Health policy in peoples republic of china sociology essay

XIAO Yunyu (Kathy) 10051554

Abstract

With the dynamic increase of economic development and military improvement, the Chinese society has experienced huge social change since the establishment of People’s Republic of China, which explicitly and implicitly led to the result of a large proportion of patients with mental health problem. However, the mental health policy in PRC has not been effective enough even through the transformation and reforms to the present. This paper argues that the enactment, implementation, and evolution of the mental health policy of PRC are on one hand, sophisticated for the undefined responsibility, complicated structure issues, and the Chinese characteristic culture like stigmatization and folk misunderstanding, while on the other hand, and to some extent, straightforward as they are largely based on a government–led ideology, or party-interest-led goal, rather than a psychiatric or psychological strategy. Through the historical and chronological summary of the mental health policy, this paper will utilize public administration model to analyze the political, legislative, administrative, and financial rationale of Chinese government on mental health system; the outcomes and impacts, and will further discuss the challenges and prospective facing by the government in the future.

Key Words:

Mental Health Policy, People’s Republic of China, Reform, Challenge目录Introduction: The Transforming Mental Health Policy in PRC

Background: Reforming Mental Health System in PRC

Mental health problems are common and pose a huge burden for the patients, their families, the societies and the countries worldwide; the situations China is not excluded. Since the economic transformation in the late 1970s, there has been a significant change in the resource distribution and social structure, leading to an increase number of mental illness patients, which exceeded 100 million in 2010 (Chen, 2010). As social burden and unrests caused by mental health increased by quantum leaps, the state has been making several reforms and efforts to institutionalize mental health policy through institutional building, financial backup, and legislative oversight so as to maintain social stability while accommodating profound changes. However, despite the drastic economic development health care reforms in these decades, there are various challenges for policy makers and care professionals in providing adequate and qualitative services for persons with mental health problems in China. To name a few, these challenges include insufficient mental health facilities; great diversities in social, cultural, and political contexts among different regions in China; poor mental health literacy, and highly inadequate financial support to mental health facilities and so on. All of these occur not only in fast growing urban cities where mental health problems increase significantly within a highly competitive and stressful city life, but also as in deprived rural areas where mental illnesses are neglected facing the unsolvable poverty problems as priority. These problems are even complicated and intractable by the fact that mental health services, especially mental hospitals are not solely shouldered by the Ministry of Public Health but also the Ministry of Civil Affairs, Ministry of Public Security, Ministry of Defense, Ministry of Labor and even Ministry of Mining as well as The China Disabled Persons’ Federation (CDPF). Various Ministries have different policies and ideologies towards providing mental health facilities and services to people with mental illness. What is worse, the complexity is coupled with the withdrawal of funding to both medical and welfare services by the central government, complicated with the tough coordination of mental health services among different Ministries, and messed up with dynamics, politics, and vested interests of miscellaneous parties concerned. Moreover, mental health professionals and governmental officials in different provinces may have different responses and interpretations towards official documents. Those in highly developed cities like Beijing and Shanghai usually play a leading role in pioneering and formulating new mental health services models, legislations, and professional training as well as registration. However, those services in provinces in the northern or western region of China may lag far behind the standard requirement or national average, lacking the access to technical resources like computers and ideologies in bio-psycho-social concepts of psychiatric cares. The above two contribute to the complexity and diversity of mental health problems of the People’s Republic of China at present. Nevertheless, tracing back to the history of the evolution of mental health policy in the People’s Republic of China and analyzing it with the viewpoint or structure of public administrative model, one is not difficult to detect that the challenges, despite those objective reality, has been de facto accumulated as a result of the political strategy and setting by the Chinese Communist Party, which is mainly for the interest of state, or to some extent, the party than the interest of people. Therefore, in China, those challenges contain more political property than public health as in most Western countries. Thus, as long as this national trend is still ongoing, the significant solution of the mental health problem in China could not be solved merely rely on the government sponsorship and leadership, but shifting to the responsibility of those non-governmental sectors as a whole. These findings are significant because they not only further our understanding of the historical and existing mental health policy of the PRC, but also deepen our awareness of what the long-term obstacles to reform the mental health policy, and where to begin the transformation that might lead to the potentials for the reform both theoretically and practically.

Literature Review

There exist different approaches of studying mental health policy in China. But most of them focus on the psychological or psychiatric perspective, while not relating the political factors into the effectiveness of enactment and implementation of mental health policy. A variety of books and articles have examined the history of mental health policy development in China through the transformation of provisions and regulations in the perspective of facts. Besides, scholars from psychology, psychiatry, social work, and sociology background, either from mainland China, or Hong Kong, or from foreign countries, have also analyzed the mental health policy of PRC in general trend as well as in subfields like Chinese students, immigrants, rural counties, urban citizens, and so on.

Sociological Approaches

Mental health within the context of Chinese society, commits three main obstacles. First is the concept of community, which has been largely rendered by social and political control of Chinese Communist Party; the second is the different family orientation China possessed, which is that whereas the western assure the rights of persons with mental illness and their family caregivers to receive support and services; Chinese family caregivers are obliged to take the sole responsibility in caring for them (Yip, 2006). The third one is the strong effect of social stigma, which has also been recognized by previous scholars (Haraguchi, Maeda, Mei, & Uchimura, 2009; Pearson, 1993; Pearson & Phillips, 1994; Phillips et al., 2002; Phillips, Pearson, Li, Xu, & Yang, 2002; Yang et al., 2010; Yip, 2007a; Wong & Pearson, 2007) through the method of open-ended question interview (Phillips et al., 2002), comparative study (Haraguchi et al., 2009), or the aspect of social morality (Yang et al., 2010). As a registered social worker, professor, and cognitive behavioral therapist, Wong specialized in studying the emotional management and cultural impetus of mental health problems in China and Hong Kong, especially those Chinese immigrants in urban cities (He & Wong, 2011; Wong & Leung, 2008; Wong, Chang, & He, 2007; Wong & He, 2008; Wong, Chang, & He, 2009; Wong, He, Leung, Lau, & Chang, 2009; Wong & Chang, 2010), Chinese students in Australia or Hong Kong (Pan & Wong, 2011), and specific group of people like adolescents (Wong, 2009; Wong & He, 2011) or mental illness caregivers (Wong, Lam, Chan, & Chan, 2012). Using the randomized trials, DSM-II questionnaires, interviews, and cognitive behavioral theories, Wong collected corresponding data and presented the trend of an increase number of mental health problems especially depression and suicide of Chinese immigrants, adolescents, and caregivers. Furthermore, he pointed out the psychological basis of the causes of this trend. Through a long-term fieldwork of visiting psychiatric hospitals in China, Veronica Pearson (1995) did an empirical study to get into the real world of state policies, professional services and family care, through which she deeply experienced the difficulty to deal with the mental disorder not only medically, but also economically, socially, and ideologically. She shared her impression that mental health in China has lost some of its sense of purpose and direction. In the 1950s, psychiatry has been deprived of its guiding force of socialism and the more concentrated form of Maoism during the 1960s and 1970s, losing its prime principle to help patients recover. Hence, it mirrors the political forces embedded in Chinese society during the last few years (Pearson, 1992; Pearson, 1988; Pearson & Phillips, 1994; Pearson, 1995).

Historical Approaches

Professor Yip (2006) summarized the development of mental health services in China into four stages: The pre-asylum before 1949; initial political mental health from 1949 to 1963; full political mental health care during the Cultural Revolution; and the commercialized mental health care after modernization (Ye & Gao, 2012; Yip, 2006; Yip, 2007a). He (Yip, 2007) also pointed out five challenges faced by the Chinese government dealing with current situation of mental health problem in mainland. The first challenge was a huge demand of persons with mental illness within a population of nearly 1. 4 billion; the second was spontaneous and deeply rooted political influences on diagnosis, treatment, and rehabilitation of persons with mental illness; the third one was the dilemma between a highly centralized government enacting related official documents and policies for mental health services and a highly localized implementation and service delivery of mental health to related clients and patients, mainly shaped by the diversity of geographical, demographic, cultural, social, and political context in various distinct regions in PRC; the fourth challenge was a comparatively underdevelopment of related mental health legislation and respect of human rights of persons of mental illness in China; and the last was the difficulty in indigenization of western models of treatment and rehabilitation for persons of mental illness to better suit the situation in the PRC, in particular those psycho-social models such as psychotherapy and counseling. The other two challenges, which are the supply of mental health services and the demand for family caregiving in Chinese family, were pointed out in the newly-published book in 2012 after working with mainland scholars and sharing in the conference (Ye & Gao, 2012). Besides, scholars also trace back the history and figure out the unique design and implementation regarding the delivery of mental service in China (Ran, 2005), which was described as a relatively tortuous experience. After the first mental hospital was established in 1898, the shortage of psychiatric facilities and physicians has been recognized (Xiao & Zhang, 1981). Gradual development and expansion of mental health services was setting up after 1949, including the first national meeting of the Working Group for the Prevention and Management of Psychiatric Illness (Nanjing Conference) and the Five-Year Plan for Mental Health (1958-1962), in which the nonphysical treatment for mental illness was emphasized. However, an abrupt decay was followed from 1966 to 1976 in the ” Cultural Revolution” (Pearson & Phillips, 1994), during which psychiatrists became a tool of ” political” interpretation and psychiatric services came to a standstill (Ran & Zhang, 1999). After that period till the present, psychiatric services underwent a rapid period of development (Ran & Zhang, 1999). The official attitude towards persons with disability and the provision of welfare services were transformed from ” residual” welfare into a pro-active form that disabled people in the community are provided with support and rehabilitation services (Chan & Chow, 1992). Currently, mental health services focus primarily on ensuring access to medical treatment, providing employment, and preventing social disruption, which reveal the priority in the community and the resources available.

Psychological and Psychiatric Approaches

Applying the knowledge of psychiatry from a foreign perspective, Michael R. Phillips (1998), who had been worked as a psychiatrist and clinical researcher in China for twelve years, and served as Director of Research at the Ministry of Civil Affairs’ main psychiatric hospital located in Hubei province for seven years, visiting scholar in the Department of Psychiatry at Hunan Medical University for eight years, as well as the Director of the Research Centre of Clinical Epidemiology at Beijing Hui Long Guan Hospital (China’s largest psychiatric hospital) for more than four years, written down his own clinical and personal reflection of Chinese mental health transformation with the data collected through his research. Basically, he held the view that the population and the productive capacity of the PRC accordingly have been seriously undermined by mental illness, while the availability of mental health services at that time were unable to effectively address these problems because they were merely centered in urban hospitals that focus on the treatment of psychotic patients, especially the serious mental illnesses like schizophrenia, bipolar affective disorder, and epilepsy. Furthermore, judging from the social, political and economic imperatives that direct the development of mental health services in China, he predicted that that both the quality and accessibility of services will decrease in the future. As a well-know psychiatric specialists, Yu, Liu, and Ma (2011) employed a historical as well as psychiatric points of view to review the mental health system in China, presenting the current scenario, development of mental health reform, barriers and challenges to reform process, and the suggestions for future policy. They pointed out that mental health development in China, a country with highly centralized government structures, needs strong and continuous support from not only central government, but also local-level governments. Without this support, the mental health sector will find it hard to fulfill the management demand of psychoses. In addition, there is a need to improve the awareness of the NGOs and their potential roles in integrating various social resources and providing valuable supplementary services, including prevention, treatment, and rehabilitation, for mentally ill patients living in the community to enhance and consolidate their recovery. Finally, they analyzed the Chinese experiences as response to international advocacy, summarizing that mental health services in China, as in many low- and middle-income countries (LAMIC), have a long way to go to meet the target of providing mental health care in the community.

Organizational Approaches

In the People’s Republic of China, there is still not specific organization emphasizing mental health services, while the major burden of care falls to the family, there is little or no outside help from rather the mental health system or organizations. Nowadays, only some therapy stations are run by the Department of Civil Affairs or by street organizations, mainly for disabilities and partly assisting the mentally ill (Pearson, 1992). In urban areas, big factories provide medical services to some mentally-ill that proved to be detrimental to the factory (Jiang, 1988; Luo & Yu, 1994; Pearson, 1992), whereas in rural areas, the problem of care delivery has not been effectively solved (Pearson, 1995). Realizing the existing problems, few researches stick to the specific organizational factor to analyze China’s mental health services, though the importance of institutional development and organizational effects are highly emphasized recently (North, 1990; Thornicroft, 2011).

Ideological Approaches

King and Bond (1985) argue that Confucianism as a social theory tends to mould the Chinese into group and family orientated, which shares the opinion of Lin (1983) that ” in Chinese view, a person is a relational being, living and interacting in a massively complicated role system”. This implicitly provides the ideological basis for the government to shift some mental health caring responsibilities to the families and societies, emphasizing the importance of family to the patients and vis-a-versa. Applying the impact of Taoism on mental health in Chinese communities, Yip (2002; 2004) analyzed the cultural and ideological aspect of the problems of mental health system in China, especially for help-seeking, meaning of family, and stress coping. While social workers are strategic and important part of mental health care, the dilemma and challenges of its development in China have been pointed out (Pearson & Phillips, 1994; Yip, 2000; Yip, 2007b; Wong & Pearson, 2007). Besides the two ideologies, I also find that the leading ideas of Mohism could have impacts on the practice of mental services. Cecilia cooperated with Veronica, and then Ran (2005) on studying the family caregiving of mental health services in China, from the historical development, to reform since the 1970s, the impact of 2008 earthquake incidents (Chan et al., 2011) to present, and concluding with the similar result that there is still a long journey for Chinese government to improve in order to reach an effective network of mental health services, initiating with the increasing cooperation between the government and non-governmental organizations (NGOs) since 2008. Besides, Chan has significant contribution in integrating Chinese philosophies and concepts into holistic behavioral health, which is called the Body-Mind-Spirit Approach (Chan, Chan, & Ng, 2006; Chan, Ng, Ho, & Chow, 2006).

Economic Approaches

A fundamental component in the successful implementation of mental health service provision is that of funding (Thornicroft & Tansella, 2004). This includes on one hand how much the Chinese government allocates to mental health services in total, which is currently quite low comparing to many other countries in the world facing the extent of burden (Hu, 2003). What is more, within the limited the budget, the distribution to provinces is even imbalanced (Saxena, Sharan, & Saraceno, 2003); on the other hand, private contribution for mental health in China has not been recognized and institutionalized, even though it is recommended congruously that private sector should be an important provider of mental health services in the community (Saxena et al., 2003).

Gaps and My General Arguments

The above approaches, covering the fields from sociology, to history, psychology, organization, ideology, and economy, have definitely offered a quite comprehensive description of the mental health policy in the People’s Republic of China already. However, few of the researches have concentrated the study of PRC’s mental health policy with a public administrative perspective, and use the theories and models of political admin to thoroughly analyze the rationale for its development and transformation, as well as the theoretical foundation of challenges and future improvement. Furthermore, important questions—like what is the political motivation and influence of the mental health policy in the PRC? Why it is that influential in this country comparing with the others? How it shaped the development and transformation of mental health policy and services in the PRC? What are the flaws and disadvantages of this kind of political intention undermined? What are the challenges at present and what should be main focus to tackle in the future? — are not touched or explained precisely. In this thesis, through the process of seeking answers to these questions we shall go through the development of mental health policy in the PRC with an evolutional perspective, and specifically look at the role of the Chinese Communist Party, the government, and public administration to direct and formulate the policy. In the last place, we could conclude that despite the various explanations and descriptions of the mental health services during these periods to the present, political factors have continuously been the significant impetus that drive the whole process, and it will, at least in the short run, still remain as the predominant force in the future of the mental health policy.

Research Question

Aiming at maintaining the social stability, and instituted in the spirit of safeguarding and establishing the promoted so-called ” harmonious development”, Chinese government has been pragmatically determined to reform the mental health policy to best survive the vested interest of the party as a whole. However, with the unexpected increase of economic boom, which resulted in large social and ideological changes from the domestic pressure and western influence, the burden caused by the large population of mental illness patients could no longer be neglected anymore. Therefore, it is significant to study the strategy Chinese government utilized for the mental health policy. What are the special historical legacy and characteristic of the Chinese mental health policy? What incentives and efforts the governments hold to build and reform the policy? How have such incentives and considerations shaped and constrained the operations and implementations of the institutions and patients? What are the features, efficacies, and limitations of each policy in different periods and how do they influence the interest of mental-ill patients? What are the major challenges and possible suggestions for the future of the mental health policy in PRC? These are the questions this study seeks to answer.

Methodology

Since this study tries to explore, describe, and explain the transformation and evolution of mental health policy in the People’s Republic of China, especially based on the historical facts for policy analysis in specific context, it will mainly derive insights and data from secondary documents. The resources come from various types: 1) academic works from disciplines ranging from politics, psychiatry, psychology, sociology, and history; 2) journal articles in Chinese and English; 3) legal documents, government reports, records of typical case study in demonstrated cities and counties from previous scholars, publicly available data and statistical record; 4) mass media reports. It should be admitted that information from sources 3) and 4) may subject to a number of important limitations. First, government reports and mainstream mass media usually have instructive and promotion purpose, avoiding exposing and digging into some important problems, which may cause social instability and bring them political risk. Second, definition of the statistical items and the way official apparatuses collect those statics are sometimes ambiguous and inconsistent from different administrative organs, which lead to perplexing statistical results. Nonetheless, data from these sources are useful at a general level to provide some indications of the ideological base and systemic trends. Therefore, this study still attempts to make good use of them, and at the same time uses information obtained from the perspectives of non-governmental, or non-Chinese bystander to complement their limitations.

Study Objectives

Describe the evolution of PRC’s public services to people with mental health problems as an important background for assessing the effectiveness of mental health policy and the role of politics and public administration through the policy enactment and implementation. Analyze the role of CCP in PRC’s public service system to people with mental health problems as another important context for effectiveness assessment. Assess the effectiveness of mental health policy by the governmental apparatuses from the perspective of public administration. Review and point out the challenges and prospect for PRC’s mental health policy in the future from the perspective of public management and public administration, with some implications for international experience.

Framework of the Study

This study intends to discuss the development and evolution of the mental health policy in PRC. Specifically, it will examine the state’s incentives, rationales, and efforts in institutional building, plan formulation, and law enactment; constrains on the fairness and effectiveness of the policy and system along with the patients’ rights and interests; as well as the future challenges and prospective on the mental health policy. Through the discussion, the study further examine how the state’s incentives and efforts on building social stability have shaped and constrained both the functioning of the institutions and the implementing of policies, as well as the mutual-shaping effect of the interests between the state and mental illness patients. In this way, the gap between the change and evolution of the institutions and the broader political and socioeconomic context can be bridged by taking the party-led ideology and Chinese culture as an intermediate variable. Beyond this, the study will also explore the perspectives and suggestions for the future development. This paper consists six chapters. The first chapter will cover an introduction to the background, literature review, research questions and methodology, as well as the framework of the study. The second chapter will contain a review of some public administration theories and models, especially how the role of mental health system is related to them, this is important as the paper is written within the public administration discipline, which implies that the analytical point derives from public administration theory rather than psychiatry, though some psychiatric knowledge will be covered, and the aim of this study is to develop some useful public policies rather than psychiatric management of serious mental illnesses. From the third to fifth chapters will be a historical review of the evolution and reform of mental health policy in three significant periods: 1) before and during the Cultural Revolution; 2) reform during the 1980s; and 3) development from 1990s to the present. Under each period, the most significant historical context, institutional building, plan formulation, political motivation, and legislative enactment will be discussed to state the argument of the paper that the reform and evolution of mental health policy in China are more political-motivated than civil-motivated for the right and welfare of the people. The conclusion chapter discusses the challenges and prospective for future mental health reform, it also raises some implications of China’s mental health policy reform for international perspective, and states the limitations as well as remaining questions. Structuring Mental Health System in Public Administration and Policy Making ModelSince the focus of this study is on mental health policy, it is necessary to construct a theoretical framework of public administration and policy making model before further discussion is possible. The concepts and models discussed in this chapter will establish the basis for evaluating the mental health policy of PRC in the subsequent chapters. This chapter will be divided into four parts and concepts relating to the model of public administration, the nature of policy, and the process of policy making and, in particular, the characteristics of the policy making in People’s Republic of China will be discussed.

An Overview of Models of Public Administration

According to the United Nations Department of Economic and Social Affairs (2005), three broad models of public administration have been identified, which are public administration, public management, and New Public Management (NPM). In the first model, the government demands obedience, politicians are made accountable, the principles guiding public administration is that citizens must comply with rules and regulations, the criterion for success is output, and the key attribute required of public administrator is impartiality. In the public management model, the citizen-state relationship revolves around entitlements, citizens are considered as customers, the guiding principles are efficiency and results, the criterion for success is outcome, and the key attribute required from public administrators is professionalism. Finally, in the ” New Public Management (NPM) model, or the ” responsive governance model” the citizen-state relations revolve around the empowerment of citizens, citizens and stakeholders are co-accountable in public administration, the criterion for public administration success is process, and the key attribute required from public administrators is responsiveness. Besides, the guiding principles for this model are accountability, transparency, and participation. Appendix 1 shows a clear outline of the three broad models of public administration from the UNDESA. Clearly, when applying the three models to the mental health policy making and implementation in the context of the People’s Republic of China, the paper considers the case in the People’s Republic of China would be regarded as the first model, under which mental health rules and regulations are set by the government, and the role of citizens and other stakeholders are mainly obedience through the whole process.

Public Policy Making and Mental Health

In social planning, the process of policy making usually involves several stages, and different theories have been developed as alternative models of the policy planning process. For instance, Mayer (1985) points out that there are four major models of planning and they are: (1) developmental planning; (2) incrementalism; (3) the economic model of choice; and (4) the ethical model of choice. Each of these models places different emphasis on the technical and the ethical aspects of the planning process. Yet there is no easy rule for the government to determine which model will be the best choice for social planning. It has long been recognized that the formulation and implementation of social policies present unique problems, even in those countries which have strongly endorsed a leading government role in the field (Scott & Kathlee, 1986). There are problems arise at three different stages in the policy process. The first, as Scott (1986) noted, occurs during the process of converting values into government goals. This can be reflected when determine the goals of government in mental health policy for the mentally ill, which resulted from seldom consensus among policy makers, interest groups and voluntary agencies or the non-governmental organizations (NGOs). The second stage in the policy process relates to the allocation of resources and authoritative decisions on specific programmes (Scott & Kathlee, 1986), during which the resource allocation and government decisions have been strongly affected by crisis situations regarding the area of mental health policy of providing community care for the mentally ill. The final phrase is that of implementation and evaluation, which creates problems for the decision-maker as two kinds of structural problems are raised: one is greater co-ordination between government departments than other policies; and another concerns delicate questions of governmental intervention (Scott & Kathlee, 1986). In the context of the People’s Republic of China, comprehensive mental health care involves a multi-disciplinary approach to meet a wide range of needs and problems of the mentally ill. However, even though the role and efficiency of mental health care have been recognized, the social policy-making process involving formulation, implementation and evaluation is quite immature and overlooked. Mental health formulation is mainly based on the political interest; the implementation is lack of coordination as the responsibility for different ministries and organizations is not precise enough; and the evaluation part is even defective caused by the difficulties in collecting veritable data and specific organizations to take charge.

Top-Down Approach of Policy Implementation



Analyzing the mental health policy in China through the view of policy implementation, it is clear that it is operating under a top-down approach. Quantitatively, employing the World Health Organization Mental Health Policy and Plan Checklist and the World Health Organization Mental Health Legislation Checklist to analyze the content of mental health policy, plans and legislation in the PRC, we can find that quite a lot of inadequacies and flaws are revealed. The WHO (2007) suggests the need to develop a national advisory body to government on the implementation of mental health policies and services. Such a group could play a role in reviewing, monitoring and evaluating mental health policies and programmes. The committee could also collaborate with other sectors such as the Ministries of Education, Ministries of Justice, Ministries of Local Government, Ministries of Social Welfare, and development agencies and donors to raise awareness of the impact of mental disorders as well as the need to consider mental health when developing their own policies and programmes. However, the mental health policy formulation and implementation in PRC has tended to follow a top-down approach. There has been little consultation in both the development and implementation of current mental health. Yet it was recognized that broader consultation across all stakeholders, particularly with health workers at the district level, is vital for the successful implementation of mental health policy. This study shows that adequate and reliable data for the development of evidence-based mental health policy is seldom available. However, reliable, comprehensive and accurate data on the incidence of mental disorders, the numbers of people attending both specialist treatment, and the impact of mental disorders on the individual and family, can all pave a sound basis for arguing an increasing commitment and resources for mental health, and more effective mental health care delivery (WHO, 2005). Strengthening the evidence base through research in mental health and the development of an efficient and comprehensive mental health information system is therefore an important step for the People’s Republic of China in developing mental health policies which address those areas most in need. Although there has been widespread support among citizens, psychiatrists, lawyers, and media for the Mental Health Law. The passing of the legislation, which praised for representing best practice in such areas as the extent of consultation and in protecting human rights, was just happened in Oct. 26, 2012, and will be officially enacted in May, 2013. This Law is an essential first step towards establishing mental health legislation, and would demonstrate a political commitment towards the improvement of mental health care in the PRC. However, contrasting with the other several laws specializing in economy, national defense, or even political reform, the Mental Health Law is relatively lagged behind, not to mention that there is still a need to develop policies and plans, including the provision of more funding, which will ensure that the new legislation can be effectively implemented. Therefore, the current mental health policy still follows the top-down approach, without the official instruction, further mental health services improvement of quality and expansion of quantity for mental illness persons are difficult to implement.

Conclusion

To conclude, this chapter illustrates the theories and models in public administration and their relations with the mental health policy development as well as governance in the PRC. This study seeks to investigate the evolution of the mental health policy in PRC through those public administration models and how public administration policies can be improved, so the mental health services can be better in caring for people with mental health problems in not only urban areas but those remote rural regions. In identifying the public administration models that reflect the mental health policy, the dissertation adopts of public administration by UNDESA (2005), the Category of Political Regime Variation, in particular the Party-Prominent Regime by Ferrel Heady (2001), the policy making theories by Mayer (1985), Scott and Kathlee (1986), as well as the Top-Down Approach of Policy Implementation by Ferrel (2001) and O’Brien (1999). Points on these will be applied and discussed in the frameworks and narratives in the next three chapters. Mental Health System in Pre-1977 PRC

Situation before the Establishment of PRC

The first officially documented management of the mental illness person in China can be traced back to the Tang Dynasty (618–907 AD), when homeless widows, orphans, and the mentally ill were cared for in the Bei Tian Fang (悲田坊), a type of charity facility administrated by those Buddhist monks (Lan, 1995). After that, westernized psychiatric hospital for the homeless mental-ill persons had not been established before 1898, when an American missionary who had spent most of his adult working life in Guangzhou as the physician-in-charge of the Canton Hospital (Tucker, 1983), John Kerr, commenced the first mental hospital after more than 25 years of planning and fundraising, which was referred as Kerr’s Refuge for the Insane (Spence, 1980) and is now known as the Guangzhou Brain Hospital (Blum & Fee, 2008). The missionary literature abounds with reports of ill-treatment of mentally ill people in the community such as being chained, or walled up in small rooms at home, beaten, or even occasionally killed by their families (Ingram, 1918; Kerr, 1898; McCartney, 1926; Selden, 1905; Woods, 1929; Ingram, 1918; Selden, 1905). On contrast, humanitarian approaches (occupation, recreation, freedom within the hospital grounds, respect for patients) combined with drugs, cold baths and ingenious devices of physical restraint were mainly utilized in the Refuge (Selden, 1905; Selden, 1908; Selden, 1905), which were more or less accepted by the international standards of the time. The Chinese Society for Neurology and Psychiatry was formed in 1931 by two members of the Peking Union Medical College (PUMC) (Kao, 1979). One year later, the first full-scale academic programme in psychiatry was established by Dr. R. Lyman at the PUMC. Until 1937, he had trained a number of senior psychiatrists who enjoyed profound influence in China’s current research (Kleinman, 1986). Except that, little is known about the extent of psychiatric provision before 1949 in China. Some reported about the other separate psychiatric institutions in China raised by the Ministry of Justice for the so-called ‘ lunatic asylums’, but they were not formally verified (Lamson, 1935). Many scholars and psychiatrists described their expressions on the early mental health services in China at that time. Dr. Karl Bowman undertook the behalf of the World Health Organization and visited China for three months in 1948, observing that there was very little psychiatry in China at that time. Bowman described that the psychiatric hospitals in China were ” poorly equipped and in a bad state of repair and are giving largely simple custodial care” during that time, he also owed these condition to the shortage of funding (Kao, 1979). Lin, who was the Chinese government’s first honorary adviser on mental health in the reform decade of the 1980s appointed by the Ministry of Health, examined the pre-PRC and stated that comparing to the other Western style medical technology like surgery and drugs, psychiatry did not root in China in the same way so it got less comparable with the advances in other branches of medicine, as a result, ” few medical students choose to specialize in psychiatry and even some of those who chose to do so had to overcome the strong objections of their parents to enter…” (Lin & Eisenberg, 1985). By the time that the Chinese Communist Party (CCP) came to power in 1949, Lin (1985) stated that there were five psychiatric hospitals and a small core of psychiatrists in Beijing, Shanghai, Nanjing, Guangzhou, Chengdu, and Harbin, in which had either a large number of foreign residents or significant foreign influence. Three additional cities: Suzhou, Dalian, and Siping were offered by Xia and Zhang (Xia & Zhang, 1981) as well.

The Initiation of Mental Health Care Policy in 1950s and Early 1960s

After the establishment of People’s Republic of China in 1949, the mental health policy has been shaped largely by political control. Internationally, the world system backed to that time shifted into a bipolar balance of power, in which the U. S. and USSR have the majority of economic, military, and cultural influence. While Most Western and democratic states fall under the impact of the U. S., most Communist states would fall under the influence of the USSR, and the newly-founded PRC was one of them. It was then documented that nearly all the fields in PRC should better been copied and studied from the more advanced USSR, including economy (heavy industry was prior than the light one; or collectivism should be promoted); politics (socialism and the Communist Party shall dominate power); ideology (Marxism, Leninism, and Maoism were the most influential); education (which science was preferred than art); or even culture (literatures from the Soviet Union was widely spread). Therefore, the medical technology was inevitably contained in this trend. Domestically, the whole country was experiencing the sanfan-wufan movement or Three-anti and Five-anti Campaign (三反五反) which targeted at political opponents and capitalists, especially wealthy capitalists (Dillon, 1998). The Communist Government of the new People’s Republic of China decided to sever all ties with the non-Communist countries of the Western world and leaning toward the Soviet model of societal development. The Soviet Union then became the core of scientific and cultural relations. Hence, while there were dramatic improvements in psychopharmacology, diagnosis, and neurobiological research happened in the West, the Chinese psychiatry was relatively cut off and lagged behind this trend. The mental health treatment in PRC during the early 1950s exerted a monopolistic impact from the Soviet psychology, which was constructed by the Pavlov’s theory and Marxist ideology (Baker, 2012). The previous psychology departments that had been functioning before 1949 were soon replaced by a handful of reconsolidated departments and the so-called Institute of Psychology in the Chinese Academy of Science, based on the Soviet Model. Accordingly, “[P]sychology became a secondary discipline in the departments of philosophy or education” (Jing & Fu, 1995). Following the pervasive tide, psychologists were gravely forced to accept the dialectical materialism as an increasingly dominant theory for all psychological studies (Zhang & Xu, 2006), using Marxist theory as a guide, and reform psychology based on Pavlov’s theory (Pan, 1984). In 1953, Pavlov conferences were held in major cities of PRC, resulting in a centralized act to promote Pavlovian theory among the intellectuals, especially psychologists to understand human behavior. Soon after that, a well organized nation-wide and influential movement was launched together by the Ministry of Public Health and the Chinese Medical Association to encourage, or to some extent even coerce, all the psychological professionals to learn Pavlov’s theory (Lin & Eisenberg, 1985). ” Books by Soviet psychologists were translated into Chinese” (Barbanshchikova & Koltsova, 1989), and this continued to prevail over other Western theories until the end of the Cultural Revolution. In fact, taking the reasoning from Breger (1984), “(the Western) psychological testing points our individual differences and, according to the values of the Cultural Revolution, did not serve to integrate man into society,” the mechanism to replace the formal leading ideology with the Socialist one contributed to the loyalty of Chinese people to the Chinese Communist Party. Stimulating by the importance that the central government gave to improving the health of the people, there immediately appeared to have been a surged passion on those engaged in psychiatric work, leading to the increase of institutional restructuring. The Chinese Society of Neurology and Psychiatry was formed in 1954 with 585 psychological workers registered, coordinating and facilitating nationwide psychological research (Baker, 2012), and the first Society’s journal, The Chinese Journal of Neurology and Psychiatry (Acta Psychologica Sinica) began to publish in 1955.

Tentative Development of the Socialist Psychology

The Soviet-led reeducation trend halted since the 1957, when several political changes occurred in both the internal and external arena. Internationally, the Sino-Soviet relationship turned from sour to open antagonism after 1956. The economic infrastructure, scientific research, and strategic planning in the PRC, which were modeled and relied on the Soviet Union, soon collapsed upon the withdrawal of all Soviet economic and technological support. Accordingly, the ideological and scientific source of reform for the Chinese psychiatrists was broken off, they became further marginalized (Baker, 2012). Domestically, in order to pursue an economic boom, the central government promoted the ” Great Leap Forward”, accompanied with the ” The Hundred Flowers Campaign” in 1956, which the central government encouraged elites to raise different opinion towards others, and it was referred to as a transient ‘ period of post-revolutionary liberalism’ (Blowers, 1998). Short after the announcement, the sense of intellectual freedom burst out and many psychologists sensed the responsibility that they shall change the society and improve people’s lives, resulting in a series of debates, advancement of applied psychological work and decrease of dogmatic theory studies. However, ” Hundreds Flowers” didn’t bloom that long as they expect. The next year, many active psychologists were officially denounced and classified as the ” rightist”; a label for those criticized the leadership of the central government and the party (Blowers, 1995; Gao, 1991; H. Shen, 2000). What made the situation worse in the following years was the enormous crisis named as the ” Three-Year Disaster” by the CCP, although many historians and politicians examined it as an artificial accident as a result of the Great Leap Forward, Hundreds Flowers Campaign and the Anti-rightist Movement. Fortunately, under this unfavorable environment, another landmark in the development of mental health policy occurred, which was the First National Conference of Psychiatric Specialists held at Nanjing in 1958. It was organized by the Ministry of Health and around 90 persons in key positions of mental health participated, setting the formal directions for Chinese mental health policy (Ho, 1974). While been harmed by the actions of Soviet Union’s withdrawal, the Conference advocated the indigenous development with the slogan ” destroy superstitions, believe in ourselves” (Pearson, 1995). Under this guideline, collective action to overcome the mental health problem was emphasized; the ” individualistic” or ” personal” practices were largely condemned; shift of services provided in the urban centers to the rural areas were evident; and more interestingly, a relatively ” humanitarian” way, in which the psychiatrists move away from the use of restraint and explore more methods reflecting the dialectical materialism thought in the treatment of patients were demanded, pursuing the therapy of ” no shrieking in the adult wards and no crying in the children’s wards” (Chin & Chin, 1969; Ho, 1974). However, it was not every member agreed with these new proposals and there was heated debate about whether to give up the use of restraints and mechanical treatments or not during the conference (Shen, 1958). Besides the difficulties of struggling for proper treatment and mechanism, the trouble for recruiting mental health practitioners was apparently a large obstacle caused by the not only the low status of this job but also high risks of being attacked or verbally abused by patients, especially if not using the restraints. This dilemma continued further later when Mao emphasized the importance in health policy to provide medical services to the rural community, aiming to unity the ” mass line” and promote the reputation of CCP (Lieberthal, 2004). Following that instruction, many psychiatrists and nurses in urban areas were agitated to serve the rural areas under the Down to the Countryside Movement and ” bare foot doctors’ were proposed, most of which were uneducated village people with few basic hygiene and drug dispensary training. The national Five Year Plan from 1958 to 1962 ended up to be the only five year plan dealing with mental health with the Chinese way for many years; however with the quasi-Pavlovian explanation of mental illness which did little to enlighten: ” Mental illness is one in which the higher nervous activities of human body are chaotic and there is a mental block. It brings not only pains and distress to the patient but also brings certain perils to industrial and agricultural production as well as social security” (Pearson, 1995). Starting from this initiation, the objectives of institutional building, ideological setting, professional ethics, and mental health treating were largely leaned to out-patient facilities and early prevention. Three aspects were advocated: First, organizational pattern should be contributed to three categories –medical base, preventive unit, and sanatoria. The establishment of ‘ mental disease sanatoria’ or ‘ mental disease convalescent village’ was to some extent seemed to prepare for chronic patients, reflecting the purpose that they shall partially self-supporting through agricultural, light industrial, and handicraft work as mentioned by Chao (Chao, 1965). This related to the second key emphasis on the placements of mental illness persons, which they shall be treated at home or sent to rural areas for labor necessity. Thirdly, while many hospital managers were criticized for the convenience-oriented treatment that restrained the freedom of patients, four kinds of cure were then promoted — by the combination of Chinese and Western therapies; by organized sports and cultural amusements; by labor contribution; and by systematic educational therapy—which then continue to support the rationale for major psychological guideline in PRC (Pearson, 1995). Consistently, the Five Year Plan did not envisage the project for building more mental health hospitals as the government still promoted the physical and out-patient approach that can both reflected the CCP’s core value to serve the people and utilized the mental illness patients as one of the labor sources to promote the production of this newly established regime. At the same time, six regional collaborative centers were established in Beijing, Nanjing, Chengdu, Changsha, Guangzhou, and Shanghai to train the medical workers and administrative cadres so that they can ” adopt the communist working style of imagination, outspokenness, and daring” (Liu, 1985). Regarding psychology education, the Institute of Psychology and Chinese Psychological Society established an educational psychology committed in 1992 and three important textbooks were published, namely General Psychology (Cao, 1963), Educational Psychology (Pan, 1964), and Child Psychology (Zhu, 1963), which were seen as the first syntheses of Marxist dialectical and historical materialism and the indigenous research in psychology in PRC (Barbanshchikova & Koltsova, 1989). But even this tentative endeavor ceased soon later. In a word, during this period, an indigenous guideline and treatments for mental health patients promoted by the CCP revealed several prominent features that corresponded with the Party-led mental health policy in China. Firstly, under the Great Leap Forward, the motto ” Everything for the patient and everything for the cause of socialist reconstruction” was embedded into the health and mental health workers that stimulated them to zealously pursue their clinical, academic, and educational activities with the political propaganda intention (Chin, 1973; Ho, 1974). Patient management was then radically reformed to be open-door policy that not only increased the occupational and recreational activities but also encouraged political discussion and political participation by the patients. Hospital wards were required to offer a platform filled with ” revolutionary optimism” atmosphere for the purpose to inspire self-help and self-regulation within the patients themselves to recover and contribute to the social reconstruction under the leadership of the Chinese Communist Party (Leung, Miller, & Leung, 1978; Wu, 1962). However, the extraordinary national attention it provoked revealed the presence of a high tension surrounded in the revolutionary development, and the superficial vitality, productivity, and optimism during the Great Leap Forward and Hundreds Flowers Campaign which was supposed to stimulate the Post-Liberation reconstruction finally turned out to a sudden reversal (Lin & Eisenberg, 1985). The ” Mass Line” was de facto under the same political exhortation and suffering from extreme material, physical, and psychological hardships without any means of venting their frustrations or political views. Those intellectual workers, including those served the mental illness patients, were also trapped into this party-interest-packed political and social conditions. Nevertheless, the series of large-intensive campaigns also popularized psychiatry and concerns of mental health so that they were followed by participations of many governmental officials, party members, schools and factory workers as well as community groups at all levels to bring more public consciousness upon the mental health problems, which was reflected in the Five Year Plan (Chao, 1965; Chin, 1973). Undesirably, while the emphasis finally turned to mental health, the sudden halt of this marked campaign soon belied the original intention of the CCP when the Cultural Revolution occurred, during which destroyed the previous progress of mental health research and practice in People’s Republic of China.

The Peak of Political Control on Mental Health Policy – the Cultural Revolution

The Great Proletarian Cultural Revolution, commonly known as the Cultural Revolution, was a social-political movement aiming to removed the ” revisionists”, which were the bourgeois elements that infiltrating the government and society, through violent class struggle. Unfortunately, psychology was considered as well as one of the ” bourgeois pseudoscience” (Wang, 1993). Shortly afterwards, ideologically driven institutions such as the Revolutionary Committees and the propaganda departments of the Chinese Communist Party assumed a dominant role in the society. They widely and intensively promoted the idea that all forms of deviance, including most types of mental illness, manifested the political errors of revisionism, bourgeois ideas, and capitalism. In a sweeping trend, many psychiatric hospitals were closed and those remained open were forced to use political and party-oriented means to diagnose mental illness, make decision of hospitalization, and set process of treatment (Phillips, 1998). When diagnosing the persons with mental illness, not only psychiatric symptoms will be recognized, but also their political orientation, including problems in understanding Marxism, Socialism, or Maoism, as well as preferences in the evil bureaucratism and capitalism, will be emphasized (Yip, 2007). In other words, mental illness was regarded as a sort of ” paper-tiger” that can be mainly defeated through class struggle (Ho, 1974; Sidel, 1975). In terms of the decision in hospitalization, as the Revolutionary Committees had already penetrated into the workplace, residential areas, and many social infrastructures including the medical services, they held the predominant authority in the decision process of hospitalizing those mental illness persons through persuading, supervising or even demanding the related stakeholders in admitting or readmitting those patients (Ho, 1974; Leung et al., 1978; Yip, 1989; Leung et al., 1978; Yip, 1998). Therefore, those politically-diagnosed as mental illness may also be one of the patients if the Committees declared their mental disorder. If necessary, coercion or involuntary hospitalization would be implemented as well (Brown, 1980). This was the origin of the heated debate about ” hospitalized by force” in the recent years (Yip, 2004). The political dominance of mental health policy in the Cultural Revolution period can be further incarnated in the series of treatments for mental illness. The revolution slogan, ” egalitarianism, decentralization, and self-alliance”, became the leading principles of mental health policy. On June 26, 1965, Mao clearly instructed the Ministry of Public Health to apply the principle of egalitarianism so that the focus of mental health work should be shift to the rural areas, not only the health services, but also medical education and recruitment of health workers (Lin & Eisenberg, 1985). Demanded by the principle of decentralization was then reflected of the emphasis to spread the primary health care to improve the access to people, ranging from rural communes, urban neighborhoods, and production brigades, showing the intention of the Revolution Committee to establish the supervisory satellite to catch up those revisionists. The third principle, self-reliance, which was derived from the significant role it played in the previous period, continued to dominate the psychiatry through revolutionary optimism promoted by the Gang of Four, and Sidel (1973) described that in four aspects: First, the individuals’ feelings should be dependent on the group in which he belonged to – the family, the classroom, the commune, or the entire society; second, the individual is always subordinated to the revolution, and this revolution shall ultimately end in victory; third, it is joyful and glorious to participate this ultimately victorious revolution, even if the road to revolution is paved with sacrifice; last but not least, the capacity to learn of people is infinite, so they shall fulfill their mind with the faith in revolution for the sake of this glorious revolution. Combined with the three pragmatic political ideologies of egalitarianism, decentralization, and self-reliance, the concept of barefoot doctors was widely adopted, and participation in community health care by those grass-roots with no medical profession was promoted by the CCP (Ran, 2005). On the other hand, many psychiatrists were sent to communes in countryside for reeducation to learn how to live with the farmers and factory workers (Lin & Eisenberg, 1985), resulting in the blank of psychiatric research during this period. What was worse, viewed as the tools of bourgeois revisionists, psychiatrists received harsher treatment at the hands of the Red Guards. Those leading figures in the psychiatric field were humiliated, severely tortured, starved, or sent to do manual labor in arduous environment. As a result, many of them died or committed suicide (Lin & Eisenberg, 1985; Pearson, 1988; Yip, 2004; Lin & Eisenberg, 1985; Pearson, 1988). Eventually, both the increasing lost of mental health specialists and considerable close of psychiatric hospitals lead to the halt of mental health policy during the Cultural Revolution. The Dynamic Scenario of Mental Health Policy during the 1980s

Recovering and Rehabilitation from the Destruction – Reopen to the Country and World

After Mao’s death and the downfall of the Gang of Four in 1976, the mental health policy in the PRC has been gradually reformulating and recovering from the previous disaster from 1977 to 1980. At first, there was significant growth of enthusiasm by the policy makers and psychiatric professionals to gain the reconstructive effect. On one hand, they began to admit and examine problems and inadequacies in mental health service in mental health knowledge and services in China. They realized the misunderstanding caused by the political coercion, quoting Dr Young Derson: ” We do not believe that you can get a disease from a wrong idea – nor will a ‘ correct idea’ cure a patient. We try to teach the meaning of illness, based on scientific knowledge” (Achtenberg, 1983). Therefore, more psychiatrists began to consider non-biological explanations for mental illnesses and experimented with more creative methods of psychological rehabilitation service delivery (Ran, 2005). On the other hand, while many previous treatments like using Mao’s works to purify the patients’ value system faded away (Achtenberg, 1983; Bloomingdale, 1980; Masserman, 1980), communications with professionals from Western countries flourished (Li & Chan, 2003). Hence, comparing with the great number of Western psychiatrists coming and publishing their observations of the newly raised ” socialist system” of Chinese psychiatry, through which politics had more authority in diagnosis and treatments, the publications after the Cultural Revolution suddenly decreased. This was not only because the willingness of Chinese psychiatrists started searching the facts of mental health, but also there was an increase publication in English about the situation of PRC by the Chinese psychiatrists (Pearson, 1995). However, the vitality was also tempered disappointingly by two obstacles, at least in the initial stage. First and most significantly, the political winds and the government’s attitude to the outside exchange were confined with uncertainty. Secondly, after being cut off for more than three decades, they were shocked by their sudden exposure to the unfamiliar world, committing a great deal of subversions against their deep-rooted political, professional, and cultural ideas (Pearson, 1995). As time moved on, they gained a certain degree of confidence in learning and communicating with the Western technology and this was further aided by the new policy favoring the improvement on professions and intellectuals (Sidel & Sidel, 1982).

Reorganizing and Reconstruction of Mental Health Policy – Centralized Approach

Stimulated by the repressive enthusiasm of researches during the Cultural Revolution, in 1982, the first nation-wide epidemiological study was done by psychiatrists and scholars in seven regions in People’s Republic of China. As a result, the prevalence of mental illness was estimated to be 11. 8% (Zhang, Shen, & Li, 1998), and it was reported that there seemed to be an increase in the percentage of schizophrenic patients in mental hospitals, from 70% in the 1970s to 80% in 1980 (Yang, 1994). Obviously, this signified a great demand of mental health services within the society and more effective mental health policy was imperatively required by the dominate Party and government. In Article 45 of the 1982 Constitution of the People’s Republic of China that still practices till now, it clearly stated the state’s willingness for offering the welfare and support to ensure the health of its people:” Citizens of the People’s Republic of China have the right to material assistance from the state and society when they are old, ill or disabled. The state develops the social insurance, social relief and medical and health services that are required to enable citizens to enjoy this right. The state and society ensure the livelihood of disabled members of the armed forces, provide pensions to the families of martyrs and give preferential treatment to the families of military personnel. The state and society help make arrangements for the work, livelihood and education of the blind, deaf-mute and other handicapped citizens.” (National People’s Congress (NPC) of the People’s Republic of China, 1982)However, while applying the concept of ‘ welfare mix’, which developed to analyze the various sources of welfare including health polices in most states and societies (Higgins, 1981; Pinker, 1985; Rose & Shiratori, 1986)(Higgins, 1981; Higgins, 1981), the PRC has to envisage and admit the relatively marginal role that the state plays, as in the three-concentric circle framework of ‘ welfare mix’ in this Party-dominated state, the family locates at the centre, the collective (by danwei or by the neighborhood) situates the next, and the state passes to the outer ring (Wong, 1992). Nevertheless, there have still been relatively continuous reforms and efforts the People’s Republic of China took since the 1980s (Wong, 1992). In 1987, the Second National Conference on Mental Health Work was held in Shanghai, 28 years after the first one in Nanjing in 1958. After the discussion, an important official document named Some Opinions about Strengthening Mental Health Work was issued and a central policy was formulated together with three governmental apparatuses: Ministry of Health, Ministry of Civil Affairs, and Ministry of Public Security (Ministry of Health, Ministry of Civil Affairs, & Ministry of Public Security, 1987). In this document, several difficulties and inadequacies in the 1980s were emphasized, including the fact that there was only 50% of the funding for the general hospitals of the same grade went to psychiatric hospitals, and almost 80% of the people with mental illness or disorders received no treatment, with fairly 5% of them could be admitted to a hospital (Pearson, 1996). Accordingly, six recommendations or directions were offered: Practically, strengthen the overall coordination of mental health services by three governmental ministries (Ministry of Health, Ministry of Civil Affairs, and Ministry of Public Security), specifically in funding, staffing, training and educating.