This dissertation is a study of the changes in health care policy and implementation of the structure of health services delivery in the Xiangtan Prefecture of Hunan Province in the People's Republic of China, during the post-reform era of the 1980's and 1990's. Xiangtan is a medium size, second class prefecture in a designated agricultural area. The comparative illustrations of three economically divergent areas of the largest county in Xiangtan Prefecture frame a case study of the sub-prefectural administrative level (the county and its corresponding townships and villages). Ethnographic data, health reports, journal articles and other materials were collected in Xiangtan and Changsha, the provincial capital, from 1992 to 1994 and reflect the perspective of health workers, rather than sufferers or consumers.
Using a political economic perspective, I trace the evolution of the local health system from its missionary base through the process of communist state acquisition and collectivization, and finally through the gradual development of the socialist market. The local agricultural dependance, the pervasive, parasitic bureaucratic structure coupling the government organ and service work units, and the local health worker's choices in the process of implementing a health policy stipulating that the state plan covers rural preventive while the market is the proper domain for urban, medical care are linked features of the local political economy. The research findings indicate that the health market structure and activity constitute a form of bureaucratic mercantilism in which a state bureaucratic organization is the location for the production of health services that circulate as commodities; although, the relations of production and distribution within the organization are not capitalist. Certain structural parameters of health provision are set within the central government; however, health workers at every level of the health system create this bureaucratic mercantilist structure. Furthermore, the local health status statistics, the development of infrastructure, health financing, and the credentialing process of local health workers suggest a pattern of rural health involution evident in Xiangtan and most likely linked to the local policy implementation.
