Sunday, 11 October 2015

Hospitals heed Xi Jinping's call to make use of "social capital", then rip off investors

One of the cornerstones of Xi Jinping's healthcare reforms is the urging of public hospitals to take advantage of "social capital" (ie private investors) for future expansion and development.

Unfortunately, in China's murky and non-transparent climate of investment, things are quickly going wrong in predictable ways. A hospital in Jiangsu now owes its mom and pop investor almost a billion yuan, according to reports in the People's Daily. The Workers Hospital of Suqian asked locals and employees to put their capital into the hospital's investment fund and promised regular interest and dividend payments.

In 2012, a man called Chen heeded the call to invest in the Suqian hospital to help fund the building of a new hospital and to further develop and expand medical services. The hospital guaranteed a fixed income and this was backed by the local government. Mr Chen put in his 2 million yuan retirement savings and was initially  pleased with the interest payments he received on a regular monthly basis. In fact, Mr Chen was so impressed he persuaded his family and friends to invest their money in the hospital as well. In addition, local TV advertising that was aired to promote the fund resulted in more than 2000 small time investors putting close to 900 million yuan into the Worker's Hospital Investment Fund. However, things started to go wrong in April this year when the hospital defaulted on its interest payments. Investors who asked why they hadn't received their usual payments were fobbed off with non-commital replies.

However, as public complaints and protests increased, the local police and authorities have opened a financial investigation into the missing monies. So far they have found that there is not enough money to pay the interest and also not enough to repay the principal sums that were invested and which most investors are now demanding be repaid.

Several of the hospital financial managers have been detained for further investigation and the local authorities say they are now tracking a number of unauthorised financial investments. It looks very much like the Suqian people have had their social capital blown on the roller coaster Chinese stock market that crashed so spectacularly this year.

Putian cartel?

Meanwhile, China's private hospital market has started to take off in a big way with more than 8000 hospitals and clinics in the loose "Putian Network" forming an procurement alliance. The Putian hospitals network is a loose association of healthcare establishments set up from the 1980s onwards by entrepreneurial families from the Fujian town of the same name. Although suffering from a poor reputation for marketing of dodgy services such as fertility clinics and cosmetic centres, many of the Putian hospitals are trying to transition into more respectable establishments. Several of the hospitals have formed groupings and sought investors through IPOs. Now the Putian group hospitals say they are seeking to consolidate and form buyer's groups to give themselves greater purchasing clout. However, Putian hospital are still suffering from a credibility after being banned from Baidu for their dodgy advertising claims.

Tuesday, 8 September 2015

Having a break

No posting until the end of September: I'm cycling in Heilongjiang and Russia.

Monday, 31 August 2015

Science Communication in China

On this blog you'll often see me harking on about the lack of health literacy among otherwise well educated Chinese people. The media in the west are always looking enviously at China's education system for the high marks in subjects such as maths and science. How is it, then, that Chinese people have such backward views on scientific matters such as antibiotic overuse and resistance? Is there no equivalent of Mythbusters in China?

One factor in the lack of scientific literacy in China is the poor level of science communication. There is little real popularisation of science in China, and few science communicators in the public eye. The reasons for this are well illustrated in an excellent - if somewhat academic - article in the journal Public Understanding of Science this week. Written by Zhang Yueyue (currently at the University of Kent, UK), the article entitled "The Credibility Paradox" explores why China's scientists don't connect with the public - and why the public don't listen to them.

The basic answer is that like many things in China, science is heavily politicised and a no-go area for individuals who are not officially approved. Zhang says that what little science communication there is in China is a "top down" process and is mostly concerned with policy. Science has long been seen as an instrument of Party policy in China, and its role is to serve politics. There is no popular participation in science debate, and no debate or discussion about science beyond the most basic principles.

In the west, we are used to seeing science communicators in the media who are independent and who express their own views and theories about scientific matters. Science communicators are often sceptics and are ready to challenge the official line - whether it be government, business interests or popular misconceptions and quackery. In China, it is a very different situation. Commentary on scientific matters is the preserve of a few "Big Experts" who have official blessing. There is little or no role for grassroots or frontline workers in science fields such as the biomedical sphere. There is no tradition of independent or dissenting thought in science, and there is little willingness among scientists to come forward and engage the public to popularise science.

And because science is seen by the public as being part of the political process, there is little trust or interest in what science commentators say. The top-down official model of science communication has little credibility with the ordinary Chinese citizen - they are alienated from science and there is no engagement.

This lack of interaction is a two-way process. Zhang's journal review describes the feedback she got from nine biomedical scientists who were interviewed abut their views on science communication. Most said they had little interest or willingness to get involved in public discourse or engagement around science. They did not see it as their role and would not want to take on the role.

When asked why, the scientists said they did not want to get involved in politics or become labelled as "stirring up trouble" by starting a public debate. Most scientists also said they were not qualified or entitled to talk about science in any official capacity as they were not "Big Experts" only "frontline workers". They would not comment about science in online forums or by writing articles because this would bring pressure from their institutions and have an adverse effect on their careers, they said.

Another reason that scientists cited for not getting involved in science communication was that experience showed them that nobody paid attention to what they had to say. They remarked that there were few good outlets or forums for science communication, and they were kept "out of the loop" by leaders and managers on science policy, so there was little point in discussing it anyway.

Interestingly, many scientists said they did not want to be associated with official science communication because they believed that science spokespeople had little credibility: "Nobody would listen to you or believe you" was one comment made.

However, the scientists said they did love talking about their work and explaining their scientific methods on an individual basis in informal situations. In other words, they were happy to be science communicators so long as they did not have their official hat on.

Ultimately, the lack of science communication means there is little understanding of science and thus poor science literacy in China, the scientists concluded.

In practical terms, this means that when biomedical scientists in China comment publicly about health and medical matters they are seen as having little credibility, and are viewed as simply spouting the "official line" or propaganda - and not to be trusted. And even when they are believed, their views and outlook are often not understood or given much attention.

This may explain why China's healthcare system is often dominated by unscientific practices - and why China's "medical experts" have little credibility in the public eye.

Sunday, 23 August 2015

High Noon for dodgy drug trials: China cracks down (again) on pharmaceutical data fraud

Eight years ago, the Chinese government took a rather drastic step to clean up fraud and corruption in its drug regulator - it shot the director of the State Food and Drug Administration. However, this has  now been shown to be just another example of the uselessness of capital punishment as a deterrent, because the Chinese government has now announced ANOTHER crackdown on pharmaceutical drug registration fraud.

Although not spelling it out as such, the Chinese ministry of health has basically admitted that there has been ongoing and widespread clinical trial fraud since 2008. Not exactly a ringing endorsement for the succesors to the hapless Zheng Xiaoyu (above).

Despite efforts to correct the situation, the new director of the China FDA, Bi Jingquan (in office since 2015) has announced that the problems of clinical trial fraud have not been fixed. On 22 July he issued proclamation 117, which states that the China FDA is to review the registration applications for more than 1600 drugs, to verify the data as genuine. In a sign of how bad things are, the China FDA has described this as a "last chance amnesty" for all the naughty companies who have submitted false data to come clean. Leniency for those who confess ... and for those who don't - three years exiled in the wilderness. Yes, the China FDA is going to blacklist the drugs and companies that are found to have acted fraudulently - if they don't put their hands up and admit to it. They will be banned from re-submitting any drug registration applications for at least three years.

Not surprisingly, the pharmaceutical industry is not happy with this situation. In fact, they are shitting bricks and calling it "7-22" - the industry's play on 9-11. They know the government means business this time because of what happened to GSK - the Anglo-US company was fined a whopping 3 billion yuan ($489 million) for dodgy goings on within its sales force.

But to be fair on Big Pharma, it's not all their fault. The real villains are the so-called Clinical Research Organisations (CROs), which are agencies that actually do most of the local clinical trial work on behalf of the pharma companies. According to Caixin magazine, industry insiders acknowledge that the CRO sector in China is riven by fraud and corruption. Pharma companies pay the CROs to obtain the clinical trial data for China and submit it to the regulators. However, it's an open secret that the trials allegedly run in China's hospitals have been fixed or faked,  and the regulators bribed or blindsided.

To use the words of a regulatory agency insider, "the chaos has not been effectively curbed" since 2008 and therefore the CROs are being invited to undergo a period of "self examination" and verification of their results. The China FDA is tearing up its 2001 guidelines for drug registration and is starting afresh with more rigorous rules. The CROs have a chance to correct their irregularities or will be banished for three years. It is hope the shake-up will clean out what it currently a rotten and severely compromised sector - but this remains to be seen.

The last word goes to an insider at a reputable company - he says the short term effect may well be a kick up the arse for the CROs and the pharma industry, but old habits die hard. He says the only way to achieve positive long term change is to overhaul the management of CROs and pharma companies - and build expertise based on technical and scientific ability, not an ability to bend the rules

My article in the BMJ on the medical response to the Tianjin blast

China’s health authorities have activated disaster response plans to send in medical teams to help treat hundreds of casualties from the massive Tianjin chemical explosion on Wednesday 12 August.
Official reports have said that at least 112 people were killed, 95 were missing, and 722 were admitted to hospital for treatment of injuries from the blast, which destroyed a wide area around a container storage area in the northeastern port city of Tianjin.
Many of the dead and wounded people were firefighters sent to tackle the blaze that triggered the huge explosion at around midnight on 12 August.
Doctors treating casualties at the nearby Taida Hospital said that most of the injuries were blast injuries such as burns and fractures, although hundreds of nearby residents were also … 
Read the rest at BMJ 

Sunday, 9 August 2015

Medical school places unfilled: nobody in China wants to be a doctor, and there are three good reasons why they don't

In western countries there is fierce competition to get a place in medical school. Only straight A students with an impressive portfolio of extra-curricular activities need apply. In China, the picture is very different. Even the top medical schools in China are struggling to attract students.

This week, Professor Yang Jun a distinguished cardiologist and head of the First College of Clinical Medical Sciences, Hubei, notes that Shanghai's prestigious Fudan University has had to drop its entrance mark threshold by 58 marks this year. The same "dumbing down" has been seen at the city's Jiatong University medical school and other medical schools across the country. When China's top medical school at  Peking Union Medical College allotted 10 places to Guangzhou students, only four applications were received - and of these only one was deemed to make the grade.

What's happening? The fact is, nobody with any ambition wants to be a doctor in China right now, and you can see why. The three main reasons are poor pay, long hours and terrible working conditions - including the real possibility of abuse and violence.

Writing in the International Journal of Cardiology, Professor Yang notes that the average salary of a doctor in China is 72,000 yuan a year (US$11,600) -  and many doctors earn a lot less than that, especially if they work in unpopular specialities such as paediatrics or emergency medicine (the so-called ambulance riders).

Poor pay for doctors in China: paediatricians are at the bottom, with only 63,000 yuan a year
For this salary, doctors have to work long hours - more than 50% of doctors work more than the 'specified' 40 hours a week and 30% work more than 60 hours a week.  Doctors also face huge workloads - as many as 80 patients in a single morning shift. As Professor Yang observes, the Mayo Clinic in the US has fifteen times more staff than the Peking Union Medical College, and yet it has only half the patient numbers.

Doctors in China simply don't have time to practice adequate medicine - and the consequences are unhappy patients who take out their frustration on staff. A recent survey of almost 10,000 doctors found that 60% had recently experienced abuse from patients, and 13% had experienced physical assaults.

Doctors also have to study long and hard to qualify - up to ten years including undergraduate and postgraduate qualifications. On top of this they have to publish articles and to gain academic merit for promotion.  Doctors have lost the status and respect they once had - and only 6.8% of doctors say they would advise their children to follow  a career in medicine.

This is already causing problems in the less popular branches of the profession. On 27 July, the National Health and Family Planning Commission announced that it would be waiving the usual entry criteria for admission to the specialities of paediatrics and emergency medicine. Medical student candidates who did not achieve the usual pass mark would be allowed to become trainee paediatricians and emergency medicine doctors if their coursework was of sufficiently high standard, the NHFPC announced. This has caused outrage among  doctors currently working in these specialities, who say it is a desperate and self -defeating move that will further reduce the attractiveness of their branches of medicine.

They say there is a need to improve pay and conditions in their work rather than lowering the bar to entry. Paediatrics and emergency medicine and notoriously poorly remunerated and yet high pressure jobs in the Chinese healthcare system. Assaults on doctors in these departments are numerous as they are in the front line seeing critically ill patients - especially the treasured offspring in a one-child system.

The doctor's social network site DXY echoed many of the criticisms of the "dumbing down" move. As one doctor wrote: "We work longer hours for less pay in unsafe conditions, but we stick to our posts because of the duty we have to the little ones who thank us after we have care for them."

Tuesday, 4 August 2015

The medical appointment "add-on" phenomenon - why China's doctors see far more patients than are booked to see them


A fascinating article run by Xinhua this week describes the so-called "add-on" (加号) system in which doctors squeeze in far more patients than are registered to see them. The official reason for this practice is that doctors often feel sympathy for ailing out-of-towner patient who cannot get a booking to see them that day. However, as the article reveals, the add-on patients are often more to do with doctors making informal arrangements seeing patients with guangxi (connections) or to see patients who have bought their booking slips from ticket scalpers.

To understand the add-on phenomenon you first have to understand how China's medical appointment system works. To see a doctor in China you have to 'register' (gua hao, 挂号) at the front desk of the hospital before you can get to wait at the clinic And with demand for doctor appointments far outstripping supply, this means patients have to queue very early (often overnight) and for a long time to get one of the limited slots available to see a doctor in their chosen department. There are two kinds of bookings: general and specialists.

Typically, a doctor in a  hospital outpatient clinic will work a morning shift from 8am to 1pm. Assuming that he or she works five hours without a break and sees patients for an average of five minutes (far too brief for an adequate consultation), the doctor could be expected to see 12 patients an hour - or 60 patients per shift. However, some doctors are seeing 50% or even 100% more patients per day than their official limit. Why so?

The Xinhua reporter describes the situation in the Chaoyang Hospital dermatology department, where he sees an impoverished family of 'waidiren' (out of towners) sitting with their ailing grandfather in the waiting room late in the afternoon. They are surrounded by their travel luggage and are telling the clerk that they have come from a remote town in a nearby province especially to see the doctor. At 6pm it is time for the doctors to finish their shift, but the doctor agrees to see the old man without a booking as a jia hao (add on).  The patient is given a ticket with the doctor's signature and the clinic chop, and his family are able to take this to the registration desk to get an official registration slip to see the doctor.

The doctor later explains to the reporter that because of his conscience he feels unable to turn away the desperate family who have been waiting there all day. However, he says he nevertheless feels guilty because his 'extended shift' also means that others have to stay behind - the nurses, clerks, pharmacists and security staff.

The doctor says that all departments have 'add-on' patients, some more than others, and each clinic and each doctor has a different policy about how to deal with them. Some doctors and clinics refuse to have 'add-on' patients, even putting up signs saying they are banned, while others reluctantly agree to see some of the more pitiful cases - the elderly and the seriously ill. Some clinics even leave spare room for add-ons and the doctors try to 'triage' their add-on patients to sort out the most deserving and to weed out the tricksters, malingerers and the ones who have paid for their registration.

The situation is complicated because not all 'add-on' patients are genuine. Some are simply putting on an act because they could not or would not wait in line to get a registration ticket. The doctor describes one woman who came to the waiting room with a wheeled suitcase, lamenting that she had  got off the train from a distant town and needed to see the big city specialist. However, an eagle-eyed nurse noted that the woman's suitcase was very light and obviously empty.

The other big problem with add-on patients is that they are exploited by the thriving trade in add-on appointments by scalpers known as 'hao fanzi' (号贩子).  These are the 'black hand' middle men who hang around the hospital lobby pretending to be patients and getting registration tickets which they then sell on illicitly to  patients who have missed out or don't want to line up early in the morning. To combat this, hospitals have introduced a system of ID checks, with registration tickets only valid for the person who has booked them. If the scalpers are unable to get registration tickets directly from the lobby office, they instead try to get bookings by posing as add-on patients. According to Xinhua, the going rate for a scalper-obtained place to see a doctor is 200 yuan for a general appointment and 300 yuan for a specialist booking.

One doctor told the reporter that the fake scalper 'patients' were often convincing or persuasive and he felt too tired at the end of a long day to try work out if an add on patient was genuine or not. The scalpers also cause annoyance to Beijing residents. One local 70 year old man waiting in the rheumatology department told the Xinhua reporter that he had tried to get to see the doctor for three days but had not been able to get a ticket despite queuing for hours each day. He said he resented outsiders and scalpers taking up the appointments that should be prioritised for local patients.

However another doctor hinted that about half the 'add-on' patients were not outsiders or scalpers but connections - guangxi. They would be patients with some connection to an important person, whom the doctor would 'fit in' to repay a favour, build up guangxi 'credit' or perhaps they were just friends or relations. There are also hints that many of the add-on patients use 'hongbao' bribes to be fitted in to see the doctor at the end of his or her clinic. But another doctor said that add-on patients were not a source of extra revenue - quite the opposite. He said doctors were paid a base salary and therefore if they saw more patients they did not increase their income.  He added that it was not uncommon for a doctor to work a five hour shift from 8am to 1pm without a break. He joked that he dare not drink tea while at work as he never even had an opportunity to go to the bathroom because of the number of patients waiting to see him.

For whatever the reason, the problem of add-on patients is obviously a major one - and yet another example of the problems that come from a health system centred on overloaded city hospitals.

Sunday, 2 August 2015

China enacts draconian curbs on foreign healthcare NGOs

When a Chinese minister says a new arrangement is a "win-win situation" you know have lost. And so it is with China's new NGO Management Law, which is in effect a piece of highly restrictive legislation that will drastically curtail the activities of foreign health and medical NGOs, put them under the direct control of relevant ministries and subject them to tight monitoring and suppression by the Public Security Bureau. 

In what seem to be a parallel with the widespread crackdown on civil and legal rights with the mass arrest of lawyers, Xi Jinping has launched an aggressive campaign to strike against the increasing activities of health NGOs. Many of the activities of groups such as Oxfam and Project Hope may seem relatively inocuous to westerners - but programs focused on poverty alleviation, disability awareness, environmental health and promoting reproductive health, and offering health services to minorities are a highly sensitive subject for China's supposedly Communist administration. You only have to look at the crackdown on HIV organisations to see how the authorities react to any imaginary threat to their authority or the questioning of it.

Perhaps the authorities fear the so called "Third Sector" groups will undermine their legitimacy by highlighting the failures of the government to provide basic services. Or perhaps they are just paranoid, with ministers already on record as saying that NGO claims about "Big Society" are an underhand way of bringing about social revolution - a kind of Velvet Revolution in scrubs.

Whatever the reasons, the new conditions are harsh. The new law for regulating NGOs specifies that
  • At least 50% of staff must be local Chinese, 
  • All NGOs must register and gain permission for all programs in advance, 
  • NGOs must put themselves under the control of the relevant health ministry and departments.
  • Programs will only be permitted if they are in line with Chinese government policies. 
  • NGOs must also clear all their activities with the PSB and make all their documents and staff subject to instant inspection and ongoing monitoring.
Of course, this is not how the NGO Management Law has been reported in official media. On the contrary, it has been described as a measure that finally recognises the high value of NGO work and seeks to bolster the status of such efforts. The Chinese government said the new law it would provide better management "and strive to provide more convenience and service, better environment and security."

A meeting held to launch the new regulations was told that China "welcomed long-term friendly exchanges and cooperation, and that foreign NGOs brought China international capital, advanced technology and management experience, and their activities were conducive to the development of Chinese science and technology, people's livelihood, welfare and other aspects of business."

However, it was notable that the launch meeting was chaired by Minister of Public Security Guo Shengkun rather than ministers responsible health or development. Guo said that China placed great importance on the work of health NGOs and wanted to further encourage them.

Nevertheless, the security chief also warned that NGOs must strictly obey Chinese laws and regulations, and the new NGO regulation was needed to ensure that NGO programs were conducted according to their stated purpose and "in an orderly manner" - that's Chinese official speak for not doing anything that is vaguely beyond government control.

Another speaker more pointedly warned against NGO "trickery", using the Chinese idiom of "displaying a sheep's head but selling dog meat" (“挂羊头卖狗肉”)

However NGO representatives and diplomats especially from the EU have strongly criticised the wide ranging and oppressive conditions in the new law. They say health NGOs already find it difficult to operate in China and the new law will make it even harder. The law curtails almost all the rights and functions of NGOs and their staff, and makes them subject to vague but sweeping and draconian powers of the PSB and ministries.

An EU representative said the new laws will impose an excessively heavy burden in terms of administrative, financial and personnel requirements on NGOs and greatly increase operating costs of the organizations, making their China programs unviable.

The meeting heard that there were about 1000 NGOs with long term programs in China and as many as 7000 with short term or one off aid programs. How they will be affected by the new measures remains to be seen.

Sunday, 26 July 2015

Universal health insurance comes one step closer - but who's paying?

The big healthcare news from China this week is that a health insurance safety net for serious illness is being extended nationally. This means that if all goes to plan, poor people who develop catastrophic diseases such as cancer should not be left destitute by medical bills for care. Pilot programs that have been running at provincial level will now be extended to all provinces, according to an announcement by the State Council on July 22.
This will be good news for the many sad and desperate Chinese families who face financial ruin because of medical bills - or who are simply unable to pay and have to watch their loved ones die of treatable diseases. Some of them resort to all kinds of bizarre publicity stunts and begging methods to try raise the money to pay the medical bills. I have recently before about a girl who offered herself as a bride to any man who would pay her brother's medical bills.

According to the China Daily (hardly the most reliable of outlets), the meeting chaired by Premier Li Keqiang, cover for major illnesses will "cover all the subscribers to the urban and rural resident basic medical insurance as of the end of 2015", with full implementation in all 6800 public hospital in China by 2017.

A spokesman for the council said that there were 700 million impoverished people in China, of whom about 10 million are suffering from a chronic disease or major illness.The scheme will cover 50% of expenses initially, but this will be increased over time.

According to state media, the funding for the scheme will come from existing insurance accounts and therefore "will not be a financial burden to the beneficiaries". However, it also slipped in the detail that the safety net scheme will be run by commercial insurance agencies chosen by the government through bidding, with limits of 2-5% on profit margins.

"Introducing the third-party commercial insurance as operators will bring a better inspection performance to control medical fees and prevent waste or ill-designed fees" a government spokesman said.

China's commercial insurance companies are keen to get into the lucrative business of providing private health insurance. However, reading between the lines, it looks like the government has told them that covering the safety net for the impoverished will be a condition of their getting access to this market.

As China Daily, puts it:

Wu Ming, a professor of public health at Peking University, said many insurance companies may compete for the business despite lower profit margins, since it can bring many potential benefits.
"Participation in the program can pave the way for the insurers to enter further into the medical care sector in the future," she said.

However, as the more reliable Caixin magazine reports, commercial insurance companies are worried about the financial implications of taking on serious health insurance policies. The various pilot projects run in places such as Jiangsu and Zhejiang have shown the potential for major cost blowouts for uncapped schemes, and also problems with defining which illnesses are covered and who should pay for what. In some cases local governments, which administer (and fund) health insurance schemes tried to unload all their difficult patients onto the safety net. Or as they told Caixin magazine: "all the risk, none of the power, no voice".

The commercial companies also fear that they will be required to take on patients only after they have gone through the regular health insurance system over which they have not control. They believe that if they have a full package of insurance they would be able to control costs (and potentially prevent patients from developing serious illness) rather than just picking up the pieces.

At the State Council meeting chaired by Premier Li Keqiang, the government said it would be keeping a close watch on the safety net scheme and conducting many checks and inspections to ensure there was no abuse of the scheme.

Sunday, 19 July 2015

What are hospitals like in China? (Answer: congested)

Another week and another series of brutal attacks on hospital staff in China. This week it was the turn of an unfortunate female neurologist in Huizhou, Guangdong, who had her hand almost severed when she hacked with a machete by a disgruntled male patient. The man said he was unhappy with his treatment and attacked without warning when the doctor was on her ward rounds.

The authorities have made the usual responses - they have arrested the offender and tightened up security at the hospital. Tributes and donations have poured in from citizens sympathetic to the plight of the injured doctor. A petition against violence in healthcare has garnered half a million signatures from doctors - and the Guangdong health department has ordered that all medical institutions have a police office installed and manned around the clock.

The attack was one of 12 high profile violent incidents against health staff that occurred last week in China - including the smashing up of the 301 PLA Hospital in Beijing. What is the underlying reason for these attacks? One of the main factors often mentioned is that China's hospitals are simply overloaded and cannot offer adequate care to all patients - who then become angry and violent.

Is this because China's health system is underfunded or inefficient? Some interesting answers on the real situation about China's congested hospitals emerged this week in a lengthy paper in the academic journal Health Policy and Planning. It's worth reading if you want to know the background to China hospital system and how it got into the mess it's now in.

The authors paint a much more nuanced picture of China's hospital system than the usual overcrowded/underfunded/profit-seeking complaints. First of all they bust some myths. For a start, China's healthcare system is not massively underfunded by international standards - but it is  unevenly funded, with most resources devoted to city hospitals.

Also, China's hospital system is not uniformly overloaded - only the tertiary (highest level) hospitals are. The lower-level hospitals at county and township level are often underused and deserted because patients flock to what they perceive as the top quality care available at tertiary hospitals in cities.

The authors explain that this has come about for two reasons. Firstly, when China's hospitals were reformed by Deng Xiaoping, the high level city hospitals got a lot more investment and incentives than the township and country hospitals. This created a vicious circle because the large hospitals were able to invest in better equipment, and attract more patients. better staff and thus earned more 'business' (and income) while the county hospitals lost out.

However, the high level hospitals had two problems - they invested in infrastructure rather than staff, creating a shortage and misallocation of skills at the tertiary hospitals, where many staff are wasted dealing with minor illness.

Secondly, the tertiary hospital were bound by tight regulations on prices for essential drugs and medical services.  To overcome this, they invested in many unofficial services (eg cosmetic surgery, fertility clinics etc), which diverted resources away from frontline care. The restrictions on prices meant that hospitals had to overservice to gain more revenue - but it also meant that patients had no 'price signal' to seek care from local hospitals. They could get good care  at the tertiary hospital for the same price - even if it meant facing overcrowding and rushed consultations.

This, then, is the current situation in China's hospitals - an imbalanced system in which all patients flock to the short-staffed higher level hospitals, creating congestion and strife. The article by Dr Sun Zesheng and colleagues at the Zhejiang University of Science and Technology, Hangzhou, offers a simple solution: deregulate prices. They say that tertiary hospitals should charge a premium for their services, and patients should be encouraged to seek less expensive alternatives for non-urgent care at local hospitals and clinics. However, they also warn that the government must invest in better equipment and medical staff resources at lower level hospitals.

Until that happens, the big city hospitals will remain congested - and the pressure (and attacks) on staff will persist.

Sunday, 12 July 2015

The medical side-effects of China's stockmarket crash


Headaches, irritability, depression and most of all insomnia are the most common medical side effects of China's stockmarket crash, doctors say.

Mental health specialists at Guangzhou's prestigious Sun Yat Sen Hospital say they have seen a stream of unwell patients this week suffering from the mental effects of severe stress from the stockmarket collapse.

"Some people can not sleep at night, have difficulty falling asleep or wake up in the early hours three or four times a night.
Many people have overt physical symptoms such as palpitations, chest tightness, aches and pains, stupor and confusion," says psychiatrist Dr Wei Qinling.

Dr Wei says the worst affected people are those with a casino mentality towards the stockmarket and those with little mental resilience, who are most at risk of severe depression, mental confusion and possible suicide risk. Other common reactions are despair, alcohol abuse and loss of motivation. Some workers in the finance industry say there is nothing to work for anymore, and they have lost a reason to work. Others have lost their livelihoods altogether. Dr Wei says some have gone on extreme drunken binges to try wipe out the stress.

And in what some are calling "stocks syndrome", people suffers from sever stress from the sudden reversal from riches to destitution. This is a mix of severe anxiety, guilt, frustration and mental paralysis. Dr Wei says some people have symptoms that are so severe they may require hospital admission and antidepressant treatment.

However, at the Beijing Union Medical College Hospital Department of Psychological Medicine, Dr Li Jianzhong says some people are looking for a quick fix for symptoms such as insomnia. Some of the most difficult to treat are those who were most greedy when the market was good and became obsessed with the stockmarket. After making large gains they are now in denial and are unable to accept that they have made losses and cannot adjust to reality. Counselling may be needed, but it requires people to learn about "spiritual wealth" as well as financial wealth, he says.

Dr Li says there are two steps to treating "stock syndrome". Firstly, people must identify the cause of their symptoms and learn to manage the stressors through activities such as deep breathing and findings distractive activities such as walking or sport. Secondly, people must find an alternative to obsession with the stockmarket and focus on that.

In Shanghai, psychologist Dr Chen Gong says there has been an increase in patients with 'financial stress' but it would be an exaggeration to say his department has been overwhelmed. For him, two of the most serious consequences of mental stress from the stockmarket are cardiovascular and cerebrovascular disease. These may be triggered by severe stress, and people must learn to change their habits and behaviour to have a more balanced life, he suggests. Another problem with financial stress is its effect on the family,and relationships, he adds. He recommends that people talk openly with their family and focus more on family activities rather than being preoccupied with speculating on shares.

Dr Wei, however, warns that for some people the stockmarket has become a form of addiction, just like gambling. He warns family members to look out for signs of addiction and to recommend counselling and treatment for those who have become addicted to the stocks - and are at risk of withdrawal symptoms.

Monday, 6 July 2015

China's universal health insurance? Well, that depends what province you live in

China's government now claims that something like 90% of the population are covered by health insurance. It's a statistic that's repeated by people who should know better - including the editor of the Lancet.
In reality, the level and breadth of health insurance varies significantly between different provinces. Some have high rates of coverage, some have high rates of investment in their health funds. Some have both, some neither. An interesting analysis in Caixin by Yang Mingyu shows why the patterns of health insurance have emerged.
[Health insurance coverage (left) and investment per person (right) by province]

He divides the provinces into four groups, characterised by their health insurance profile.
Some he describes as ideal, with high rates of cover (80-90%) and investment (100-1800 yuan per person). These tend to be the affluent eastern coast provinces of Guangdong, Zhejiang, Jiangsu. A second group, typified by Beijing, Shanghai, Tianjin, (and weirdly, Tibet) have high rates of investment in their health insurance systems, but coverage isn't so great - sometimes as low as 60%. The third kind of insurance pattern is the 'cover' province: Sichuan, Guangxi, Chongqing, which have high rates of insurance cover but only modest investment in them. And finally we have the poor relations - the low cover and low investment provinces such as Heilongjiang, Jilin, Liaoning.

Yang Mingyu says the  patterns are explained by a combination of economic strength, internal migration and the government's policy to maintain social stability. Investment in healthcare is seen as a major way of preserving social stability. Therefore, the government has invested heavily in health insurance in some of the  provinces where there have been large inflows of migrant labour. Conversely, some of the poorer provinces  have a left behind population of mostly elderly and children with high healthcare requirements but little capacity to contribute to healthcare costs. The government has promoted wider membership of health funds in these areas to reap premiums needed to support the health infrastructure.

However, there have been some 'backward' conservative provinces with few financial resources and also little investment in the health funds.

The article concludes by saying that some provinces need to be encouraged to reform their health insurance systems and provide more cover or investment to suit local needs, even if the local circumstances do not favour it.

Sunday, 5 July 2015

China healthcare's "Sunshine Act" and the journalist who exposed corruption: common cause?

[Banner outside Beijing court says: Support Journalist Chai Huiqun!]


With China's media often containing significant items of "managed opinion" it's hard to tell whether common themes that emerge in coverage are coincidence or not. Take this week's high profile case of a health journalist involved in legal action over an article in which he exposed corruption in purchasing at a Sichuan hospital. Is this a case of censorship by litigation - or is the government trying to use this case to back its own policy of reforming hospital purchasing?

The legal action in question is between the China Medical Doctor's Association and Southern Weekend journalist Chai Huiqun. The CDMA has lodged an official complaint against Chai to authorities over his reports about corruption in purchasing of medical equipment at the Mianyang Hospital following the major earthquake there in 2008. Chai wrote articles exposing inflated prices claimed for old equipment. The scam was based around the hospital claiming generous funding was spent on expensive ultrasound scanners but actually buying cheap second hand ones.

As reported by RFA, the CMDA put in a complaint to the All-China Journalists Association (ACJA), claiming that the stories were fabricated, and offered as evidence receipts proving that the hospital equipment was genuine. The ACJA accepted the complaint, which was a major blow to Chai's reputation and which effectively blacklisted him.

Now Chai has counterattacked with a legal action in a Beijing court, claiming 20,000 yuan damages and demanding that the statements and articles issued by the CMDA are retracted. In his claim, Chai points out that the receipts are for the wrong kind of scanners, new models which weren't even available in 2008. The court has yet to announce its verdict.

Chai is one of China's leading investigative journalists, working for the relatively liberal Southern Weekend (while it is relatively 'open' its contents cannot be syndicated). He specialises in exposing the dark side of the healthcare industry in China - and has made many enemies. If he is stymied, this will be a major blow for open-ness in the healthcare system in China.

However, Chai may be working in the right direction. Local governments and health departments are being ordered by the central government to clean up their acts and be more transparent and accountable in their purchasing of healthcare supplies.

In Beijing this week the Municipal Health and Family Planning Commission has launched a "Sunshine Program" to reveal the true value and scope of healthcare purchasing. Hospital and health institutions must publish comprehensive 'shopping lists' of all their purchasing and tenders, including all items and prices. This is to encourage and genuine free and open market for hospital supplies and to avoid dodgy backroom deals, the health department says.

If this kind of system had been operating in Mianyang in 2008, perhaps Chai would not have had anything to report.

Tuesday, 30 June 2015

Starlet snubbed; swears at surgeon

The Chinese public's dissatisfaction with the offhand and uncaring medical treatment they receive in state-owned hospital extends even to celebs. The China tabloids are today running the sensational gossip story of how singer and  Journey to the West star Han Xue (韩雪) lost her temper and screamed at a doctor who she was seeing at a Shanghai hospital for conjunctivitis.

The star has since apologised after her outburst hit the headlines, writing a piece on her Weibo blog about how the doctor treated her in a rude and offhand manner and refused to listen to her questions.

According to Han, she went to see a doctor at the Songjiang Branch Shanghai First People's Hospital after she developed a red eye from working underwater in a swimming pool as part of a film shoot. She got a ticket and waited in line like everyone else, only to be dismissed after just a cursory examination when she finally got a few minutes with a doctor.

Han Xue said the female doctor's attitude was indifferent and impatient, as she refused to even listen to her explanation of the eye problem. After a brief look at her eye the doctor wrote a prescription without saying anything to her.

When Han Xue remonstrated with the doctor, saying that she wanted a proper examination of what the problem was, the doctor merely replied that she didn't need to ask questions and could assess everything by sight. The doctor said she was busy and didn't not have time to waste. After being given a prescription and dismissed, Han Xue asked what the diagnosis was. The doctor simply said it was not a bacterial infection. When Han Xue complained about the lack of information and how the way she was treated was insensitive, the doctor said she was not a psychiatrist and didn't have time for niceties with a 'trivial' complaint like conjunctivitis. Han Xue retorted that her eye problem was not trivial to her, and that the doctor had a poor and unprofessional attitude.

The doctor said she didn't care, and this prompted Han Xue to 'lose it' and let out a stream of foul abuse at her. During the rant, the starlet asked the doctor whether she had been bullied as a child, and whether she had lost money on the Shanghai stockmarket crash. Shen finished with a shout that the doctor certainly did not deserve the title "Angel in a White Coat" (often applied in Chinese media to selfless medical staff).

On her blog, Han Xue apologised to the public for losing her temper and using bad language, but said she still stood by her judgement of the doctor as "uncaring and irresponsible" .

In the same week, Shanghai media have reported three separate physical attacks on hospital staff by irate patients and their families.

Sunday, 28 June 2015

Healthcare reform in China - The Five Reforms and why they will fail


As part of its latest round of healthcare reforms the Chinese government has released  a handy guide to the five top things it is doing to overhaul the creaky hospital system. The snappily titled "Guiding Opinions on Pilot Comprehensive Reform of Urban Public Hospitals" is really just a wish list for what the government would like to  see happening in the public hospital system.

Bear in mind that in China a "Public Hospital" is not  a public hospital as we would understand it in Britain or Europe. It's not a government-funded hospital that provides universal care. No, it's a state owned enterprise that runs a user-pays health institution. No money, no treatment. It's true that most people have some kind of government-subsidised health insurance that may cover some of their medical bills, but here again the public hospitals have a monopoly on that income - until this year private hospitals were not eligible for medical insurance rebates.

Anyway, all that is changing with the new Five Reforms:

1. Management Reform

The government says hospitals must adopt a more independent and accountable management system - recruiting outside experts and taking on board evaluation and performance review systems. They must start to subject themselves to outside scrutiny from consumer and industry groups and  - here's the killer - be transparent with their data. In other words, reveal their costings (insurance companies will love this) and their activities. A big ask. Expect massive resistance.

2. Revenue Reform

Hospital must stop relying on profits from sales of drugs and medical devices for their revenue. At the moment hospitals get 40-60% of their revenue from markups on drugs, medical equipment etc, and only a small proportion from medical fees and government subsidies. The central government wants to reverse that, and is going to ban drug commissions. To make up the lost revenue the hospitals must increase medical fees. Patients won't like that. There have already been riots in pilot trial sites in Sichuan by kidney dialysis patients who saw their cost of treatment go up 200%. The local government backed down.

3. Performance Reform

Hospitals must ditch the current system that forces doctors to overservice in order to achieve their bonuses. They must ditch the contracts that link doctor's remuneration to prescribing and procedure numbers, and replace it with a performance system based on clinical outcomes, service and efficiency.

4. Gatekeeper Reform

The government wants a primary care gatekeeper system and says tertiary hospital must stop being the One Stop Shop/First Port of Call for all and sundry.  Medical insurance policies are to be changed to force patients to attend local community clinics for minor illness and then be referred to local hospitals before going to a major tertiary hospital. The  major city hospitals will be reserved for more advanced and complex care patients. They must stop offering outpatient care for minor illnesses. This will take some getting used to because at the moment all Chinese make a beeline for 'the best hospital' as soon as they have a cough or cold.

5. Private Interest Reform

State-owned hospitals must be opened up to outside private business interests - the so-called 'social capital'. Private companies must be allowed to take on major roles within hospitals, along with insurance companies, and other medical foundations. Most importantly, they must have access to health information data.

The long and short of this guidance is that the closed and tightly-controlled monopoly situation for state owned hospitals must be bust open. At the moment, state-owned hospitals are the empires for local government bureaucrat-business chiefs. They jealously guard their business and their revenue stream - which is patients and the drugs and treatment they receive.

In an interesting opinion article in Caixin this week, Tsinghua University health economist Li Jiangge says that previous efforts to reform the hospital have failed because they simply have too much power and have too much to lose. He cites the example of government programs to provide  affordable treatment for cataracts. Although the central government provided generous funding to set up cataract treatment programs, most local governments blocked these projects in their areas because they would lose the lucrative income from doing the operations in their own hospitals. In other words - hospitals will block anything they see as competition or which undermines their own services. Likewise with kidney dialysis: China has 3 million people with renal failure needing dialysis, but only 400,000 get dialysis. The remainder go untreated and have early death because public hospitals will not allow private operators to enter this area and compete with them.

As Li Jiangge says, private investors and public hospital managers are "strange bedfellows" with conflicting and competing interests, who cannot be expected to co-operate. The few attempts at encouraging private industry to go into partnership wit public hospitals have not been a great success, he says.

Li Jiangge says private hospitals will only flourish when they are independent of the public system and have access to the same advantages such as medical insurance rebates and access to health data. Furthermore, he says private hospital development has been held back by lots of regulations that make them subject to local government control - including many "not-for-profit" rules. He says private companies should be allowed to do what they do best - make profits and take them away. The role of government should be to focus on "public health" matters such as disease control, vaccination and basic health services, he argues.