Sunday, 29 June 2014

One Country, Two Health Systems: or how Hong Kong has a socialist health system while China has a capitalist one


by Michael Woodhead
It is seldom remarked, but capitalist Hong Kong has a socialist health system while 'communist' China has a capitalist one. 
Hong Kong has a British NHS-inspired publicly-funded health service that remains efficient, good value for money and corruption free. China, on the other hand, has ditched its Soviet-era state-run 'health for the masses' system and replaced it with a state-owned user-pays system that is run on private lines. Don't take my word for it - there is an excellent article illustrating this in the obscure medical journal the International Journal of Radiation Oncology. It makes an interesting comparison of the Hong Kong and Chinese health systems through the eyes of oncologists who work in a cross-border co-operation clinic in Shenzhen.

Health systems
The oncologists note that Hong Kong's health system is based on heavily-subsidised public hospitals that provide treatment at no cost or only minor cost to all Hong Kong residents. It is an efficient system that accounts for only a modest 5.2% of GDP (compared to around 9% for many western  countries and 17% for the US). The Hong Kong public health system is perhaps a little too successful for some interest groups, as it means there is a very low uptake (27%) of private health insurance.
In contrast, China has a capitalist health system (where “money follows the patient') that is struggling to meet the needs of many citizens. Although China has a high rate of health insurance (often funded by employers), this does not cover expensive drugs or medical treatments. There is no safety net system provided by the state, and medical bills are a major burden, especially for low-income families. Initial consultation charges are a modest $2-3, but all Chinese hospitals have to be financial sustainable and thus doctors are encouraged to prescribe expensive drugs, order tests and even promote nutritional products, none of which may be justified by the patient's condition. As the oncologists say with some understatement: "there are serious concerns about the cost effectiveness and quality of services." 

Disease trends
In terms of cancer, Hong Kong and China are also poles apart. Due to preventive health and better treatment programs, cancer rates have decreased by 22% in Hong Kong in the last 25 years and cancer death rates have decreased by 29%. In China, however, rates of cancer have increased dramatically in the last decade as Chinese people have become wealthier and adopted unhealthy lifestyles and persist in smoking. In Shenzhen, cancer rates increased  from 37 per 100,000 people to 100 per 100,000 in the last 10 years. Many of the common cancers could have been prevented through screening and early detection- such as cervical cancer in women, rates of which have been decreasing in Hong Kong. Hepatitis B vaccination is another intervention that should reduce liver cancer rates. 

Doctor training
For oncologist training, Hong Kong follows the UK system of requiring several years postgraduate training regulated by peer group 'colleges' during which clinicians must demonstrate practical expertise in medical oncology, radiation oncology and palliative care, rather than being single branch specialists. Thus patients are treated by a team of oncologists in a 'one stop shop' model. In China there is no formal training program for oncologists, most specialise in one branch of oncology by doing written exams and there is no palliative care training. In China the work of oncologists is governed by 'standard operating procedures' in which the emphasis is on compliance rather than quality or outcomes. 

Access to treatment
When it comes to treatment, cancer patients in Hong Kong have access via public hospitals to the latest technology such as linear accelerators, at modest cost (US10 per attendance). Access is based on clinical need, not financial status or connections. Thus a full course of radiotherapy would be about $400 for a public patient, whereas it would cost $36,000 for a private patient. Across the border in Shenzhen, access to the latest radiotherapy equipment is - in the words of the authors - "appalling". There are only a handful of poor-quality liner accelerators and they are scattered across various hospitals - most patients and doctors do not know how to access them, and even those who do are often reluctant to use them because of fears about toxicity, not to mention the high cost. Shenzhen needs at least 16 such machines (Hong Kong has 37) but hospitals find it extremely difficult to buy such major items because of red tape from the Ministry of Health and the inflated costs of middlemen and the 'commissions' needed to import high-tech equipment into China. 

Drugs - if you can afford them
Access to chemotherapy drugs also differs markedly between Hong Kong and China. In Hong Kong, drugs are approved for use if they can be shown to be cost effective. Regulators model their the drug approval processes on those of western countries.
Patients pay US $13 per oncologist consultation and US $1.30 per drug prescribed. Some high cost drugs are not publicly funded but some costs may be covered by the public safety net or by charities.
In China, many chemotherapy drugs are not available or are long delayed in gaining approval from the China FDA. Drugs that are approved are available on a user-pays basis and can be very expensive. Pemetrexed, for example, costs US $1155 for the genuine drug in Shenzhen although a Chinese generic version is available for US $353. However, the quality of generic drugs is often poor. There are no programs for low income patients. 

Opium wars left their mark?
For palliative care, Hong Kong has developed an integrated  multidisciplinary system based in public hospitals and with hospices. In China, palliative care services are limited or non-existent. There are no palliative care specialists, and so treatment is provided - if at all - by anaesthetists. Pain relief is hampered by draconian regulations over the use of opioids. Most doctors are not allowed to prescribe them, and those who are authorised can only provide a week's supply. Many terminally-ill cancer patients are too weak to return to the hospital every week. This means that cancer pain is under-treated in China.

Looking to the future, on the positive side, health services in China are now evolving rapidly and there is a huge demand for good-quality clinical services. The authors say their Hong Kong-Shenzhen hospital has been operating for only a year but is already providing valuable lessons and experience. It has established a strict 'no-bribery' rule and has also become the first hospital in China to gain international certification for quality of management.

[Editor's note: This story is based on an article by Drs Anne Lee, Henry Sze, Lam Ka-On and Chen Xian of the Clinical Oncology Center, University of Hong Kong – Shenzhen Hospital.]

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