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rejudices 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.


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 dont 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. [5]
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 widelyrecognised 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 ora

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