HOSPITALS IN CHINA: LINES, SCALPERS AND UNEQUAL CARE

HOSPITALS AND CLINICS IN CHINA

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Waiting outside a clinic China has 23,095 hospitals, 2,889 of which specialize in Chinese medicine. China has an ambitious plan to create a community hospital system. To staff such a system its needs 165,000 doctors. [Source: Ian Johnson, New York Times, October 10, 2015]

There are good clinics and hospitals and bad ones in China. 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.

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 sit nearly empty.”

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.

Health Care at China’s City Hospitals

Jiayang Fan wrote in The New Yorker: ““When I asked Zhang about his health, he had trouble explaining the details of his condition, something that... is common among the people she sees. Until he was in his mid-fifties, he had never stepped inside a hospital, and rarely thought about his body as anything more than a machine from which he needed to extract as much work as possible. But one day, five years ago, he had coughed up enough blood to soak an entire handkerchief. When he visited the First People’s Hospital, in Yangquan, he was told that an operation was required, to biopsy a tumor on his spleen. He could not afford it, and, besides, there would be no one to care for him while he recovered. Seeking a second opinion, he ventured to Taiyuan, the provincial capital, but the verdict was the same. In the past three years, Zhang has twice stayed at Friendship and Love to receive intravenous infusions. The second time, he checked himself out early, against his doctor’s orders. It was harvest season, and Zhang had no one else to reap his corn. [Source: Jiayang Fan, The New Yorker, March 30, 2020]

“One day during my stay in Yangquan, Li Youquan and I drove two hours to Taiyuan, to visit Shanxi Tumor Hospital, the province’s largest hospital and one of the first in China to specialize in cancer care. In its vast atrium, amid a sea of red banners bearing socialist slogans, there was a no-smoking sign and a poster warning of the link between smoking and cancer. Nearby, a man sat staring at his phone, a lit cigarette dangling from his mouth. In China, the messages on posters are sometimes a better guide to what is not happening than to what is. Other signs referred to anti-corruption policies and stipulated grave penalties for bribery and profiteering in health-care settings. But, in a dimly lit stairwell, there were phone numbers and notes scribbled on a concrete wall, advertising the services of people who could falsify almost any kind of medical paperwork—patient records, diagnoses, prescriptions, bills.

“Shi Lizhen had told me that, in addition to outright corruption, there were many gray areas. Doctors at public hospitals receive paltry remuneration for patient consultations but much more when they order major procedures. As a result, surgeries are suspiciously common. For hospitals, drug sales are an important revenue stream, so overprescription is rife. Shi sometimes encounters patients who are fully recovered but are still being prescribed medication. She discreetly suggests that they ignore their prescriptions, but they usually tell her that they are afraid of offending the doctors. “So we reach a compromise,” she said. “The patient buys the medicine, so that the doctor gets paid, but they’ll just take it home instead of using it.”

Attitude of Chinese Parents About Hospitals

The China Daily reported: “Yang Dan, a Chongqing resident and mother to a 3-year-old boy says she detests taking her child to the hospital. The air circulation is poor. The area is noisy. It is so overcrowded that parents have to hold their children in their arms for intravenous infusion procedures. There have been cases of parents losing their children in the disorganized environment. Yet sending their children to small hospitals is out of the question, because they cannot provide quality healthcare, Yang believes. She says once her son was misdiagnosed even in the largest hospital in Ya’an, a medium-size city in Sichuan province.[Source: Liu Zhihua, China Daily, November 13, 2013]

“With the disparity in healthcare quality between rural and urban regions, between a top-level hospital and a less-privileged one, most Chinese parents share the belief that small hospitals are incompetent. In 2012, Capital Institute of Pediatrics, a top children’s specialist hospital in Beijing, received 2.04 million people who sought outpatient treatments, or three times its capacity, according to Wang Tianyou, the deputy president. The condition is worse in regions with fewer hospitals. West China Women’s and Children’s Hospital, in Chengdu, Sichuan province, a small hospital of only 11,333 square meters, recorded 1.7 million yearly visits, mostly sick children, according to its president Mu Dezhi.

“Zhu Zhu, mother of a 6-year-old boy in Beijing, compares visiting a good hospital to obtaining a train ticket during the Spring Festival peak travel season. She says the doctors are usually bad-tempered. “When children get sick, parents are extremely anxious and worried, but it always takes at least three hours to line up outside the doctor’s room. When we finally get to see the doctor, they spend less than three minutes on the child,” Zhu says. “Besides, the hospital staff members are normally very impatient and reticent.”

Hospital Customs in China

At public hospitals it is not possible to make appointments. Instead people have to wait in line in the morning to get a ticket to see a doctor that day. Often times all the ticket are gone by 8:00am. Those that can’t get ticket themselves can buy them from scalpers (for about $30 in the 2000s). People who need surgery or women who about to give birth often have to pay a bribe or use “gaunxi” (family connections) to secure a bed.

Hospitals provide bed sheets, but the families of patients are required to bring everything else: towels, soap, dish towels, toilet paper, pajamas, cups and extra food. Relatives are expected to feed and take care of patients while they are in the hospitals. Family members often stay in the hospital room of a sick person around the clock, and often take turns sitting besides the bed. Out of 100 people that enter a hospital building often only about 20 percent actually have an ailment of some sort. The other 80 percent are family members who have come along to provide care and offer encouragement.

Doctors and staff routinely spit in the hallway floors. In rural clinics it is not uncommon for dogs and patients with questions to wander into a room where a doctor is examining a patient. People are afraid to go to hospitals because they believe that is where people go to die.

Hospital Hassles in China

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Huashan hospital food Medical care is often less than ideal. 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."

Lines Before Dawn at Chinese Hospitals

The long lines are a standard feature of hospital visits in China.. 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.

Siu-wee Lee wrote in the New York Times: Well before dawn, nearly a hundred people stood in line outside one of the capital’s top hospitals. They were hoping to get an appointment with a specialist, a chance for access to the best health care in the country. Scalpers hawked medical visits for a fee, ignoring repeated crackdowns by the government. [Source: Siu-wee Lee, New York Times, September 30, 2018]

“A Beijing resident in line was trying to get his father in to see a neurologist. A senior lawmaker from Liaoning, a northeastern province, needed a second opinion on her daughter’s blood disorder. Mao Ning, who was helping her friend get an appointment with a dermatologist, arrived at 4 a.m. She was in the middle of the line. “There’s no choice — everyone comes to Beijing,” Ms. Mao, 40, said. “I think this is an unscientific approach and is not in keeping with our national conditions. We shouldn’t have people do this, right? There should be a reasonable system.”

“K. K. Cheng, a public health expert, who is also dean of the general practice department with Peking University Health Science Center, said that in the world’s most recognized children’s hospitals in countries such as Canada, Britain and the United States, the lines are not so long because those hospitals are only for patients with severe or complex conditions. “It is time to adopt an alternative model that strengthens primary care and community-based hospitals and clinics,” Cheng says.[Source: Liu Zhihua, China Daily, November 13, 2013]

Chinese Hospital Scalpers (Illegal Touts)

Adam Jourdan of Reuters wrote:“As day breaks, hundreds of patients wait to see doctors in a line that snakes around the Peking Union hospital in Beijing. Many will wait in vain — "scalpers" like Yu Wei have already illegally bought and sold appointment tickets for the day ahead. Yu, 32, makes a living touting the tickets that Chinese hospitals sell in advance for consultations. His tickets will get a patient in front of a doctor in two days, he says, compared with a wait that can be up to a fortnight. [Source: Adam Jourdan, Reuters, April 12, 2016]

“Dodging passing police patrols as part of his daily routine, Yu charges 850 yuan ($131) for a "special care" appointment ticket — almost three times the face value. He told Reuters he keeps 200 yuan from each sale, with the rest of the profit going to hospital insiders who he said help him secure the tickets. "The city's upper middle class are always willing to pay this amount or even higher — as long as they can get an appointment," Yu said, speaking between frequent phone calls that he said came from would-be clients. In the background, other scalpers competed for custom, shouting out their prices.

“In line with this drive, authorities have tried to crack down on healthcare corruption and police say they have detained some 240 scalpers in Beijing alone this year. Many patients and doctors say, though, the time-served practice is just a symptom of deeper issues: a dearth of doctors and low salaries meaning graft is endemic. "Scalpers are a real headache for us," a spokeswoman for the Peking Union hospital surnamed Chen told Reuters by phone. "There's a crackdown on them, but it's a hard problem to cure." The spokeswoman added the hospital and its doctors were victims of scalpers and were not involved in the practice. [Source: Adam Jourdan, Reuters, April 12, 2016]

“Authorities have promised to intensify their crackdown.A viral video in 2016 of a woman with her sick mother raging against scalpers brought a public outcry and calls for arrests and tough jail sentences. But when Reuters visited hospitals in Shanghai and Beijing, dozens of scalpers operated in plain sight, loudly offering tickets for sale.

“A spokesman at the Beijing city health department said police needed to "strengthen" their efforts, and it would take some time to see any real results. Feng Jianqi, a police officer involved in leading the crackdown on scalpers in Beijing, said the police could not resolve the issue alone. Part of the problem was that so many patients wanted to see the same doctors, he said. "It's just not realistic to totally eradicate scalpers. It's just too hard," he told Reuters by phone.

Chinese Hospital Scalpers: A Necessary Evil

Adam Jourdan of Reuters wrote: “The problem is acute for patients like Cao Dongxian. The middle-aged school teacher traveled to Beijing in May 2015 year from his home in Shandong province after local doctors refused to carry out a risky intestinal cancer operation. Keen to avoid paying scalpers, Cao spent months queuing in hospital lines for repeat tests before doctors eventually said his cancer needed an urgent operation. Cao was then told he would have to begin queuing again: this time for a hospital bed. "It was October by the time I got to have my operation ... more than four months," Cao said. "On top of that your body's in pain — it really hurts." “In hindsight, Cao said he wished he had gone to scalpers straight away.[Source: Adam Jourdan, Reuters, April 12, 2016]

Doctors also appear resigned to the practice, as wealth spreads in China and patients accept the reality that paying more will bring speedier treatment. "(Basic) appointment fees don't reflect the economic value of doctors' skills and experience," said Wu Yuan, an eye doctor at the Peking University First Hospital in Beijing. "Scalpers are simply selling the doctor's appointment at a price the market is prepared to pay," Wu said. He said the practice was routine but that he had no knowledge of any doctor involvement in ticket resales.

“For patients like Cao or Zhang Pengyu, a 38-year-old realtor from the outskirts of Beijing, scalpers are source of frustration and anger, but sometimes a necessary evil. He waited unsuccessfully for three nights to see an ear, nose and throat doctor at Beijing Tongren Hospital. He finally gave in to scalpers, paying 3,000 yuan for a 10-minute appointment that should have cost just 200 yuan. "I wanted to queue myself and not pay so much money, but I just couldn't wait any more. I didn't have time," said Zhang.

Health Care for Rich and Upper Middle Class Chinese

The growth of China's upper middle class has created rising demand for high-quality care in hospitals. Xie Yibo, a general manager in Suzhou of a company that makes firefighting trucks is a member of the emerging middle class. told the New York Times. "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]

According to the Financial Times: Chinese patients pore over rankings of top hospitals produced by institutions such as Fudan University in Shanghai, while online forums and increasingly popular medical apps allow them to pinpoint the doctors with the best reputations. Wu Shouguo, a 55-year-old Beijing resident, hosts 40 to 50 people a year, mostly from his home province of Sichuan, who visit the country’s capital hoping to see top doctors. “They come because they didn’t get treated well by local doctors,” he said. [Source: Tom Hancock and Wang Xueqiao, Financial Times, December 31 2019]

“State insurance only covers some costs, and coverage varies regionally. Patients in wealthier areas have more generous insurance, intensifying the concentration of medical skills in larger cities because their better insurance means they can afford more expensive treatment. Some patients have no option but to try to fund treatment out of their own pockets. Wealthier people in China’s regions are able to pay out of their own pockets to have top doctors come to them.

When Chen Zhe’s mother-in-law was diagnosed with late-stage colorectal cancer, he sought out Li Jin, a Shanghai doctor recommended by another medical professional. “This is how people get to know and judge a celebrity doctor, by word of mouth,” he said. Mr Li sees up to 60 patients a week, and says they often arrive at his hospital as early as 6am in the hope of getting an appointment. He did not expect demand to diminish. “I have even had patients track me down at academic conferences,” he added.

China’s Best Hospitals

Peking Union Medical College Hospital (PUMCH) is regarded as the best hospital in China. Located in Beijing and founded by the Rockefeller Foundation in 1921, it is affiliated to Peking Union Medical College (PUMC) and the Chinese Academy of Medical Sciences (CAMS. This renowned general hospital has been one of the top ranked hospitals in China for over 80 years. With the most advanced medical equipment and technologies in China, the hospital has 40 clinical departments and 15 adjunct departments, including 10 national key disciplines (in 12 departments). [Source: China.org.cn, 2013]

According to What’s On Weibo: PUMCH offers 2000 beds, has more than 4000 employees, and 57 clinical and medical departments. The hospital recently also launched its online services, including consultation, prescribing medicine, and electronic medical recording, which reportedly will expand to all clinical sections of the hospital.

West China Hospital Sichuan University is considered the second best hospital in China. Founded in 1872, is China’s biggest hospital and ranks second in the world in terms of size. The hospital has a capacity of 4300 beds and there are 46 clinical departments. It was in the news recently as it developed its own experimental COVID19 vaccine. [Source: Manya Koetse, What’s On Weibo. November 26, 2020]

People’s Liberation Army (PLAGH), also known as 301 Hospital or PLA General Hospital, is ranked third. The largest general hospital under the People’s Liberation Army, it was founded in 1953 and used by China’s top leadership. It has a capacity of 4000 beds. It received International attention for being the first medical facility in Asia to provide newly advanced (ZAP) non-invasive technologies to treat brain tumors.

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. According to the New York Times: “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.”

Black Clinics in China

Hui Li and Ben Blanchard of Reuters wrote: A one-room shack with a single, bare light bulb on a non-descript Beijing side street is 29-year-old Chinese migrant worker Zhang Xuefang's best recourse to medical care. “Not recognized as a Beijing resident, she does not qualify for cheaper healthcare at government hospitals, and her hometown is too far away to take advantage of medical subsidizes there. Like millions of other migrant workers, Zhang, on whose labor China's economic boom depends, is forced into a seedy and unregulated world of back ally "black clinics" if she falls ill. [Source: Hui Li and Ben Blanchard, Reuters, March 27, 2013]

“World Bank's Zhang also pointed out that China's health care insurance system is a fragmented one, mostly coordinated within counties. But migrant workers usually have to seek medical treatment outside their home counties. "Black clinics are the dark corner of China's medical system," said Jiao Zhiyong, a professor at Beijing's Capital University of Economics and Business. "Migrant workers are their main patrons largely due to flaws in the health insurance system."

“The Beijing government has shut down about 1,000 black clinics a year since 2010, according to government figures. Many, however, reopen nearby or at the same place only days after being closed. While China has never published numbers for how many black clinics exist, every so often state media reports deaths at these unlicensed health centers. In January, Chinese newspapers reported that a migrant worker from Fujian province died from a cardiac arrest hours after receiving an intravenous drip to relieve her cold symptoms in a black clinic in one of Beijing's gritty outer suburbs.

“Migrant worker Zhang has seen the dangers of black clinics close up. On one occasion, out of fear that authorities might be nearing the illegal clinic, Zhang's doctor locked her inside the clinic, still hooked up to an intravenous drip, as he fled. "We don't want to go to those places, knowing that the substandard hygienic conditions affect us, but we really can't afford big hospitals," said Zhang, who once paid 800 yuan, a quarter of her monthly salary, for treatment of a common cold at a government hospital in Beijing.

Why Black Clinics Flourish in China

According to Reuters: The existence of black clinics “highlights the two-tier nature of China's overburdened health care system and goes to the heart of a heated debate about how to reform the contentious "hukou" system of household registration, a cornerstone of government policy for decades which essentially legalizes discrimination between urban and rural residents. The hukou system, which dates to 1958, has split China's 1.3 billion people along urban-rural lines, preventing many of the roughly 800 million Chinese who are registered as rural residents from settling in cities and enjoying basic urban welfare and services. [Source: Hui Li and Ben Blanchard, Reuters, March 27, 2013]

“China's government” under Xi Jinping “has vowed to change this divisive system with reforms aimed at sharing more equally the bounty of China's economic growth and consumption-led growth. Premier Li Keqiang vowed to press ahead with reforms to narrow China's urban-rural gap, including giving migrant labor more equal access to medical insurance.

No details were announced, so black clinics will remain the affordable last resort for migrant workers."Health care insurance and other social insurances are closely linked to hukou. Providing better social insurance is, I believe, an incentive to reform hukou system", said Zhang Shuo, a senior Health Specialist with the World Bank's Beijing office. "China's urbanization will be unprecedented in speed and scale," Zhang explained, "Portable social insurances is key to encourage labor migration, but it will take some time for a country as big as China."

Image Sources: Wiki Commons, University of Washington; Harvard Public Health; Nolls China website

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.

Last updated September 2022