care, referrals to hospital for childbirth, complications, rescues and morbidity/mortality of women and children. The CHWs are paid each summer according to the number of births attended, antenatal care, referrals to the clinic for ultrasound and well-baby checks. Since 2009, the timely hospital referral for complicated and high-risk pregnancy has risen as more CHWs are recognizing warning signs.” The result has been a sharp decrease in MMR, although infant mortality remains worrisome.
The efficiency argument assumes factor endowment in remote areas is so low that it can never be economic to extend such community health services beyond urban hubs. Recent interest by Yushu Prefecture Public Health Bureau in taking up the challenge of training and employing CHWs may overcome the centripetal tendencies of the current system. New technologies may also help. The crucial importance of ultrasound technologies in timely diagnosis, and cold-chain-controlled availability of oxytocin to stop obstetrical haemorrhage, remain for the moment powerful arguments for ongoing centralised hospitals and clinics. However, technology is changing. It may not be long before oxytocin will no longer need a refrigeration chain, and could be available to birth attendants in remote areas, for oral delivery. Ultrasound no longer means bulky apparatus installed in a clinic, as hand-held, battery-powered ultrasound is now available.
Mobile pastoralists of Tibet do have mobile phones, so maternal health initiatives in China could provide essential prenatal health checks that often identify problem deliveries in advance. Mobile ultrasound devices connected to mobile phones are a promising idea. However, current m-health (health delivered by mobile phone) in China is solely for those literate in Chinese language, which is very seldom spoken or read by Tibetan nomad women.
Maternal mortality in Tibet remains high, official statements notwithstanding. Until recently, this seemed inevitable, since Tibet has neither a tradition of skilled birth attendants, nor affordable and accessible clinics or hospitals. The women of Tibet remain caught between two models – the efficiency model and the SBA model – both of which condemn them to giving birth alone and without access to help. Both models perceive the land, the people and the culture of Tibet negatively, defined by what is lacking. From the standpoint of the efficiency model, Tibet lacks, scale, density, concentration, and critical mass. The answer from efficiency model standpoint is urbanization. From the CHW/SBA standpoint, Tibet lacks a tradition of birth attendants; its healing system is male dominated and androcentric. The answer in the CHW/SBA school of thought is to train a new breed of SBA community health workers empowered to challenge the male bias of sowa rigpa. Unfortunately, neither model has the will or capacity to significantly alter the realities of maternal health care in the foreseeable future.
Having dwelt at length on obstacles to reducing the MMR, we may conclude with two promising prospects. One is for a revitalised role of the amchis, if they can be recognised by official health care bureaus as having a more constructive role to play.
The other hopeful development is the prospect of scaling up small-scale projects targeting MMR, initiated by NGOs, and suffused with traditional Buddhist beliefs of having positive regard for others. They show that active compassion, relevant skills training and new technologies can greatly reduce MMR. This new approach means creating a new profession of community health worker birth attendants.
Much can be achieved, yet China remains wedded to the standard efficiency model of restricting resource allocation to urban hospitals and clinics, and has little inclination to decentralise. However, those centralised services are beginning to trial the training and deployment of outreach staff, as community health workers. In four townships of Yushu Prefecture, CHWs will bring the mothers to the clinic for ante-natal and post-natal exams, and well baby exams in addition to birthing. This project has built-in triple incentivization: incentivization of the mother, the community health worker and the doctor. The method relies initially on training by highly skilled foreign doctors in the four township hospitals. The training is selective and somewhat competitive, unlike the mass lecture training given by UN WHO or the use of the Advanced Life Support in Obstetrics instructional materials. A health policy goal of this training is to reduce the salaries of the trained doctors and introduce a system of incentivization, so that when their performance increases, so does their income. The measured criteria for increasing the pay of staff is patient numbers, amount of medications prescribed, live births, return visits, referral from village providers, referrals to County or Prefecture Hospitals.
Right now, Tibetan women remain at risk and will continue to experience one of the highest maternal mortality rates in the world. Hopefully, that will change.
A version of this blog series will be published in 2015 by Nova Science Publishers, in a global textbook called ‘‘Maternal Mortality: Risk Factors, Anthropological Perspectives, Prevalence in Developing Countries and Preventive Strategies for Pregnancy-Related Death”, edited by David Schwartz.
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 Tan Ling-Fang, Huang Cheng-Li, Yang Cun, et al.; Physician behavior analysis under a free health care system: an empirical research on Surmang Charity Clinic in Qinghai Tibetan Area, Chinese health economics, Oct 2011, Peking University Institute of Population Studies, http://surmang.org/cms/PKU%20assessment.pdf accessed 7 Dec 2014