Sunday, 26 April 2015

Rural doctors in China; Free cancer screening; New TB vaccine; Do doctors have good cardiac skills?


In a sign of the increasing concern about the demise of rural healthcare, China's 1.4 million rural doctors have now been given their own professional organisation.
Although it's not quite a trade union, the Chinese Medical Association has established a rural doctors section that will represent the interests of the many village doctors. The move is in response to the ageing of the semi-skilled workforce, most of whom lack medical degrees and have only high school education and a short training course on healthcare provision. According to the CMA, the new Rural Doctors Association "will assist the government to strengthen and promote rural doctor team building for the survival and development of rural medicine and safeguard the legitimate rights and interests of rural doctors."
Earlier this year Premier Li Keqiang acknowledged that it was important to retain doctors in rural areas, because their primary care role was "more effective than building a large hospital." The State Council acknowledged that rural doctors were the cornerstone of primary healthcare for hundreds of millions of rural residents.
However, most rural doctors are approaching retirement and younger people do not want to work in remote 'backward' areas in a role that is poorly paid and has few career prospects. Rural doctors by decree are paid the same salary as rural teachers - which is a pittance.Their miniscule pensions are an even greater cause for complaint.

Free screening programs for breast cancer and cervical cancer are to be developed nationally in China, according to the National Health and Family Planning Commission. The ministry said 48 million women in rural China had already received cancer screening interventions since 2009,  and there were now plans to increase promotion of screening services, co-ordinated by the All-China Women's Federation.

Despite studying medicine for seven years, China's junior doctors are unable to manage the basics of dealing with a heart attack, a study shows. A survey of 362 new medical graduates found they had little knowledge about basic cardiac diagnosis and resuscitation. Only about 50% of the doctors were able to identify common normal and abnormal ECG changes such as ventricular fibrillation. Likewise only half knew the basics of which drugs should be given for such conditions. The findings showed that many medical graduates were unprepared to manage the most common cardiac emergencies said researcher Dr Xi Huijun and colleagues from the Changhai Hospital, Shanghai.

China is leading the world in developing a new TB vaccine to replace the largely ineffective BCG vaccine against tuberculosis. At a TB vaccine conference held in Shanghai, researchers heard that a vaccine called Vaccae developed by an Anhui pharmaceutical company is in Phase 3 trials, whereas other candidate vaccines from other countries are only in the preliminary stages. Researchers said the vaccine would probably of most use in the elderly, who are expected to account for more than half of tuberculosis cases in the future.

Monday, 20 April 2015

Are Chinese hospitals safe? Fear of blame and shame is common, but the overall safety climate is good


China may not have as many ambulance-chasing lawyers as the US, but healthcare staff live in fear of making mistakes because of a culture of blame and shame. Not so much "Better Call Saul" as "Better Keep Quiet".

While in the west there is now an attempt to make healthcare staff be more open and transparent in reporting medical mistakes, it seems like China has a long way to go in overcoming cultural barriers to admitting to errors. In a survey of 1272 healthcare staff at Shanghai hospitals, researchers found that there was a high level of fear of being blamed and fear of being subject to shame. Almost three quarters of staff said they would be disciplined if found making a mistake and 42% thought that asking for help was a sign of incompetence. A similar proportion of staff - 42% - thought that telling others about mistakes was embarrassing, and 40% of thought that it was better to not report errors in the hope that nobody would notice the mistake.

Worryingly, work pressure was also a major factor in mistakes - and covering them up - with about 60% of staff saying that with higher workloads, management forced them to work faster and taking shortcuts that might negatively affect patient safety. About 40% of hospital staff said they had witnessed a coworker do something that appeared to be unsafe in patient care in the last year and one in three staff admitted they had done something that was unsafe for patient car.

The fear of blame and shame phenomenon appears to be an Asian and Chinese concept. The 40-70% levels of 'blame and shame' fears seen in the study were much higher than the 5% rates seen in U.S. hospitals. As the authors note:

"Chinese society tends to be more collective than the Western society, which is called “familial collectivism” People admitting mistakes do not only embarrass themselves but also embarrass the team. Thus, [healthcare] workers may be reluctant to admit to making mistakes in China."

Interestingly, doctors had the highest levels of  “fear of shame” and the researchers said this chimed with the finding that Chinese doctors do not believe that “human error is inevitable”,  - in other words, Chinese doctors feel they must act like gods and be seen to be infallible - whereas admitting a mistake would be a sign of incompetence. This is consistent with “fear of shame” being particularly high among physicians. The Confucian ethic was also seen in the high levels of fear about reporting mistakes made by more senior staff that endanger patient safety.

Nevertheless, the overall safety climate in hospitals was no worse than that seen in the US, with 15% of staff giving 'problematic' responses to safety questions. As the authors said, Chinese healthcare workers are only likely to report mistakes and safety issue when they feel psychologically safe and do not have to fear being blamed and shamed.

The findings are published in BioMed Central.

Sunday, 19 April 2015

Alibaba Health, iKang, Online consultations, Tobacco advertising ban, Antibiotics in food, HIV discrimination


Hello and welcome to another week of China Healthcare. As China makes headlines around the world for its slowing economy, few have remarked that China's entrepreneurs are taking a different and more rosy view by re-focusing on healthcare. This week the Alibaba internet billionaire Jack Ma has issued a $2.5 billion vote of confidence in the prospect for online pharmacy in China by transferring his pharmacy e-commerce section to Alibaba Health ("Ali Jiankan" or  According to the WSJ, "Alibaba said the deal would position it to sell prescription pharmaceuticals should China’s reforms allow retailers to move in that direction".

At the same time, Forbes has profiled another internet millionaire who has made his fortune by turning to health. Zhang Ligang made his first fortune by founding the travel booking site e-Long, but he is more famous for building a chain of private clinics under the banner iKang. And if China really does shift to a more private healthcare system, companies like iKang should be at the forefront of the wave.

The NHFPC has banned online medical diagnosis. In a statement this week the health ministry said medical consultations cannot be conducted online as there have been too many cases of unqualified people offering medical advice, purporting to be experts. The ban does not seem to apply to accredited hospitals that have approved programs. What this means for online doctor apps such as Spring Rain ( remains to be seen.

Children in China are exposed to a wide variety of antibiotics in food, which may promote resistance. A study in Shanghai that tested the urine of more than a 1000 children aged between 8 and 11 years of age found that as most had traces of at least one antibiotic and many had several antibiotics in their system.  Altogether 18 different antibiotics were found in the urine of Shanghai children, reflecting the high levels of antibiotics used in food production in China. This was confirmed by another report out this week which noted that the Chinese food and livestock industries use 100,000 tons of antibiotics  a year to promote growth in animals reared for their meat.

A total ban on tobacco advertising n China has been urged by the WHO. The head of the China office of WHO said China had a treaty obligation to phase out tobacco advertising, and should start to do so at retail points of sale. However, the powerful state-owned tobacco industry might baulk at that. The relative power of the health and tobacco industry was shown this week when health minister Li Bin noted that new graduates could earn twice as much in the tobacco industry compared to medical graduates working in hospitals. She made the point that the basic salary for a university graduate working in the tobacco industry was 4571 yuan a month compared to only 2100 yuan a month for a junior doctor. Li Bin said there was a need to learn from Adam Smith and pay the market rate for medical graduates - and this would mean patients being prepared to pay higher medical fees.

And finally the question arises of whether anti-HIV discrimination still exists in the China's hospitals. A patient at the Sichuan University Huaxi Hospital says he was refused surgery when doctors discovered his HIV positive status. The man said he had been scheduled to have surgery for haemangioma but it was cancelled and he was told that he would instead be kept 'under observation' instead. The hospital rejected the discrimination claim, saying that it was standard practice to keep patients under observation before going ahead with surgery for this condition.

Private health insurance in China: expansion blocked by hospitals

One of the key elements of the Chinese government's health reforms is to increase the role of private health. One way in which they are doing this is to encourage Chinese citizens to take out private health insurance to supplement the meagre coverage provided by government. The government is expected to offer policy support - including tax breaks - to encourage commercial health insurance providers such as PICC. However, according to Caixin, the growth of private health insurance is being stymied by the entrenched power of state-owned hospitals. Insurers are unable to offer a viable insurance product when they have no control over hospital costs or procedures - in other words, insurer-dictated managed care is essential for health insurance to make a profit. In addition, insurers need access to data and social security system figures if they are to manage their risks adequately - and they have been denied access to this information by local governments who fear losing control over their social security arrangements. Some Chinese health insurers have tried to partner with foreign insurers to build on their experience and technical know-how, but a joint venture between China Pacific Insurance Group C. (CPIC) and Germany's Allianz SE in Shanghai collapsed after less than a year when the European partners found that the insurer had no sway over hospitals.
We have already heard how doctors are unwilling to work in the private sector  - despite official encouragement - because they fear being 'excommunicated' by their main employers, the all-powerful state hospital system. The entrenched power of the big hospitals also appears to be another major barrier to any evolution towards private provision of healthcare in China.

Tuesday, 14 April 2015

How much does it cost to go to the doctor in China?

by Michael Woodhead
How much does it cost to see a doctor in China? Well the basic consultation fees may be cheap at just 20 yuan or so, but figures released by the health department of Dongguan in Guangdong show that the average cost of a hospital clinic visit is about 155 yuan (US$25).
The average cost of clinic visits per person in a year was 530 yuan ($85). Bear in mind that most people with an illness in China go direct to hospital, where they will register and wait several hours to see a doctor for just a few minutes. No wonder they call it kan bing nan, kan bing gui (看病, 看病Difficult to see a Doctor, Expensive to see a Doctor).
The figures released by the Dongguan health department also show how much you might expect to pay for inpatient treatment. At this medium level city in an affluent part of China a public hospital bed will cost you 910 yuan a day (US147). The report says that the average costs per person per year of hospital treatment overall were 7820 yuan ($1260).
These costs were lower than the average for larger hospitals in cities such as Guangzhou, where a hospital clinic treatment would cost 250 yuan ($40) and an average hospital stay might be as much as 14,000 yuan ($2250).
These are the upfront costs for hospital treatment. Many people will be covered by some kind of basic national health insurance. Typically this might cover 30% of outpatient clinic costs and up to 70% of inpatient costs.
This means that a patient might face a 'gap fee' of 100 yuan per clinic visit and 300 yuan per day in hospital. However, like health insurance schemes everywhere there are major restrictions on eligibility,  procedures covered and 'caps' on reimbursement.
Some people questioned the high costs put out by the health department, saying they were not the fees they expected to pay for visiting a clinic for a cold or fever. However, the department said they were average costs, based on hospital finance department figures, and included costs of medicines and other services. For some patients undergoing procedures such as surgery, they could be much higher, raising the average.  They said they fees were higher at tertiary level hospitals and they had released the figures to show that it would be much cheaper for people to seek treatment for minor illnesses at community level "general practitioner" clinics.
For comparison, a mainland Chinese reporter went to Hong Kong to see how much it cost to see a doctor there. They found that in public hospitals the doctor consultation fees were a nominal 50HKD (40 yuan) and the costs of an inpatient stay was 100 HKD per day (80 yuan), including all food. There were very few queues. Locals said they preferred to go to local GP clinics for minor illnesses, or a private GP clinic, where the cost of a consultation was a modest 100HKD, rather than hospitals, which were for more serious illness.

Sunday, 12 April 2015

Some good news about the chaining of mentally ill patients in China, from the 686 Program

by Michael Woodhead
In recent years there have been several media articles about mentally ill people in China being chained up - usually by families - because there are no mental health services. 

The impression given by the articles is that this is a widespread practice and is going unchallenged. "This is an example of how mental disorders are dealt with in rural China" said The Independent. It is enlightening, therefore, to read that such practices are rare and have been targeted for elimination for more than a decade. In a sobering paper published in PLOS One this week, Dr Lili Guan and colleagues at the Peking University Institute of Mental Health talk abut the so-called 686 program that has been running since 2005 to provide basic mental health services and ensure human rights are upheld for people with severe mental disorders.

In their article they describe how they recruited village health workers across China to seek out and identify mentally ill people who had been chained up by families. Their program found 271 such people - some of whom had been in chains for 28 years, but most had been chained for shorter periods and intermittently as circumstances arose, rather than continuously. Cases of chaining were rare - accounting for only 0.2% of mental health patients reviewed in the program.

Most of the chained people had schizophrenia and none of them were receiving care from mental health institutions, usually because there were no such community services in their area, or the families could not afford it. The patients were restrained mostly because they were violent and abusive, causing harm to people and property.

The program of 'unlocking' was focused on providing free antipsychotic medications. Patients were first admitted to psychiatric units and assessed, and then families were provided with free medications and a treatment plan. The 'unlocked' patients were then returned home to live in the community.
The good news from the program is that regular treatment rates went from 1% to 75% and most patients complied with treatment and showed great improvements. Their functioning improved and the family burden also lightened significantly. Relapse into ''locking' occurred with only 21 patients (8%), with families citing lack of adherence to medication and return to violence or harmful behaviour and lack of caretaker/financial resources to access help.

"The finding that more than 92% of those unlocked and entered into continuous treatment by the 686 Program remained free of restraints by 2012 demonstrates the feasibility of improving the human rights of persons with severe mental illness by increasing access to mental health care in the community, even with limited societal resources," the researchers said.

"Nevertheless, the failure to prevent relocking for 21 individuals suggests that considerable room for improvement of our mental health care practice still exists."

The researchers also noted that their program covered less than 1% of the population of mentally ill people in China, and said it would require more resources to allow it to cover the whole country.

"There is obviously much to be done in China to scale up the 686 Program for the whole nation and to improve quality of care. This will require substantially increased investment in mental health services. However, the success of the program in maintaining the severely ill individuals in treatment over three to seven years, and the benefits of the intervention for those who have lived for years with untreated psychosis and for their families, attests to the feasibility and social value of the “686” model."

Authors note: Restraint for people with mental illness is not uncommon practice in  western countries, particularly for elderly people in nursing homes. Medical groups in countries such as Australia have expressed concern that patients who are agitated and have challenging behaviour are sometimes restrained due to lack of staff and for convenience, rather than for their own wellbeing.

China's Five Year Plan for healthcare: what's what

At the end of March the State Council released a lengthy document outlining the five year plans for various sectors. For health, the only thing that really made the headlines was the announcement that China would double the number of doctors between now and 2020 (actually I don't think they actually said this - they meant they would try increase the number of available doctors per thousand population).

Anyway, here is a more in-depth look at what's in store for health, according to the State Council. The main section on health was relegated to part 41:

The overall aim is to to speed up reform and improvements in the basic healthcare system by:

1. Improve basic medical insurance cover for urban and rural residents by increasing subsidies increased from 320 yuan to 380 yuan per person per year,

2. Introduce direct billing of medical expenses.

3. Further develop primary health care by strengthening general practitioner system,
Extend reform of county-level public hospitals,

4. De-link drug profits from doctors' income and reduce drug prices.

5. Increase fees for medical services paid make up for drug price curbs.

 6. Encourage doctors to work in community clinics instead of hospitals

7. Accelerate the setting up of medical dispute resolution mechanisms prevention.

8. Increase funding for basic public health services

9. Pay rises for rural doctors

10. Strengthen the prevention and control of major diseases.

11. Promote use of Chinese Traditional Medicine.

In addition, the State Council said there would be a need for more hospitals, with a target of  six hospital beds for every 1000 people (up from 4.55 beds per 1000 people in 2013). 

Workforce will be expanded, aiming to increase the number primary care doctors from 1 to 2 per 1000 people and increase the number of nurses.

According to the BMJ, the government also aims to retreat from health service provision (almost 90% of China’s hospitals are public) to “policy-making, overall planning and supervising, to make sure the medical system benefits the public, while the market will decide the distribution of medical resources,” the statement said. The plan states that 1.5 in every two beds per 1000 people should be provided by the private sector by 2020.

The current move to reduce restrictions on restrictions on foreign investor involvement in the healthcare market will continue.

Thursday, 9 April 2015

Military hospitals in China: unaccountable and a law to themselves

by Michael Woodhead
It comes as a surprise to many visitors to China to discover that the swish medical facility in the middle of town is called something like the People's Liberation Army 301 Hospital. 

Military hospitals are a major feature of China's healthcare system - most cities have a major hospital run by the military, whether it be the army, navy or airforce. But don't expect to see them staffed by China's answer to Hawkeye or Major Burns. They are, for all intents and purposes, little different to other hospitals in appearance. No uniforms in evidence, they seem to be just state-owned profit-driven operations, like any other Chinese hospital.

However, according to an article by Zhao Han in Caixin this week, the military hospitals are a law unto themselves. The reporter relates the case of a bogus doctor working in Beijing who stole the identity of a real Shanghai doctor. When the Shanghai doctor discovered this, she demanded that the fake doctor return her identity documents and records. However, when reporters made further inquiries, they hit a brick wall of military secrecy because the fake doctor had been working at a clinic affiliated with the military PLA 466 Hospital.

When the matter was taken up with the authorities, they also got short shrift from the army hospital:

"The health bureau that oversees medical facilities in Haidian District, where Beijing No. 466 Hospital is located, said it does not have the authority to supervise military-affiliated hospitals.
Calls to the health division of the People's Liberation Army's General Logistics Department were not answered," Caixin reports.

This case illustrates a common observation about military hospitals in China - they are effectively beyond the control of the health department. What this means for China's health reforms - and the supposed development of private hospitals in the country - remains to be seen.How will the military react to the unpopular proposals to deregulate hospitals and reduce  profit-linked overservicing practices? Will they also support the move to primary care by allowing doctors to work in the community and accepting new referral networks (and thus losing revenue?) I doubt it.

And as we have recently seen with illegal organ transplantation, the military hospitals network is also protected from action against unethical practices. How the military hospitals are treated will be a true test of whether Xi Jinping is serious about health reforms and rule of law in China.

Wednesday, 8 April 2015

Ten questions that raise doubts about the claims of forced organ harvesting in Human Harvest

I saw bits of the film Human Harvest by Leon Lee last night on SBS Dateline. It seemed like fairly blatant Farlun Gong propaganda, and disappointingly there was little questioning of the claims or those who were making them. I'm no apologist for the Chinese government and you can read my previous reporting on the problems with illegal and unethical organ transplantation in China here. However, I think the FarlunGong claims made in the Human Harvest program are more to do with political propaganda and the agenda of the cult rather than reality of organ transplantation in China.

Haven't had time to do a full article on this, but here are some of my nagging doubts raised by this issue:

1. The claims about an Auschwitz-like camp in which 4000 FarlunGong supporters were murdered for their organs have never been supported by any evidence.

2. Claims that widespread forced organ harvesting had taken place in Liaoning were investigated by on-the-spot visits to the prison and refuted by reputable labour camp survivor and campaigners Harry Wu of the Laogai Foundation

3. Why have the Farlun Gong claims not been supported or taken up by reputable human rights organisations such as Amnesty International or Human Rights in China or reputable medical groups such as The Transplantation Society?

4. Why have claims not been accepted by the United Nations Special Rapporteur on Torture, who sent personal rapporteurs to China to investigate?

5. Why there no independent evidence and no allegations from people or medical staff not connected with Farlun Gong?

6. China has a prison population of 2 million – if it was such a lucrative trade, why would forced organ harvesting only be targeted on a tiny group such as Farlun Gong?

7. Why did Farlun Gong only start making these claims in 2006 despite organ harvesting being apparently widespread since the 1980s

8. Those making claims about forced organ harvesting belong to Neocon think tanks such as “the Foundation for Defense of Democracies” who have previously been accused of peddling "alarmist rhetoric and fear mongering".

9. Why has Farlun Gong put a block on the Wikipedia page relating to their claims on organ harvesting?

10. What has been the role of Farlun Gong cult founder Li Hongzhi in these claims – what is his background in the Party and his agenda in opposing former PRC leader Jiang Zemin?

Monday, 6 April 2015

Well that escalated quickly! Chongqing's 'market price' health reforms abandoned after just six days as dialysis patients take to streets to demonstrate

by Michael Woodhead 

The introduction of 'market prices' for healthcare services - one of the fundamental health reforms being introduced by the Xi Jinping government -  triggered immediate and widespread opposition in Chongqing and was abandoned after just six days.

In what is likely to be a major setback for health minister Li Bin, the centrepiece of her healthcare reforms was publicly shouted down by angry demonstrators who took to the streets of Chongqing last week. The new policy was intended to move hospitals away from the flawed policy of relying too much on drug sales for income. However, by shifting to a 'zero commission' policy for pharmaceuticals the hospitals are then forced to start charging more realistic (ie higher) rates for other medical services.

When introduced in Chongqing on March 25, about a thousand dialysis patients took to the streets, complaining that the cost of their daily treatment had more than doubled from 95 yuan to 200 yuan. This would mean their monthly costs would rise to about 3500yuan, most of which was not covered by their state health insurance.

Dialysis services were just one of 7886 medical items that were 'adjusted' from march 25 by the Chongqing health department. According to official media, the prices of consultations, surgery and other care services rose from 13% to 30%. The health department also said that some fees were reduced by up to 25%.

However, after angry demonstrations, the Chongqing mayor Huang Qifan convened an emergency meeting on April 1 and announced that the hospital fees would return to the 2014 'standard' level until further notice.

The demonstrations have been reported in the media, with patients telling reporters about the actual effect of the price changes on their medical expenses. Haemodialysis patients said their monthly medical bills would increase by thousands of yuan as a result of the price hikes.

Health analysts told Caixin that the market price adjustment policy failed because there was no 'free market' system for health in China. They said the sector-level reform was 'backward' and there was an underlying problem of national health underfunding, with patients being under-insured and cities such as Chongqing lacking the funds to meet the increasing demands of an ageing population's healthcare costs. They said the reforms simply passed on healthcare costs to vulnerable patient groups such as those needing dialysis, who would face impossibly large 'gap fees'.

The reforms have now been put on hold for further public consultation. What this means for the introduction of similar reforms planned for 16 of China's major cities remains to be seen.

Friday, 3 April 2015

Five Easter medical headlines

1. Pornography sent to hospital leaders in extortion attempt
A Fujian man planned to send pornographic pictures to the directors of most major hospitals in China in a  bid to blackmail them. He was caught by polce and confessed to being put up to the mailing by a mystery "Older Brother".

2. Beijing launched anti-corruption drive in top hospitals
The health department in Beijing is launching an inspection tour of the capital's top 12 tertiary hospitals to root out corruption and check whether hospitals are adhering to the Nine Forbidden's directive against accepting commissions and bribes.

3. Lack of nursing homes leads to bed block
The lack of residential aged care facilities in China means that many hospital beds are occupied by ailing elderly people who do not need treatment but who cannot manage in the home environment.

4. Rural children plagued by worms
More than two out of five children living in rural China are infected by soil-borne worms such as hookworm. However, parents rarely seek help due to ignorance or a belief that treatment is not possible.

5. Government aims to double the number of doctors
The State Councils five year plan for healthcare includes a plan to boost doctor numbers by 100%, with the aim of having two doctors per thousand people by 2020. The 'roadmap' also sets a target of moving away from public hospital provision of healthcare, with 90% of beds currently provided by the public system.