Wanted: 400,000 GPs for China
The Chinese have a saying: "Kan bing nan, kan bing gui," which roughly translates as "It's difficult and expensive to see a doctor".
This is evident at 8am in the foyer of a hospital in Kunming, the largest city in Yunnan Province, south-west China. There are lengthy queues to obtain one of the coveted ‘registration tickets' necessary to see a doctor, and arguments are breaking out among those who have been lining up for hours.
This is the frontline of healthcare in China because there is no primary care gatekeeper system to filter and triage.
Since the early hours, scores of people with minor ailments have arrived, hoping to claim a place in one of the outpatient clinics. Many of them are poor families from rural areas, who have come to the city because they have little faith in their primitive township clinics and under-trained barefoot doctors.
To see a doctor at a Chinese hospital, you first have to register and pay a cash deposit. However, the unrest in this morning's hospital queue has been triggered for another reason.
Because of the value of the registration tickets, scalpers exploit the economic possibilities and are brazenly working the queue, reselling tickets for many times their face value. And faced with long and often unsuccessful waits to get a clinic appointment, there is no shortage of willing buyers.
This is the reality for China's creaking healthcare system, which, through a mixture of underfunding and half-baked reforms, embodies the worst of both communist and capitalist healthcare models — long waits combined with high cost.
Hospitals are state-owned enterprises that receive meagre funding from government following the market reforms of the 1990s. The basic cost of a medical consultation is pegged by law at round 20 yuan ($4).
To cover their operating costs, hospitals resort to a wide range of surcharges that inflate medical bills. They have also come to rely on the commissions they charge on medicines, tests and procedures.
While most Chinese citizens are, in theory, covered by a national health insurance system, in practice, the caps, exclusions and lack of portability of these policies means that most people still face high out-of-pocket fees. Healthcare in China is strictly user-pays: no cash, no care.
People rush into Peking Union Hospital in Beijing, China, in the early morning, April 2016. Photo: Reuters
‘Infusion room' syndrome
All this can create perverse incentives. For instance, the reliance of hospitals' budgets on drug mark-ups means that there is widespread overprescribing and overtreatment.
This is evident in the ‘infusion parlour' of the general medical outpatients clinic of the Kunming hospital.
The large room is filled with rows of seats, along which sit patients hooked up to IV drips delivering antibiotics or ‘tonics'. This is the routine first-line treatment for any patient with a fever, cough, cold or gastro complaint in China.
The hospital charges about 100 yuan ($20) per infusion — a healthy profit for them but unhealthy for patients who need only simple analgesics, fluids and rest.
"Hospitals giving infusions for minor illness has become a long-established bad habit, which is one of the important factors for antibiotic drug misuse," according to Professor Wu Yunming of Xuzhou Medical College in Jiangsu Province.
"Hospitals are businesses, and infusions represent a significant source of revenue for them."
To be fair to China's doctors, it is not individual greed or ignorance on their part that drives this poor practice.
Chinese doctors know antibiotic infusions are not best practice for minor illnesses, but infusions have become embedded in routine care because doctors depend on commissions for about a quarter of their monthly income.
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The basic salary of a hospital resident is about 4000 yuan ($800) a month, equivalent to that of an entry-level public servant or teacher.
However, their contract includes performance bonuses of a further 1500 yuan ($300) — the so-called ‘grey income' — which doctors receive if they meet prescribing quotas in line with the hospital's revenue targets.
Senior doctors, especially those working in procedural specialities such as orthopaedics, can make considerably larger sums of money from commissions.
The government is trying to tackle this well-recognised cause of overservicing by banning drug commissions and allowing hospitals to charge higher consultation fees.
However, the early signs from pilot programs carried out in regional and rural healthcare facilities suggest that hospitals simply shift from drug mark-ups to additional fees for services.
Patients at Kunming Hospital scramble to fill prescriptions. Photo: Michael Woodhead
Violence against doctors
Unsurprisingly, this mix of overservicing and overcharging is a source of widespread public distrust of doctors and hospitals. The feelings of being short-changed extend to the short consultation times.
The 80/20 rule, which prohibits GPs from billing 80 or more services on 20 or more days a year, is used by Medicare in Australia as a benchmark of poor care. But not so in China, where doctors working in clinics routinely see 80-100 patients during a four-hour shift.
"I'm so busy I don't even have time for toilet breaks, let alone lunch. I eat at my desk," one doctor told me during my visit to the hospital in Kunming last year.
A patient can expect to be with the doctor for about three minutes — six minutes if they are lucky. The perfunctory nature of such medical consultations means some patients resort to verbal and physical aggression to vent their frustration over perceived mistakes or miscommunication. Violent attacks against medical staff are commonplace.
In a survey by the Chinese Medical Doctor Association, more than 60% of doctors said they had been subjected to physical abuse and 13% had been physically assaulted in 2015. That year, there were 115,000 reported disputes in hospitals with 4600 serious "security incidents" leading to 1425 arrests.
There have also been several widely reported fatal attacks against doctors by disgruntled patients or their family members.
The most recent, in early May 2016, saw an emergency surgeon bludgeoned to death at a Hunan hospital by relatives of a traffic accident victim. After they were arrested, the assailants claimed the doctor had "not been vigorous enough" in treating their relative and had told them to wait their turn, according to Xinhua News Agency.
Such attacks have led to walkouts and public demonstrations by medical staff calling for authorities to crack down on violence.
On each occasion, the government has vowed to "strike hard" against offenders, but aside from ordering hospitals to hire more security guards, little has been done in reality.
Some doctors have taken to wearing personal protective gear such as stab-proof vests to work.
Primary care the solution?
China's health ministry is well aware of these problems and has two strategies to relieve the burden on hospitals: privatisation and primary care.
One of the key healthcare reforms underway in China at present is a move to bring "social capital" (namely, private investors) into the hospital sector. To encourage this, the Chinese government has relaxed laws to allow private operators to set up hospitals, with pharmaceutical companies taking a lead in the sector.
Just as importantly, China's health ministry has also eased employment regulations for doctors so that they are no longer tied to state-owned hospitals and have the freedom to work where they please.
In the past year, there has been a rapid increase in the number of ‘independent doctor groups' being set up to run private clinic services — the Chinese equivalent of US groupings such as the Mayo Clinic.
China's second major healthcare reform is a plan to boost the primary care system. This is a much tougher challenge. The current ‘community clinic' sector is very much an underdeveloped and underresourced poor cousin to the culturally prestigious hospital system.
Some of the reasons may sound familiar. Few of China's doctors are willing to work in community clinics because the pay is poor, the clinics have little equipment and, unlike the hospital system, there is little prospect for promotion or career advancement.
Patients at Kunming hospital. Photo: Michael Woodhead
China's health ministry has set itself a goal of having one family practitioner for every 2000 citizens by 2020 (the GP-patient ratio in Australia is around one FTE GP for every 1080 people).
But to meet this target, China would have to train an additional 400,000 medical practitioners. The scale of this task can be grasped by the fact that there are only 170,000 doctors in training, of whom 13,000 are in the generalist community practitioner training stream.
Primary care pilot projects have been trialled in China's major cities such as Shanghai and Shenzhen, but with mixed results.
They are declared a success by their proponents, on the basis of achieving 90% enrolments in their areas. However, there is still a marked reluctance among the Chinese public to actually use community clinics as the first port of call. Most still make a beeline for the major hospitals, which are still seen as the ‘centres of excellence' for medical care.
China's health ministry — like so many Australian governments — is nevertheless proclaiming that primary care is the way of the future for healthcare. They have also been mixing carrot-and-stick approaches to encourage the public to use primary care clinics, such as offering free consultations, but also making it mandatory to get a GP referral for a hospital appointment.
The ministry has also ordered that GP training pathways be set up and requires medical schools to introduce ‘primary care pathway' training quotas.
Meanwhile, the effects of a medical system that has embraced the alleged wonders of hospital-based care, can be seen.
Back in the Kunming hospital, by mid-afternoon the corridors are crammed with patients, hanging about at the doors of the clinics in the hope that a doctor will "squeeze them in" at the end of their official list.
But as one doctor told me, "It's too much. I'm supposed to finish at 5pm but most days I'm here for an extra hour or more. I am always late for dinner. I studied medicine for eight years and yet I work longer hours and earn less than a hairdresser."
He adds: "My parents are doctors but I wouldn't want my child to be a doctor."
Michael Woodhead is Australian Doctor's clinical editor.