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An Evolving Rehabilitation Service Delivery System in the People's Republic of China.

In the past ten years, the author has traveled to China several times for conducting research in rehabilitation services for people with disabilities. During these trips, she had opportunities to visit various rehabilitation programs in order to discuss, with rehabilitation practitioners and individuals with disabilities, the impact of the socioeconomic reform on the delivery of rehabilitation services for people with disabilities in China. It appears that China is experiencing a transitional period marked by rapid economic growth and profound social change. These changes have challenged the old residual welfare system which provided limited services for people with disabilities in the past. Facing the challenges, service providers and individuals with disabilities have attempted to develop a rehabilitation service delivery system that calls for collaboration between different governmental agencies and the active participation of people with disabilities.

This article presents an overview of the evolution of China's rehabilitation services delivery system. As Driedger (1989) states that disability is a worldwide issue. Understanding changes in rehabilitation services in a distant land (e.g., China) may expand American rehabilitation professionals' knowledge of rehabilitation from a different perspective. It is noteworthy that China is still a developing country with a Gross Domestic Product (GDP) per capita of $1,838 compared with a GDP per capita of $23,220 in the U.S. (Gelb, 1996). Results of previous studies (Mazumdar, 2000; Stretton, 1995) suggested that the development of social services in a country was related to the wealth of that country. Hence, when we review rehabilitation services in China, we need to consider this country's socioeconomic developmental level.

The Prevalence and Classifications of Disabilities in China

China is the most populous country and has the largest disability population in the world (Sonnander & Claesson, 1997). According to the Chinese Government (State Council, 1996), at least 60 million Chinese have a disability. In China, a person with a disability refers to "one who suffers from abnormalities or loss of a certain organ or function, physiologically or psychologically, and has lost in part or whole the ability to engage in activities in a normal way, and is thus hampered in his/her normal functions in certain areas of social life" (State Council, 1988). There are six categories of disabilities including visual, hearing, speech, physical, psychiatric disabilities, and mental retardation. Unlike the U.S., learning disabilities and substance abuse disorders are not included. Of the 60 million people with disabilities, 20.57 million have hearing disabilities, 11.82 million have mental retardation, 8.77 million have physical disabilities, 8.77 million have visual disabilities, 2.25 million have psychiatric disabilities, and 7.82 million have multiple disabilities (China Disabled Persons' Federation, 1998). About 25% of these individuals live in the urban areas and 75% reside in the rural areas (Lu, 1993). Working-age (15 to 60 years old) individuals constituted 45% of the total population of people with disabilities and the employment rate for those who lived in urban areas was estimated to be 70% in 1997 (China Disabled Persons' Federation, 1998).

Evolution of Services for People with Disabilities

Pre-reform era. From 1949 to the early 1980s, the Chinese government adopted a "residual" welfare approach to the delivery of services for people with disabilities (Deng, 1999). The goal of the services was to "provide for basic livelihood" (preventing people from starvation and becoming homeless) of people with disabilities through emergency relief, institutionalization, and sheltered employment. Two government ministries, the Ministry of Civil Affairs and the Ministry of Public Health, were responsible for making policies and operating rehabilitation, employment, and social services for people with disabilities. However, there was no national benefits system to assist people whose disability resulted in mobility, education, employment, and general financial difficulties.

The Civil Affairs Ministry was the most centrally involved in providing employment, rehabilitation engineering, and social services for people with disabilities. It established numerous "welfare enterprises" in which people with disabilities constituted at least 35% of the productive lines. These enterprises enjoyed tax exemption or deductions and were administrated by the ministry and the local civil affairs bureaus (LCAB) under the country's economic planning system. The Civil Affairs Ministry also established various social welfare institutions to accommodate people with severe disabilities who had no family members to support them. In addition, there were prosthesis factories, clinics, and a research institute of prostheses under the Civil Affairs Ministry and the LCAB. However, the majority of staff members in these institutions/enterprises and in the ministry's social welfare department did not have formal training in disability and rehabilitation-related issues.

Another distinctive characteristic in the pre-reform era was that the work unit was fundamental to personal identity in China. Most Chinese (with or without disabilities) began and ended their working lives in a unit (e.g., a factory, commune, hospital, or school) and horizontal mobility between work units was very rare (Liberman, 1994). The work unit, on the other hand, had lifelong responsibility to take care of its employees, including providing housing and child care, covering medical care costs, and paying compensation to employees who were unable to work due to sicknesses or injuries.

Theoretically, people with disabilities would receive social services and welfare benefits from either their work unit or the Civil Affairs Ministry. In reality, families were the primary providers of care to people with disabilities. The national census indicated that in the 1980s, 67% of people with disabilities in China depended on their families for basic sustenance, 30% supported themselves through employment, and only 3% were supported by the state (Li, 1988). Because traditional Chinese values emphasized family self-reliance and life-long interdependence between family members, many family members felt that taking care of their loved ones with disabilities was the right thing to do and wanted to do it. Furthermore, the 1980 Marriage Law and the 1982 Chinese Constitution reinforced the responsibilities of family members for persons with disabilities. According to these laws, spouses, parents, and children have the obligation to offer each other support and assistance during times of sickness and disability.

The Public Health Ministry and the local public health bureaus, on the other hand, ran the public hospitals and oversaw community health centers that appeared in the late 1950s and flourished in the early 1970s across the country. Under this national health care system, state employees, including those in welfare enterprises, received free medical care. Both Western and traditional Chinese treatments (e.g., acupuncture, acupressure, herbal medications, meditation, hydrotherapy, musical therapy) were provided in hospitals and institutions for people with disabilities. However, Western style medical rehabilitation services were very limited due to the non-existence of professionals in rehabilitation medicine/psychology, occupational therapy (OT), speech therapy (ST), or physical therapy (PT) prior to the reform era.

The reform era. Over the past 20 years, China has been in transition. Market mechanisms have gradually become an important part of the economy. In the rural areas, the collective communes have been dismantled and replaced by a "family responsibility system" in which each household operates an independent agricultural enterprise and makes their own decisions on agricultural production and distribution. In the urban sector, private businesses are booming. Many stated-owned enterprises have been or will be privatized and the fate of employees has begun to be related to their personal production successes and failures and to the companies' profits and losses. The old job assignment system is gradually being replaced by an open labor market system. The "iron rice bowl" (guaranteed lifetime jobs) has been broken.

As the changes offer new opportunities for the majority of Chinese people, they are taking a toll in the country's old "residual" welfare system (Ding, 1997; Zhang, 1996). The shift away from a command economy means that the unprofitable "welfare factories" are facing cut backs or even shut downs (Deng, 1999; Lu, 1993). The new hiring requirements (e.g., a high school diploma) held by many companies make it increasingly difficult for people with disabilities to obtain jobs (Lu, 1993). Employed persons who become disabled due to illnesses or accidents are often prevented from returning to work because they are perceived as having poor work functions that would affect co-workers' bonuses (Lu, 1993). In 1997, 58 million Chinese were under the absolute poverty line nationwide. Of them, approximately 28% were persons with disabilities (Deng, 1997; State Council, 1998). Although 14 million of the 16.7 million people with disabilities who lived under the poverty line were able to work, they were not employed (Deng, 1997; State Council, 1998).

On the other hand, people with disabilities in China are more aware of their rights thanks to the publicity of the United Nations' International Year of Disabled People in 1981 and the United Nations' Decade of People with Disabilities (1988-1998). Beginning in 1984, a group of people with disabilities and their supporters led by Deng Pufang, who was paralyzed during the Cultural Revolution and is the son of the former Chinese leader - Deng Xiaoping, established the China Welfare Fund for the Handicapped (CWFH). The CWFH has raised money to build the first modern rehabilitation facility - the China Rehabilitation and Research Center which provides medical rehabilitation services for people with spinal cord and brain injuries, stroke, cerebral palsy and amputations. In 1988, the CWFH, the Chinese Association of the Blind and the Deaf (established by the Civil Affairs Ministry in 1950s), and other organizations (e.g., the Chinese Rehabilitation and Research Association - a rehabilitation professional organization) consolidated to form a national organization - the China Disabled Persons' Federation. Led by Deng Pufang, the Disabled Persons' Federation is playing a very important role in developing China's rehabilitation service delivery system for people with disabilities.

Furthermore, policy makers and service providers in China have recognized that economic reform was leading to the increased marginalization of people with disabilities and have started reforming the old "residual" welfare system. Since 1988 China has completed two five-year work programs for people with disabilities and is implementing the third five-year work program. These programs were initiated by the Disabled Persons' Federation and ratified by the State Council. They cover the areas of rehabilitation, education, employment, physical and social environment improvement, and leisure and sports activities. The goal of these programs has shifted from "providing for basic livelihood" of people with disabilities to "narrowing the gap in living conditions between people with and without disabilities" and to "improving social environments in order for people with disabilities to participate fully in social life" (State Council, 1996). Meanwhile, the government is trying to fill the welfare gap by promoting the development of various types of private social insurance and by encouraging private organizations to assume responsibility for some welfare services. For example, welfare lotteries are becoming an increasingly important source of funds for the Civil Affair Ministry and these lotteries are now starting at provincial and local levels (Lu, 1993).

In addition, the Disabled Persons' Federation orchestrated the promulgation of China's first law concerning the rehabilitation of people with disabilities - the Law of the People's Republic of China on Protection of Disabled Persons. This Law was passed by the 17th Convention of the Standing Committee of the Seventh National People's Congress in December, 1990 and became effective as of May 15, 1991. The Law defines responsibilities of the government in rehabilitation, education, employment, welfare, environment, and the prevention of disabilities and establishes a quota system for the employment of people with disabilities. The quota varies from one province to another with an average of 1.5 (disabled persons) per 100 employees. Government agencies, enterprises, and nonprofit organizations, who fail to hire people according to the quota, are mandated to pay fines to the employment fund for people with disabilities (The Legislative Committee of the National People's Congress, 1991). This fund is overseen by the Disabled Persons' Federation.

With respect to the training of rehabilitation professionals, year-long courses that prepare physicians to train the OT, PT, and ST, have been provided in two major medical schools since 1989 (Chen, 1992; Williams, 1990). In 1991, the Public Health Ministry and the Disabled Persons' Federation issued a joint circular which requested all medical schools in China to develop teaching programs for PTs, OTs, and STs (Chen, 1992). Moreover, the State Personnel Bureau has recently recognized these rehabilitation professionals by putting them under a new professional entity entitled "rehabilitation workers" and has put these professionals on the official pay scale.

In addition, the Chinese government has established the State Coordination Committee on Disability, which is headed by a Vice Premier Minister and consists of 34 government agencies, institutes, and representatives of disabled persons' organizations, to coordinate rehabilitation services for people with disabilities. The secretariat of the committee is in the Disabled Persons' Federation. At present, the focuses of rehabilitation services for people with disabilities in China include community-based rehabilitation (CBR), vocational education and training, and employment (State Council, 1996).

Community-Based Rehabilitation Service Delivery System

The concept of CBR was recommended by the World Health Organization as an antidote to the poor coverage of rehabilitation facilities in developing countries due to economic constraints (Scorzelli, 1995). Unlike in the U.S., where well-trained professionals make up a large proportion of rehabilitation personnel, service providers in the CBR model are often volunteers who have limited training (Collins, Lumerman, Conover, & Susser, 1999; Crisha, Sinason, & Yabsley, 1999; Mitchell, 1999).

The CBR model was introduced to China in the early 1980s and was well received by Chinese service providers (Deng, 1999). In league with the Public Health and Civil Affairs Ministries, the Disabled Persons' Federation is working hard to integrate CBR into the country's existing "three-level" (hospitals at the city/county and township levels and health centers in villages and neighborhood committees) disease prevention and treatment networks. Theoretically, the community-based rehabilitation network may include the following components: (a) national organizations (e.g., the Public Health Ministry, the Civil Affairs Ministry, and the Disabled Persons' Federation), (b) provincial organizations (e.g., provincial branches of the relevant ministries and the Disabled Persons' Federation), and (c) urban community and rural community rehabilitation committees. These committees consist of representatives of different governmental and non-governmental agencies and people with disabilities in the communities. It was hoped that, with the support of the central and provincial organizations, the grass-roots rehabilitation communities would mobilize and coordinate local resources to meet the rehabilitation needs of people with disabilities in their communities. However, in practice, this network is far from completion. Limited documents (Chen, Shen, Wang, & Ma, 1992; Deng, 1999; Jin & Li, 1994; Luo & Yu, 1994; Ma, 1993; Phillips & Pearson, 1994; Qiu & Lu, 1994; Shen, Chen, Zhang, Xi, & Tian, 1990; Sonnander & Claesson, 1997; Sun, 1996; Wang, 1994; Wang, Gong, & Niu, 1994; Zhang, Yan, & Phillips, 1994) indicated that CBR services in China were primarily a phenomenon of large cities. The lack of financial and personnel resources in rural communities compounded by the lack of awareness in local authorities and "turf wars"(*) between different governmental agencies have hampered the growth of CBR services in China.

Liberman (1994) noted that work was an important piece of the CBR programs. For instance, people with psychiatric disabilities often spent a great amount of time in the programs' "work therapy unit" where they received vocational training and learned a functional worker's role (similar to work adjustment in the U.S.). Although the work was often unskilled and simple (e.g., making boxes), clients enjoyed having something to do. Meanwhile, staff members of these programs provided a variety of services including home visits, basic medical care (e.g., measuring blood pressure), occupational therapy (e.g., calligraphy and creative art), information about local resources, making referrals for clients who needed further medical treatment or rehabilitation, helping clients obtain jobs, find a prospective spouse, and solve marital problems. The roles they played were a combination of the roles of rehabilitation counselors, social workers, and perhaps occupational therapists and physical therapists in the U.S. However, unlike the rehabilitation professionals in the U.S., the majority of these staff members were neighborhood committee members or volunteer retirees who had very little formal education and almost no professional training in rehabilitation.

Preparing people with disabilities to live independently, which was so central to concepts of rehabilitation in the U.S., was not a goal of these CBR programs because the social valued position was to live with family members. It is noteworthy that, in the past several decades, people in the urban areas in China were assigned to an apartment by their employers and had to wait for a long time for such an apartment. Although the recently reformed housing policy allows people to buy their own apartments, housing is still very scarce. This may be the economic reason for the lack of intermediate services (e.g., a group home, etc.) in the communities. Nevertheless, the intact Chinese family and its willingness to care for members with disabilities constitute a great resource for CBR (Liberman, 1994; Phillips & Pearson, 1994). However, if Chinese families are to play a major role in CBR, systemic outreach and case management services and counseling that provide guidance and support to both persons with disabilities and their family members will be needed.

Vocational Training, Employment, and Rehabilitation Counseling

Vocational training. Vocational training has occupied an important position in preparing people with disabilities for employment in China. Several approaches have been developed to address the training issue. First, all special education schools for people with disabilities provide their students with vocational training programs. Courses offered by these programs include acupressure, appliance repair, data entry, gardening, sanitation engineering, sewing, etc.. Second, vocational schools or acupressure schools provide a variety of associate degrees for people with disabilities. Third, thousands of vocational training centers that provide short-term training have been established by the Disabled Persons' Federation and other social organizations. After successfully completing training programs in these centers, people with disabilities are eligible for various certificates. Finally, entry level workers with disabilities in "welfare enterprises" receive training on the job.

Employment and rehabilitation counseling. Employment has been a focus of China's service programs for people with disabilities (State Council, 1988, 1992, 1996). In rural areas, people with disabilities work on farms allocated to their families or find employment through village-run welfare factories (Lu, 1993). In urban areas, three approaches have been used to place people with disabilities (Lu, 1993). Self-employment, which constituted about 53% of the total employed individuals with disabilities in China at the end of 1998, is the major way for people with disabilities to obtain jobs (China Disabled Persons' Federation, 1999). Also, welfare enterprises under local civil affairs bureaus hire people with disabilities. These welfare enterprises enjoy the exemption or deductions of a variety of taxes (e.g., income, import, product, value-added, and turnover taxes; Lu, 1993). By the end of 1998, workers with disabilities in the welfare enterprises formed about 26% of the total employed people with disabilities in China (China Disabled Persons' Federation, 1999). Finally, governmental agencies, enterprises, and nonprofit organizations are required to hire people with disabilities according to the quota system mandated by the Law of the Peoples Republic of China on Protection of Disabled Persons (Lu, 1993). By the end of 1998, individuals with disabilities, who were hired according to this quota system, made up approximate 21% of the total employed people with disabilities in China (China Disabled Persons' Federation, 1999).

However, employers' negative attitudes and the lack of training among people with disabilities were two problems that appeared to affect the implementation of this quota system. For example, most employers are reluctant to hire people with disabilities on the assumption that hiring people with disabilities would affect the companies' productivity and cut into their narrow profit margins (Lu, 1993). Consequently, many companies would rather pay the fines than meeting the hiring requirement. Although the Law specifically prohibits discrimination against people with disabilities in employment, there are no legal penalties. So, it is unlikely that people with disabilities or their families will try to bring their cases to the courts. Because enterprises have been given relative independence to manage their own affairs, the government no longer has the leverage to force enterprises to hire people with disabilities (Phillips & Pearson, 1994).

On the other hand, many people with disabilities do not have formal education or training that would qualify them for different jobs due to the lack of access to schools (Lu, 1993). Compared to people without disabilities, individuals with disabilities have a much lower educational level (He, 1995; Lu, 1993). About 30% (vs. 4% in people without disabilities) of urban working-age individuals with disabilities are illiterate and only 16% (vs. 31% in people without disabilities) have a high school or college degree (Lu, 1993). Although the recently passed Regulations on the Education of Persons with Disabilities (State Council, 1994) specifies the right of people with disabilities to receive education, it will not change the current situation immediately. To remedy the problem, the Disabled Persons' Federation has joined the Civil affairs and the Labor Ministries to establish more than 2,600 employment and vocational training centers to provide short-term training programs in typing, cooking, appliance repairing, data entering, etc. (China Disabled Persons' Federation, 1999). The funding of the training and employment services mainly comes from the fines paid by enterprises, donations, and the welfare lottery (Hu, 1997; Lu, 1993; Sha, 1997).

The author has visited several employment and vocational training centers in China. It appears some of the services provided by the staff in these centers have similar characteristics to the services provided by vocational rehabilitation counselors in the United States. For example, staff members in these centers spent a great amount of time on finding jobs for their trainees. They must go to various employers and advocate for trainees who want to work for these employers (similar to job development/placement in the U.S.). They also helped trainees who wanted to have their own business, obtain permission from various governmental agencies (a Chinese version of case management). However, unlike in the U.S., these centers have not yet established a systemic method to address issues of vocational evaluation and assessment, vocational counseling, career development, personal counseling, case management, and job development and placement. Most staff members of the centers do not have formal training in these areas and their approach appeared to be "to do it first then talk about why it works."

Although vocational rehabilitation has been recognized as an important perspective in order for people with disabilities to achieve full participation (Deng, 1995; He, 1995), it has not been incorporated into the rehabilitation service delivery system. When Chinese professionals, officials, and individuals with disabilities use the term rehabilitation, they mean medical rehabilitation. Vocational rehabilitation is not conceptualized as part of the total rehabilitation process. There are no rehabilitation counseling or similar programs in any Chinese university. Consequently, the new professional entity entitled "rehabilitation workers" does not include vocational rehabilitation practitioners.

It is noted that vocational rehabilitation is unique to rehabilitation professionals in the U.S. Theories and the practice of vocational rehabilitation counseling (e.g., individual-tailored vocational rehabilitation plans) have been developed based on the characteristics of socioeconomic structures in the U. S and cultural values of American society. In comparison with the U.S., China has had very different cultural values and social and economic systems. For example, China did not have an open labor market for decades and jobs were allocated for life according to economic plans. Individuals with or without disabilities did not have the right and opportunities to choose and find jobs based on their own vocational interests and qualifications. Accordingly, the social skills of finding and keeping a job were less important for Chinese people with disabilities compared with their American counterparts. However, as China's economic system is gradually transferring from a planned economy to a market-driven economy, vocational rehabilitation may be needed by many people with disabilities who now have to find employment in an open labor market. This new employment environment requires a change in the official and professional conceptualization of rehabilitation and the development of approaches to address this issue.

Conclusion

China has a similar geographic size to the U.S., yet, it possesses six times the population of the U.S. In terms of national wealth, China has a low Gross Domestic Product per capita ($1,838) compared with a high GDP per capita ($23,220) in the U. S. (Gelb, 1996). The enormous population of the country and the limited resources constitutes a unique challenge to rehabilitation service providers in China. For many years, a centralized resource-allocation and service delivery system was preferred in China (Phillips & Pearson, 1994). Not surprisingly, the evolution of the rehabilitation service delivery system has followed a top-down approach. Policy changes and rehabilitation programs were initiated by influential individuals (e.g., Deng Pufang), supported by the central government, and then local authorities complied. However, as the reform moves forward, local authorities will have more power in making their own decisions. New approaches of rehabilitation services must develop in order to adapt to a growing decentralized competitive environment in China.

In comparing the development of rehabilitation services in China to that of the U.S., the importance of the legislation deserves attention. Without a series of rehabilitation laws (e.g., the Smith-Fess Act of 1920, the Vocational Rehabilitation Act of 1954, the Rehabilitation Act of 1973, and the recently passed Work Investment Act), we would not have had the resource to support the federal-state rehabilitation system and to train qualified rehabilitation counselors in the U.S. Similarly, the Law of the People's Republic of China on Protection of Disabled Persons appears to provide a framework for the development of rehabilitation services in China. However, unlike rehabilitation services in the U.S., vocational rehabilitation has not been given the same recognition as medical rehabilitation, although CBR programs and employment centers are providing services similar to rehabilitation counseling in the U.S. This is due, at least partly, to the different socioeconomic structure in China and the conceptualization of rehabilitation among Chinese policy makers and rehabilitation practitioners. Furthermore, the evolution of the rehabilitation service delivery system in China reminds us where we came from. For example, many problems (e.g., the lack of resources, the lack of qualified rehabilitation professionals, bureaucracy, etc.) challenging the Chinese sound familiar to American rehabilitation professionals, although the scope of these problems may differ between the U.S. and China.

In closing, rehabilitation services in China have made noteworthy progress. Despite many existing problems, there has never been a more favorable climate for developing rehabilitation services for people with disabilities in China (Ding, 1997). However, as an old Chinese saying states - "the future is bright, but the road to the future is bumpy with many turns." It will take a great effort to keep the momentum of the evolution. Any assistance, including international aid (e.g., providing training for Chinese rehabilitation practitioners), will be helpful for our Chinese counterparts.

(*) China has a well established hierarchical administrative system. From top to grassroots, there are five levels in this system: (a) the national, (b) the provincial, (c) the city/county, (d) the district/township, and (e) the neighborhood/village committee. The two Ministries (the Civil Affair and Public Health) that are responsible for providing rehabilitation services have branches or representatives at each level. These branches or representatives sometimes have different views of rehabilitation services for specific individuals (e.g., which department has the power to make decisions and who is responsible for providing services, etc.).

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Nan Zhang Hampton, Ph.D., CRC, Graduate College of Education, University of Massachusetts at Boston, 100 Morrissey Blvd., Boston, MA 02125. Email: nanzhang.hampton@umb.edu
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Author:Hampton, Nan Zhang
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Date:Jul 1, 2001
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