HEALTH CARE IN CHINA--DOCTORS, INSURANCE AND COSTS

HEALTH CARE IN CHINA

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China Japan Friendship Hospital
China has the most hospitals (60,784) and the most doctors (1.97 million) of any country in the world. In 1949 when the Communists came to power there were only 2,600 hospitals in China. In China there are now 17 doctors per 10,000 people compared to 25 per 10,000 people in the United States. Put another way there are 730 people per doctor, compared to 32,650 in Ethiopia, 611 in the United States and 210 in Italy.

About 4.5 percent of gross domestic product (GDP) allocated to healthcare, half of which comes from the private sector. By comparison the average healthcare expenditure of countries in the European Union is 9 percent of GDP, while in the United States it is nearer to 16 percent.

Health care in China can range from a tooth pulled by sidewalk dentist at a local market to a sophisticated transplant operation performed at a major city hospital. A rural birth costs around $35. One of the busier departments in Chinese hospitals and clinics is the abortion clinic.

Improved health care was considered one of the great success’s of the Mao era. Barefoot doctors brought modern medicine and prevention strategies to places that had minimal health care. These and other Chinese health care workers are credited with 1) reducing infant mortality to a lower level than in New York City, 2) eradicating small pox and nearly eradicating sexually transmitted diseases, tuberculosis and schistosomiasis and 3) raising the average life span of Chinese from 35 in 1949 to 68 years in 1979. Many of China's health statistics are comparable with those of a much richer country.

Since 1978 health care improvements have slowed. Life expectancy has only increased by 3.5 years and deadly diseases such as tuberculosis and schistosomiasis have returned. China spends only 4 percent of its gross national product on medical care, compared with 15 percent in the United States. Some criticize the Chinese government for spending billions on huge infrastructure projects like the Three Gorges Dam rather than providing cheap, basic health care.

By the 1990s, China's healthcare system was “in crisis” and, with only 10 percent of the population entitled to benefits, it ranked 188th out of 191 countries in a World Health Organization (WHO) equality report. Subsequent government attempts to develop an employee-employer co-funded insurance scheme were of limited success, and by 2005 had achieved only 40 percent coverage. The government's response was to increase healthcare spending by 87 percent over the next two years - a monumental rise - and to outline plans for a national healthcare system by 2020. Further spending hikes and regulatory changes have followed, particularly as part of last year's economic stimulus plan. Spending in 2010 is up another 8.7 percent, with about 4.5 percent of gross domestic product (GDP) allocated to healthcare, half of which comes from the private sector.

China’s laws formally ban foreigners entering the country with “serious psychiatric illness, infectious pulmonary tuberculosis and other infectious diseases that may constitute a major threat to public health.” It used to ban all foreigners with “psychiatric illness, leprosy, AIDS, sexually-transmitted diseases, active pulmonary tuberculosis and other infectious diseases.” In April 2010, China lifted the ban on people with HIV/AIDS and leprosy entering the country.

Websites and Resources

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Huashan hospital food
Good Websites and Sources on Health in China: Center for Disease Control on China CDC World Health Organization on China who.int/countries/chn ; Wikipedia article on Public Health in China Wikipedia ; Short UNICEF Article on Health Issues in China unicef.org ; On Health Care in China: Health Care in China, an IBM pdf file ibm.com/de/healthcare ; Pape on Chinese Helat Care from the 1990s mtholyoke.edu ; Library of Congress Country Studies countrystudies.us Paper on Chinese Health Insurance allacademic.com ; Ex-Pat Report justlanded.com ; China Health Care Blog chinahealthcareblog.com Asia Health Care Blog asiahealthcareblog.com

Links in this Website: HEALTH IN CHINA Factsanddetails.com/China ; HEALTH CARE IN CHINA---DOCTORS, INSURANCE AND COSTS Factsanddetails.com/China ; HEALTH CARE IN CHINA--- TRANSPLANTS AND DRUGS Factsanddetails.com/China ; TRADITIONAL CHINESE MEDICINE Factsanddetails.com/China ; ACUPUNCTURE Factsanddetails.com/China ; QI GONG AND MOXIBUSTION Factsanddetails.com/China ; ANIMAL PARTS AND CHINESE MEDICINE Factsanddetails.com/China ; DISEASES IN CHINA Factsanddetails.com/China ; AIDS-HIV IN CHINA Factsanddetails.com/China ; SARS IN CHINA Factsanddetails.com/China ; INFLUENZA AND A/H1N1 FLU IN CHINA Factsanddetails.com/China ; BIRD FLU IN CHINA Factsanddetails.com/China ; FOOD SAFETY IN CHINA Factsanddetails.com/China

Health Care in Modern China

Medical care is often less than ideal. When patients go to a hospital, they often have wait to get a number, then go to another window, and get another number and wait again. To get into a hospital sometimes people starting lining up at three o' clock in the morning to squeeze through the doors in a suffocating rush when hospital finally open at nine, with children and old ladies getting squashed in the process.

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Modern doctor
Describing the scene at a local hospital Peter Hessler wrote in The New Yorker, “Most children were accompanied by both parents, and often at least two grandparents as well. The adults bickered and shoved in the queue; the children whined and cried. Near my feet, a small child vomited on the floor. Inside the lab area, a little girl slipped out of the line to tinker with a tray of test tubes and slides. “Stop that!” a nurse shouted, slapping the child’s hand. A sign on the wall proclaimed, “With Your Cooperation and Our Experience, We Will Take Good Care of Your Precious.”

Jingying Yang wrote in the New York Times, “On an unseasonably cold afternoon in April, Da Yong, from Harbin,in the far north of China, stood for six hours in a biting wind outside the Peking University Medical College hospital, waiting with 15 other patients to get a number. He had been in Beijing for two weeks, he said, standing in lines to seek treatment for his wife’s facial boils. Sure, there are hospitals in Harbin, he said, but I wanted the best for my wife, so we came here. It’s like this at all the big hospitals. There’s no other way.

In some ways the Chinese health care system is incredibly inefficient. Medicine is wasted. Hospitals are so overstaffed that many doctors spend more time playing mah-jong or drinking beer than treating patients. A lack of competition has resulted in a decline of services and care.

But in other ways China’s health care is efficient. In the New York Times magazine, Sheryl Wudunn wrote, "China, has channeled it money to basic care---an approach that is far more cost effective. For example basic treatment for leukemia costs about $5,000 and on average adds a bit more than a month to a patient's life. The same $5,000 used to buy vitamin A supplements for children, adds a total of 10,000 years of life expectancy."

The government fixes prices on all medical services and pays doctors like public officials. The salaries and fees are often very low. This has led those in the medical profession to seek other ways to make money and to doctors choosing better paid professions.

Health Care in China in the 1980s

To address concerns over health, the Chinese greatly increased the number and quality of health-care personnel, although in 1986 serious shortages still existed. In 1949 only 33,000 nurses and 363,000 physicians were practicing; by 1985 the numbers had risen dramatically to 637,000 nurses and 1.4 million physicians. Some 436,000 physicians' assistants were trained in Western medicine and had 2 years of medical education after junior high school. Official Chinese statistics also reported that the number of paramedics increased from about 485,400 in 1975 to more than 853,400 in 1982. The number of students in medical and pharmaceutical colleges in China rose from about 100,000 in 1975 to approximately 160,000 in 1982. [Source: Library of Congress]

“Efforts were made to improve and expand medical facilities. The number of hospital beds increased from 1.7 million in 1976 to 2.2 million in 1984, or to 2 beds per 1,000 compared with 4.5 beds per 1,000 in 1981 in the United States. The number of hospitals increased from 63,000 in 1976 to 67,000 in 1984, and the number of specialized hospitals and scientific research institutions doubled during the same period. [Ibid]

Rural Health Care in China in the 1980s

The availability and quality of health care varied widely from city to countryside. According to 1982 census data, in rural areas the crude death rate was 1.6 per 1,000 higher than in urban areas, and life expectancy was about 4 years lower. The number of senior physicians per 1,000 population was about 10 times greater in urban areas than in rural ones; state expenditure on medical care was more than -Y26 per capita in urban areas and less than -Y3 per capita in rural areas. There were also about twice as many hospital beds in urban areas as in rural areas. These are aggregate figures, however, and certain rural areas had much better medical care and nutritional levels than others. [Source: Library of Congress]

“In 1987 economic reforms were causing a fundamental transformation of the rural health-care system. The decollectivization of agriculture resulted in a decreased desire on the part of the rural populations to support the collective welfare system, of which health care was a part. In 1984 surveys showed that only 40 to 45 percent of the rural population was covered by an organized cooperative medical system, as compared with 80 to 90 percent in 1979. [Ibid]

“This shift entailed a number of important consequences for rural health care. The lack of financial resources for the cooperatives resulted in a decrease in the number of barefoot doctors, which meant that health education and primary and home care suffered and that in some villages sanitation and water supplies were checked less frequently. Also, the failure of the cooperative health-care system limited the funds available for continuing education for barefoot doctors, thereby hindering their ability to provide adequate preventive and curative services. The costs of medical treatment increased, deterring some patients from obtaining necessary medical attention. If the patients could not pay for services received, then the financial responsibility fell on the hospitals and commune health centers, in some cases creating large debts. [Ibid]

“Consequently, in the post-Mao era of modernization, the rural areas were forced to adapt to a changing health-care environment. Many barefoot doctors went into private practice, operating on a fee-for-service basis and charging for medication. But soon farmers demanded better medical services as their incomes increased, bypassing the barefoot doctors and going straight to the commune health centers or county hospitals. A number of barefoot doctors left the medical profession after discovering that they could earn a better living from farming, and their services were not replaced. The leaders of brigades, through which local health care was administered, also found farming to be more lucrative than their salaried positions, and many of them left their jobs. Many of the cooperative medical programs collapsed. Farmers in some brigades established voluntary health-insurance programs but had difficulty organizing and administering them. [Ibid]

Hospitals and Clinics in China

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Waiting outside a clinic
There are good clinics and hospitals and bad ones. Most are clean and neat, the doctors and nurses are well trained and disciplined, and good records and charts are kept on the patient, but shortages of medicines, sterilized needles and supplies are common.

Hospitals and clinics sometimes have good medicines and vaccines but lack the infrastructure---refrigerators, clean syringes and nurses---to keep them safe and deliver them. Sometimes needles are reused, spreading disease and infection, and vaccines are given even though their effectiveness has been compromised by lack of refrigeration. To get around these problems, health care officials are using three cent stickers that change color when exposed to heat to indicate their contents have been spoiled, pre-filled injection devices that eliminate the need for the syringes and vaccinations that can be given orally.

It is not uncommon for hospitals to lose electricity because of power shortages, to lose radio contact with the outside world because they are unable to pay their electricity bills, and to loss their ability to provide ambulance service because there is no money for gas. The supply of basic medicines is variable. Well-stocked clinics are often that way through the work of lucky, aggressive and well-connected pharmacists.

China has an ambitious plan to create a community hospital system. To staff such a system its needs 165,000 doctors.

Structure of Chinese Hospitals and Problems with the System

China’s pyramidal health care system is structured around many small hospitals at the bottom, fewer midsize hospitals in the middle and a small number of very large hospitals at the top.

Hospitals still operate under soft budget constraints similar to those of state-owned enterprises in the 1980s: those with high operating deficits are given large subsidies, while profitable hospitals receive no funds, thereby locking inefficiencies into the system. [Source: Iain Mills, Asia Times, April 21, 2010]

“One of the biggest problems for health care in China is that patients always go straight to the top, even for colds or headaches,” said He Yuxiang, a fourth-year medical student at the Peking University Medical College, one of the country’s top medical schools, told the New York Times. “This creates a bottleneck at city hospitals, while smaller hospitals remain underutilized...The way that Chinese people view going to the hospital is what’s causing the problems we have. It’s why the middle and lower tiers of hospitals have not had a chance to develop.” [Source:Jingying Yang, New York Times, April 26, 2010]

Jingying Yang wrote in the New York Times, “Every morning at the Xuanwu Hospital in Beijing, patients, many from far away and sometimes on intravenous drips, spill out from over-full waiting rooms into the hospital corridors, said Dai Weijia, a doctor at the hospital. Meanwhile, she said, neighborhood family practices and clinics sitn early empty.” [Ibid]

While patient preferences are part of the problem, doctor preferences also play a part. Many medical students say they do not want to work at smaller hospitals but would rather work to find work at a top-tier hospital in a big city. “Most of my classmates would not want to go work in a small-town hospital, one medical student in Beijing told the New York Times, “The education that we have received is among the best in the country. Sure, it’s possible that we could go work in a clinic in the countryside, but that would be a bit da cai xiao yong.” His reference was to a proverb meaning to make little use of large talents. [Ibid]

Need for Healthcare Reform in China

Lucy Hornby of Reuters wrote: “The soaring cost of chronic disease could tax China's effort to offer basic healthcare to 1.4 billion people. Almost one out of every eight Chinese households was racked by catastrophic health expenses in 2011, according to a paper recently published in the medical journal The Lancet. [Source: Reuters]

“Healthcare reform is needed to rebalance the economy, since Chinese salt away their savings in part because of fear of being wiped out by devastating illness. But the burden of chronic illnesses could worsen as Chinese eat more and live longer. Diabetes, for instance, now afflicts nearly 10 percent of Chinese adults -- roughly the same proportion as in the United States -- up from 1 percent in 1980. [Ibid]

“Even if treatment for diseases like diabetes are normalized, doctors acknowledge that the announced government healthcare spending of nearly $175 billion through to 2015 is only the beginning. The Ministry of Health has a pilot program to cover some chronic diseases, which may be extended to dialysis, the treatment for kidney failure that can stem from diabetes. [Ibid]

“Peking Union Medical College Hospital specialist Xiang Hongding told Reuters: "At the moment actually there is no real appreciation of how much medical reform will cost. But the nation is committed, even if the cost is high, to resolve the problem...We're a socialist country, if the government wants to get something done, it can.” [Ibid]

Chinese Hospitals for the Rich

“The growth of a comfortably wealthy middle class has created rising demand for high-quality care in hospitals. People’s quality of life is improving, said Xie Yibo, who as general manager in Suzhou of a company that makes firefighting trucks is a member of the emerging middle class. More and more people have money, so of course they will want to take care of their health. Now they have the luxury of being able to do so.” [Source: New York Times, Jingying Yang, April 26, 2010]

“Official policy is slowly making it easier for hospitals and investors to serve this new market. In 1997, the government approved the establishment of the Beijing United Family Hospital, a groundbreaking joint venture between the Chinese Academy of Medical Sciences and Chindex International, a medical supply company based in Bethesda, Maryland. The hospital primarily serves foreign and wealthy Chinese clients. The government will allow foreign-financed hospitals like to have more freedom to set their own fees---sometimes as much as eight times above normal levels.” [Ibid]

“Hospitals like the Sino-Japanese Friendship Hospital and the Peking University Medical College now have special wings for wealthy and non-Chinese-speaking patients, employing doctors who have trained abroad or have foreign language skills.” [Ibid]

Rural and Village Health Care in China

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Treatment by a doctor
A study published in the Lancet in 2010 showed children born in rural China were three to six times more likely to die before they turn five than those born in cities.Many rural people rely on local health care that is often in the form of ill-equipped clinics and local healers. There are no ambulances or 911 numbers. People often have to walk, sometimes for days, to get to a decent clinic or hospital. People with medical problems often can do nothing about them because they can't afford medicine or a visit to the doctor.

Many people don’t practice rudimentary disease prevention measures such as keeping water covered, washing vegetables, brushing teeth, vaccinating children, taking the garbage away from the house and screening windows against flies and mosquitos.

In small villages self-taught healers often serve as doctors with villagers only seeking out hospitals---often multi-hour journeys away---when they have a serious illness. One such healer told the China Daily, “I am not a qualified doctor, but I know how to handle small health problems.”

The village healers methods include tendon stretching and “scraping away fever.” Among the books he swears by are Rely on Yourself Not Doctors by Zheng Fuzhiong, Decoding the Inner Canon of the Yellow Emperor by Qu Limin, The Tao of Chinese Medicine by Yie Housheng, and Users Guide to the Meridians and Collaterals in the Human Body by Xiao Yansheng.

Describing the treatment at a Chinese hospital for a friend who was bitten by a snake with tissue-eating venom Peter Hessler wrote in The New Yorker, “A doctor sliced open the bitten finger. They had some traditional Chinese medicine; Goettig figured it was a good sign that the box showed a picture of a snake. The doctor used a mortar and pestle to grind up the pills, and then he shoved the powder directly into the incision,...The swelling continued to spread. Goettig’s arm turned purple at the joints where the venom ruptured capillaries...The next day, the doctors cut open the hand three times to shove more powder inside. The pain was intense...After the third day, the swelling began to subside. He stayed in the hospital for a week...His hand recovered fully.”

Chinese Doctors

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Chinese medicine
Fully-trained doctors are notoriously underpaid. They generally receive only a few hundred dollars a month in salary---often less than what some taxi drivers make---and are expected to supplement their income with “red envelope money,” which the families of patients pay for better care, and by selling drugs or performing operations in which they take a cut. Some doctors stop treatment and demand more money before they continue.

One medical student in Beijing told the New York Times that even in a top hospital, pay levels are barely adequate. The investment it takes to become a doctor and what you get out of it are greatly out of proportion, he said. A doctor has to spend 10 years on education. Then, if he only gets the government-given level of income, well, that’s really not enough....Even with conference fees, speaking fees and other income added in, the total income is still low. Even if we are doctors, we still have to make sure that we have food to eat and clothes to wear.

Doctors are also overworked. They typically see 50 to 60 patents a day and often spend less than five minutes with each one. Many doctors are women. Many of the male ones smoke. More than half of Chinese doctors smoke.

There is a shortage of doctors in China. There are only 4,000 general practitioners in the whole country.

In August 2005, Health Minister Gao Qiang criticized China’s hospitals for being greedy and putting profit ahead of their social functions.

Cycle of Poor Pay for Doctors and Poor Chinese Hospitals

“It’s a vicious circle, said Cao Zemin, director of social services at Xiangya Hospital in Changsha, the chief city of Hunan Province. Patients shy away from small hospitals because many members of the staff have only a bachelor’s degree, if that, Dr. Cao said, adding, Some have never received any formal training, like the barefoot doctors from before who have not had a single day of standardized, regulated medical education.”[Source: New York Times, Jingying Yang, April 26, 2010]

“With fewer patients, the doctors have fewer chances to learn and improve their technique, not to mention lower salaries. So students with the most potential head for the bigger hospitals, and the patients follow. Thousands of medical students bemoan the lack of job opportunities after graduation, yet the problem of skill shortages in second- and third-tier hospitals remains intractable.” [Ibid]

“The Chinese medical industry very much needs talented people, Dr. Cao said. It’s true that some students cannot find jobs after graduation. The key problem is that they all want to stay in the big cities. They don’t want to go to the countryside or to the lower-status hospitals. Out of about four million medical graduates a year, fewer than half find jobs in big hospitals. The rest continue in postgraduate training to improve their job prospects or look for jobs elsewhere in the health care industry---in pharmaceuticals, biotechnology or medical supplies.” [Ibid]

“Two government-backed efforts could help to make better use of the pool of trained medical talent: an expansion of higher-fee hospitals and regulated residency programs.” [Ibid]

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Chinese doctors

Establishing Residency Programs for Doctors in China

“Residency programs have been established in Beijing, Shanghai and Tianjin offering graduates three years of specialist training at leading research and teaching hospitals Wang Jianxiang, a professor of medical science at the Institute of Hematology and Blood Diseases Hospital in Tianjin, said the government was working to expand the programs to allow rural hospitals to send doctors for residential training.” [Source: New York Times, Jingying Yang, April 26, 2010]

“Still, Dr. Cao said, the programs are not ideal. In contrast with the American system, in which graduate students complete a residency before taking a job, their Chinese counterparts look for a job immediately after graduating, sign a contract with a hospital and then are assigned by the hospital to complete a residency before starting work.” [Ibid]

“Dr. Wang said, After three years in a big city, you might want a different job in a different place, but you have to go back to the hospital where you signed your contract. Or for the hospital, they hire people three years ahead of time...On the books, they have all these doctors, but in reality, these doctors aren’t working or earning the hospital any income. What’s more, for these three years, the hospital has to pay those doctors, so it really becomes an economic burden.” [Ibid]

Health Insurance in China

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Taoist god of medicine
One forth of China’s population---over 300 million people---have no health insurance. People with no insurance avoid seeing doctors, knowing that is quickest way to go broke. Even when people have insurance, insurers rarely pay out more than a couple thousand dollars.

A nationwide insurance roll-out was launched in 2009. It has made people more likely to see doctors and made treatment much more affordable. Almost nine percent of people stayed in a hospital in 2011, from less than four percent in 2003, a study published in The Lancet showed.

Under the Chinese health care system, the government pays 60 percent of hospital expenses but contributes virtually nothing for medications and outpatient services. Families of a child that is sick, handicapped to has died receive a monthly stipend of 80 to 100 yuan once the mother reaches the age of 49.

Some cities and provinces provide additional subsidies and coverage. Companies and individual can purchase private insurance policies. State urban plans often only over individuals in their home cites. If they travel to another city and need help they are not covered.

A 34-year-old editor who has commercial health insurance in addition to state coverage told the Washington Post she paid for the first $300 of the cost for her treatment for a recent bout of pneumonia and insurance covered 90 percent of the next $750.

Coverage for children often only applies if the children are hospitalized. Expenses outside the hospital which can run into the hundreds of dollars is not covered.

The Chinese government has made setting up adequate health insurance a top priority. There is a plan to establish community insurance pools and programs in which workers are forced to put a percentage of their income in an individual medical account.

History of Health Insurance in China

Until the early 1990s , medical care was provided through the work unit system which funded care out of its operating income. The Chinese National Petroleum Company, for example, once ran more than 50 hospitals for its 1.5 million workers. When economic reforms kicked in many of these state-owned companies found they had enough trouble being viable as profit-making companies and were unable to pay for health care cost for employees and retirees on their pension plans. [Source: Steven Mufson, Washington Post, October 2009]

In 1994, the State Council overhauled the system by placing urban workers in city wide insurance pools that embraced around 200 million of China’s 1.2 billion people at that time. Hospitals and industrial enterprises severed their ties. Instead employers contributed 6 percent of wages and employees 2 percent to cover medical costs. The system failed to provide descent health care. Out of pocket expenses increased dramatically, far exceeding per capita income and national health expenditures.

The government went from paying 90 percent of medical expenses in the early 1990s to 17 percent in the mid 2000s. According to the World Bank, the number of Chinese with access to state facilities shrunk from 71 percent to 21 percent between 1981 and 1993 and out-of-pocket expenses for medical care increased 100 times between 1980 and 2005.

In 2003, the Chinese government gave more money to rural medical cooperatives and set up a system in which farmers put in $3 a year and the government provided a $12 subsidy for coverage of 25 percent to 30 percent of hospital expenses but little for outpatient care. The coverage doesn’t sound that great but 850 million enrolled n it. Between 2009 and 2012 the government plans to increase its contribution by half.

In 2007, the government extended coverage to urban workers and families who had been without coverage since the end of the 1994 collapse of the work unit system. Children, elderly, migrant workers and the unemployed all qualified for the same $12 subsidy received by rural people but because health care costs are higher in the cities than rural areas, urban people have to contribute more than $30---instead of $12---a year. About 120 million people have signed up for this.

In 2009, government pledged to spend $123 billion over three years to deliver basic health care and health insurance to 9 out 10 Chinese. The law calls for a revamping of hospitals and providing better services at lower cost. One of the hopes of the program is that it will help generate growth by getting people to spend more money by removing the need to save money for a medical problems.

One of the aim of the health care program approved in 2009 is to provide some form of medical insurance for 90 percent of the population by 2011. Each person covered by the system would receive an annual subsidy of more than $17 starting in 2010. Medicine would also be covered by the insurance, and the government would begin a system of producing and distributing necessary drugs this year.

Image Sources: Wiki Commons, University of Washington; Harvard Public Health; Nolls China website http://www.paulnoll.com/China/index.html

Text Sources: New York Times, Washington Post, Los Angeles Times, Times of London, National Geographic, The New Yorker, Time, Newsweek, Reuters, AP, Lonely Planet Guides, Compton’s Encyclopedia and various books and other publications.

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© 2008 Jeffrey Hays

Last updated November 2012

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