Inequity in access to healthcare: China has the worst record of any major country

by Michael Woodhead
Despite claiming to have health insurance coverage of more than 90%, China has some of the highest levels of inequity in access to healthcare in the world, a new study shows. 

A review of socioeconomic inequities in healthcare utilisation carried by by Dr Zhang Xin and colleagues at Harbin Medical University found that China fared very poorly compared to its neighbours such as Japan, South Korea and Thailand.

The study based on data from 2008, found huge differences in access to outpatient care based on income and even greater inequities for in-patient care. Chinese on low incomes were much less likely to be able to get hospital treatment compared to their compatriots on higher incomes, according to the findings published in the Asia-Pacific Journal of Public Health.

The researchers said their findings confirmed previous work that had shown that one in four poorer Chinese had been unable to get hospital treatment when they needed it because they could not afford it. Low income Chinese people with chronic and serious diseases were particularly badly affected by income disparities and lack of access to healthcare, they said.

They said that the New Rural Cooperative Medical Scheme introduced in 2003 had made a slight improvement to access to healthcare, but poor patients still missed out on needed treatment because of  high gap fees, limits to insurance cover eligibility and high insurance fees.

Dr Zhang said most OECD countries had a relatively little inequity for healthcare access, especially those that had good primary care systems and free-at-the-point-of-care treatment.

"Despite growth in health insurance coverage, the challenge of perusing equitable pathways toward universal health coverage is still truly daunting task in China," they concluded.

"Being poor and lacking the ability to pay additional out-of-pocket charges remains a significant barrier to access [to healthcare]."

Why Chinese patients are turning against their doctors: contrasting articles by the New Yorker and BMJ

by Michael Woodhead
Two very interesting and very different articles this week on violence against doctors in China: one in the New Yorker and another in the form of a study in the BMJ Open. 

The New Yorker story is in the usual stylish narrative, but I prefer the BMJ Open article, because it has more facts and more insights, even if it is a dry scientific paper. In the New Yorker, writer Chris Beam uses the example of the murder of a doctor in Harbin to shine some light on the whole fraught situation of violence against doctors in China. The story focuses on the case of a young man from a small town who had debilitating and degenerative back pain (ankylosing spondylitis) and who was unable to get satisfactory treatment from a Harbin hospital. He also had TB, which made treatment with an immunosuppressive drug even more difficult. Frustrated at his patchy and expensive treatment, the young man returned to the hospital and attacked the first doctor he could find, and killed an 'innocent' medical practitioner who had nothing to do with his care.

Chris Beam tells the story well and uses it to give some background on the health system in China and why so many patients and their families turn violent when they are treated so badly. However, I found the article was a bit too focused on the legal side of things (the American obsession with law once again?) The article doesn't really explore the root causes of violence: the built-in pressure in the system to overprescribe and over service, the rising cost of treatment and the hugely overloaded hospital system. Beam does cover China's health reforms, but strangely fails to mention the recent moves to encourage private clinics and the use of primary care clinics.

Another factor not really touched on by the New Yorker article is the patient/family faults: for me some of the key factors in China's medical disputes are rising expectations combined with ignorance (poor health literacy) and readiness to use brute force. This is not just confined to health: see how Chinese travellers behave when flights are cancelled or hotel rooms are overbooked.

That's why I prefer the BMJ Open article by Dr Jiang Yishi and colleagues at the School of Public Health, Fudan University, Shanghai. Their article takes a look at the reality of the complaints systems that exist in Chinese hospitals - and finds them sadly wanting. Dr Jiang and colleagues undertook the first in-depth study of how the complaints system works for patients and for doctors and hospital staff. They conducted interviews with all 'stakeholders' and found that in many cases, the system is broken. In theory, a patient with a grievance has several channels through which they can seek redress. They can make a formal complaint to the hospital complaints office and can also petition via a system of 'letters and visits'. Patients can also go to mediation by a third party office to settle an unresolved dispute with a hospitals. And patients can also take legal action against a hospital via  a lawsuit.

In practice, these systems often do not work. Firstly, many patients are simply unaware of the complaints system and how to use it. Hospitals don't advertise their complaints offices, which are often hidden away in an obscure corner of the building. The staff in these offices are supposed to be able to investigate complaints and arrange mediation - but in practice they are often unqualified to adjudicate on complicated clinical matters, and they are also under great pressure to deflect complaints - or dismiss them quickly. Complaints departments are understaffed and have little sway in the hospital system. Another problem with the 'complaints office' system is that it lacks transparency. Patients make complaints but they get little feedback from complaints office staff who do everything 'behind closed doors'.

On the other hand, hospitals and medical staff also express great frustration about the complaints system. Doctors say any complaints arise because they work under great pressure to see 60 or more patients in a morning and don't have time to put on a 'warm face' or to explain things in detail to patients. This lack of connection and communication leads to many misunderstandings and unhappy patients.  Doctors also say that they become the scapegoat for failings of the system: for example, (just as in the US) they are restricted in what treatments they can offer to patients by the medical insurance rules - but patients don't understand this and often get angry at being denied treatments are given treatments that come with a hefty out of pocket costs.

Another big frustration for doctors and hospitals is the rise in unreasonable complaints and the use of abuse and pressure (extortion) to get a complaint resolved with financial compensation. More than 50 doctors interviewed mentioned this 'chao' (吵, argue) phenomenon. Doctors said many patients and relatives had unrealistic expectations about what could be done by medical staff. And when things didn't have a good outcome, patients and relatives often turned to threats and 'mob tactics' to put pressure on doctors and hospitals. These unruly groups are not interested in facts or a fair settlement but want to cause as much trouble as is needed to get a financial payout.

The BMJ Open article says the whole health complaints system in China is lacking in structure and rigour: there are no standard protocols for investigating complaints, for assessing harm and no data is collected on complaint numbers or how they are followed up - and no system for using complaints to identify weaknesses or errors and give feedback accordingly. Hospitals have no incentive to collect or document complaints because it just gives them more 'black marks'. 

The overall impression of the health complaints system is that it is perfunctory and ineffective: hospital directors want complaints to be managed quickly and made to 'go away', hence the readiness to make a quick financial settlement and avoid trouble and bad publicity, especially when angry mobs are involved.

The article by Jiang concludes by identifying three crucial areas where improvement is needed in the complaints system: organisational support, personal support from hospital managers and political leaders (and patients) - and learning system to ensure that failures are identified and rectified. The solutions put forward are sensible and obvious - and the full paper is well worth a read. 

However, I  would not be optimistic about the prospects for change: many of the problems that plague the health complaints system are common to those of Chinese society in general: there is a lack of trust in institutions (in this case hospitals and health departments) which are not accountable, lack transparency and which combine vested financial interest with political power. The solutions require open-ness, accountability and an independent watchdog with teeth. In the current environment in China, those are not likely to happen. Instead, China has top-down directives to crack down on the symptoms of these failings - the government issues stern warnings and makes some highly public arrests of wrongdoers. Ultimately it will take workable systems to fix the problems of health grievances, not campaigns and punishments.

The New Rural Cooperative Medical Scheme has failed: families are still impoverished due to ill health

by Michael Woodhead
Despite covering 90% of rural residents, the New Rural Cooperative Medical Scheme is failing to prevent rural families from becoming impoverished due to expensive medical bills.
A new study shows that 14% of rural families have experienced financial ruin due to catastrophic health expenditure, and one in three people have been unable to afford to go see a doctor when sick.
A review of the NRCMS, which was introduced in 2002, found that it only covered a small proportion of a family's medical bills because the insurance fund did not have enough money. Families typically pay 200 yuan a year to become eligible for the NRCMS, but when sick they face thousands of yuan in bills for treatments that are not covered by the scheme, and face high out of pocket expenses.
Dr Li Ye and colleagues from the Department of Social Medicine, Harbin Medical University found that households in rural areas faced a high risk of medical impoverishment, even if they were relatively affluent. The NRCMS only covered 30-40% of medical expenses, and therefore families faced high levels of out-of-pocket costs when a family member became ill. The study found that 28-30% of families did not seek hospital treatment but self treated when they were sick, because of the cost.
The researchers said the NRCMS had failed in its primary function of preventing catastrophic medical expenses because of the limited scope and low level of its reimbursements
They said that unlike urban health insurance schemes, the  pool of insurance funds in the rural scheme was managed  at a local country level and was insufficient to cover even the most basic medical expenses of someone with a serious or chronic illness. Another problem with the scheme was the lack of cost control mechanisms in the fee-for-service medical system, which meant that hospitals and clinics could take advantage of the system and encourage overprescribing and overtreatment to gain money from the insurance scheme.
"In order to offer a better benefit package for NRCMS contributory members, the financing level of the NRCMS needs to be increased. The NRCMS benefit package should align policies across the whole spectrum of health care services, including primary care, hospital care and long-term aged care. The integrated policies are also important for preventing cost shifting games.
Meanwhile, stronger attentions on provider-side measures need to be paid to control cost of health care," they concluded.
The findings are published in the journal PLOS One.

Harbin hospital charges dead patient for drugs and tests

by Michael Woodhead
The relatives of a 41-year old woman who died of pneumonia at  Harbin University No 2 Hospital are seeking an explanation for why they have been billed for two days of drug treatment and tests after her death. 
The woman spent 13 days in the intensive care unit after she developed pneumonia and kidney failure in February.  She died on 24 February and the family received an initial bill of 197,000 yuan (US$32,000) for her treatment. However when they came to transfer her body to a funeral centre they received an additional bill of 22,000 yuan ($3500) for drug treatment. The family had no option to refuse as they had already paid a deposit of 250,000 yuan as guarantee, and the hospital refused to refund the difference. They listed the additional costs as being for injections, respiratory tests and blood and heart monitoring.
The family disputed the bill, with the older brother pointing out that his sister would not have needed any tests in the 48 hours after her death. However,  the hospital refused to deal with them, so they took their complaint to the local bulletin board of Tianya. Many other local people sympathised with them and told of similar complaints of overcharging by hospitals.
A reporter from the Legal Daily took up the case and brought in accountants to analyse the bills.  They found that the bills for the extra two days were similar in size to those of previous days but they were vague and did not accurately show what treatments and tests were given or at what time.  When approached by the Legal News, the hospital's accounts department said it would review the figures. It later came back and said that after reviewing the billing it found some uncertainties and it was willing refund the family 18,000 yuan.
Other online commenters pointed the the famous case at the Harbin hospital in 2005 when a patient hospitalised for 67 days received a bill for 5 million yuan.
A spokesman for the hospital refused to comment, and the hospital manager was repeatedly said to be in a meeting when reporters sought comment from him on the case.

Tuberculosis in China often resistant to most drugs: researchers sound the alarm

by Michael Woodhead
The emergence of strains of tuberculosis that show multiple resistance to almost all available anti-TB drugs is causing great concern among Chinese clinicians.
A  study of more than 200 patients with tuberculosis in Harbin has found that one in four patients had tuberculosis that was resistant to at least one drug, and more than one in twenty had extensively drug resistant tuberculosis (XDR-TB) that was untreatable by commonly used anti-TB drugs such as isoniazid, rifampin, ethambutol, streptomycin, ofloxacin, and kanamycin.
Dr Yang Ying and colleagues from Harbin University of Science and Technology found that 26.3% of tuberculosis patients had isolates that showed resistance to at least one drug, while multidrug-resistant TB (MDR-TB) was seen in 6.8%of patients (3% of newly diagnosed patients and 22% of previously treated cases).
"The results of this analysis of drug resistance in Mycobacterium tuberculosis reflect the situation in a local hospital and indicate that the morbidity related to TB, especially MDR-TB, is still a serious health problem. Thus, the timely detection of drug resistance is of great importance to optimize treatment and to direct infection control measures to block the transmission of MDR-TB."
The results are published in the International Journal of Infectious Diseases.

Life sentence for Harbin teen who killed doctor

A Harbin court on Thursday upheld the life sentence handed to a teenager convicted of killing one medical worker and injuring three others in a high-profile hospital attack last March.
Li Mengnan, 18, appealed after being found guilty of intentional homicide and sentenced to life in prison by the Intermediate People's Court of Harbin, capital city of northeastern China's Heilongjiang Province, on Oct. 19.
His appeal was heard by Heilongjiang Provincial Higher People's Court, which upheld the original ruling.
A life sentence was the highest penalty that could be meted out to Li, who was under 18 years of age when committing the crime, according to Li's lawyers.
The original verdict also ordered Li to pay more than 680,000 yuan (108,108 U.S. dollars) to the victims' families in compensation.
Li's case was among a string of hospital attacks seen in recent years in China, amid strained patient-doctor relations in the country. Chinese patients often accuse doctors of rushing consultations and prescribing excessive medicines, while doctors have complained about overwork, low pay and being frequently misunderstood.
On March 23, 2012, Li stormed into the First Affiliated Hospital of Harbin Medical University and randomly attacked four medical workers with a knife after believing the doctors at the hospital had refused to treat his spinal disease, the initial ruling said.
Wang Hao, a 28-year-old intern of the hospital, was stabbed to death, while three others suffered injuries.
Source: Sina