Monday, 24 February 2014

Why the ban on "red envelopes" for doctors won't work

by Michael Woodhead
China's National Health and Family Planing Commission (NHFPC) this week announced further restrictions on the use of red envelopes or 'hongbao' (bribes) by doctors. 
From May, both patients and doctors will have to sign an official undertaking or contract within 24 hours of hospital admission, stating that neither side will give nor receive red envelopes, money, gifts or other inducements as part of the treatment process. A ministry spokesman emphasised that the doctor-patient agreements are part of a wider contract in which the doctor also pledges to respect the patient's autonomy, privacy and informed consent, and the agreement requires the clinician to do his or her utmost for the patient. Conversely the patient pledges to respect the medical staff, scientific medicine and to act in an orderly and civilised manner. The ministry says phone complaint lines will be set up to allow authorities to be notified of any infringements of the agreements. They say the new contracts are intended to clean up the medical system, create a professional medical system and to build harmonious doctor-patient relationships.
However, the proposals have been met with cynicism and doubt from those working within the healthcare system. A Xinhua journalist interviewed several doctors, nurses and hospital managers and was told that the plans were unrealistic and unworkable.
A manager at a major hospital said that on the surface, public and private hospitals already prohibited the giving or receipt of 'red envelopes' but the use of favours and connections was a common practice under the surface.  "What doctor would dare to say that he had never received favours, especially the surgeons!" he said. "The red envelope system is an invisible system and a piece of paper from the health ministry isn't going to change it," he said.
Some patients said they believed they had to give small tokens of appreciation to be able to get to see a doctor or to see the best doctor - and also to ensure that the doctor did their best. But doctors interviewed by Xinhua dismissed these claims, saying they would do a good job for all patients and were unlikely to do poor work just because gifts had not been received. However, doctors did admit off the record that guangxi - 'connections' - played an important role in getting prompt and good treatment. They said junior doctors worked hard and had many patients to see, and it was unlikely that red envelopes would make a difference to the way they worked. If a doctor actively solicited red envelopes then that was clearly immoral and he deserved to be caught and punished they said. However, in their clinical practice doctors said they observed that patients and families often wanted to give tokens of appreciation after the treatment was successful - was it normal or wrong to accept such gifts if they were given with gratitude? One doctor said such gifts could be anything from 200 yuan to as much as 10,000 yuan, and he had once been offered a car worth 200,000 yuan by an elderly man whose life he saved.
The main influence over doctors was not from strangers giving bribes but from 'acquaintances' who squeezed them for favours, he said.
Top specialists were much in demand, and it was common for them to give priority to 'friends' who had connections, he said. This kind of favouritism didn't mean that doctors literally had money put in red envelopes or even deposited into their bank accounts - it was more subtle than that. Such favours for connections usually were repaid in kind, he said. He knew one example where a surgeon helped a well connected man and in return the doctor's son was able to gain entry to a good university. How would the new ban on red envelopes prevent something like that?
Another common area of favouritism was in private and personal 'extra' treatment. It was not uncommon for doctors to do 'private calls' and give private clinics for those who could afford it - and for those who could do them favours. This kind of 'private practice' meant that those who did not have money or connections missed out, of course.
The doctor said this kind of thing happened because there was simply a shortage of medical specialists and resources. "There are too many patients and not enough highly skilled doctors.  China has 20% of the world's patients but only 2% of the medical resources, and no law about red envelopes will change the situation until that imbalance is fixed. It's the system that is the problem, not corrupt doctors," he said.
A nurse said that the new regulations would stop the visible giving of gifts, but that wasn't a common occurrence anyway. "Who of us in hospital depends on red envelopes?" she laughed. "It's the unwritten rules that need to be changed," she said.

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