Sunday snippets: health reformer sidelined, Hong Kong-style hospital fails, HIV activist banned

Three stories stand out this week: firstly, the  'open' reporting of Caixin is a refreshing change from the routinely stultified, narcissistic column fodder of the official English language publications such as China Daily. This week they have an interesting profile of Guangdong doctor-turned-health bureaucrat Dr Liao Xinbo. He is portrayed in Caixin as an outspoken critic of the system, who has put a few noses out of joint. One incident in particular seems to have seen him sidelined for not toe-ing the Party line - when he made promises to some pregnant women who were protesting about the one child policy. However, on closer reading Dr Liao doesn't seem to be that much of  maverick. His outspoken-ness relates to his advocacy of two policies that are already at the forefront of NHFPC reforms, namely allowing doctors more flexibility to work in the private sector and promoting 'social capital' (ie private investment) in medical facilities. Perhaps Dr Liao's real crime is to have highlighted the fact that the NHFPC is a relatively weak government ministry, and the real decisions are being made by ministers for finance and social security and the he National Development and Reform Commission. To the embarrassment of the NHFPC he also points out that local governments are a major barrier to real reforms - because they have a huge financial vested interest in running local hospitals (and the profits from drug sales).
On a related note it is interesting to see a model health reform project faltering. Shenzhen has set up a joint venture hospital with Hong Kong, in an attempt to bring in Hong Kong-style health systems - most importantly a 'gatekeeper' system in which patients are triaged by a generalist practitioner before going to see a specialist. Unfortunately for the project, mainland Chinese residents do not seem to be taking to this new model of care. Despite huge overcrowding in Shenzhen hospitals, they are staying away in droves from the Hong Kong-China hospital. And it's not because of the cost - fees are subsidised by the Shenzhen government to an embarrassingly generous  extent. According to one report, the HK joint venture hospital is costing a billion yuan a year - almost all of the Shenzhen city budget for supporting city hospitals. And yet it is operating at only a quarter of its capacity. The hospital management are pinning their hopes on the opening of a VIP section of the hospital to bring in some much-needed revenue - and yet VIP medical wards are exactly the opposite of what China's health reforms are supposed to achieve, and other hospitals have been ordered to phase them out. It looks like China health reforms have a rocky road ahead of them.

And finally, just when you think China is opening up and showing a more enlightened approach to health, the government shows that its repressive, authoritarian ways extend to advocates for appropriate HIV treatment.  Ms Ye Haiyan, a Hubei-based advocate for sex worker health, was banned from attending the International AIDS Conference in Melbourne. Her crime, it seems, has been to criticise Xi Jinping's crackdown on the sex trade, pushing brothels and sex workers further underground.Ye says this will inevitably make it harder to detect and treat HIV. Another more high profile HIV activist, Hu Jia, was assaulted by plainclothes police in Beijing. We can only hope that these regressive actions by the Xi Jinping administration  are raised at the International AIDS Conference.

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.]

Survey reveals the bad antibiotic habits of Mainland Chinese

by Michael Woodhead
Chinese people have developed bad habits of antibiotic misuse such as self medicating with OTC products, not finishing the course and hoarding leftover antibiotics for later use, a new study shows.
Doctors at the University of Hong Kong made the worrying findings when they surveyed recent Chinese immigrants on their knowledge and attitudes towards antibiotic use.  They conducted focus group interviews with 56 recent migrants from mainland China and also conducted phone surveys with 134 Chinese and 1600 Hong Kong residents.
The survey showed that both Chinese and Hong Kong-born Chinese had many erroneous beliefs about antibiotics, including the belief that they were effective against viruses and the common cold. One in ten Chinese patients had never heard of antibiotic resistance and most believed that antibiotic would weaken the immune system. A significant minority of Chinese believed antibiotics had significant side effects such as drowsiness or loss of appetite, and said they would stop taking antibiotics when the symptoms had cleared up rather than finishing the full course. About one in seven said they would  keep leftover antibiotics and store them in the fridge to 'recycle' them for later use. A similar proportion said they would seek to self medicate with antibiotics bought over the counter  - sometimes for 'prevention' of infections - even though OTC sale is illegal in Hong Kong.
In the focus groups, many mainland Chinese said they were accustomed to the IV antibiotic infusions that are routinely given to feverish patients in China, and they believed that the oral antibiotics prescribed by doctors in Hong Kong were less effective and led to the infection persisting for longer. However, some respondents said they trusted doctors in Hong Kong more than those in China, and tended to accept their advice on antibiotics and would not ask for antibiotics if they were not recommended.
The researchers from the University of Hong Kong said their survey dispelled the myth that mainland Chinese demanded more antibiotics from doctors. It showed that many recent mainland Chinese migrants had acquired some knowledge of appropriate antibiotic usage during their stay in Hong Kong, but the knowledge was not always translated into practice. They suggested that antibiotic education campaigns were needed for both Hong Kong Chinese and their mainland counterparts.

Shenzhen takes to family doctors

by Michael Woodhead
On International Family Doctor Day a Shenzhen joint venture clinic with Hong Kong University is claiming that general practitioners are proving popular with patients. 
The HK University Shenzhen Hospital clinic offers a GP service in which patients with chronic diseases can book face to face appointment with their family doctor. The clinic has an 80% return rate and the main diseases treated are cardiovascular disease, diabetes, arthritis and mental health problems, according to GP Dr Liu Ruihong. He said other hospital clinics are not open to external referrals, and only accept internal referrals. However, the GP clinic works on international model in that a GP can refer to the hospital clinic and vice versa. He says that according to WHO criteria, patients with chronic diseases are best treated by a generalist doctor with continuity of care and an emphasis on preventive care. With good GP care, patients with chronic diseases can stay healthy and avoid the need for hospital treatment for decades, he says.
After six months of a pilot program, the clinic is proving popular with patients and an increasing numbering are registering with the clinic and returning to see their personal doctor, he added.

Armed with SARS lessons, China fights H7N9 influenza

by Shannon Tiezzi
10 years after SARS, China is fighting another viral outbreak – and seems to be winning.
Hong Kong reported its second case of the avian flu strand known as H7N9 today, showing that the virus which first appeared in mainland China back in February continues to spread. To date, H7N9 has infected 138 in total. Of those, 45 have died.
According to reports, the first reported H7N9 case in Hong Kong was a 36 year old Indonesian domestic helper, while the latest case was an 80 year old man from Shenzhen. The Indonesian had also recently traveled to Shenzhen, leading Dr. Leung Ting-hung, Hong Kong’s controller of the Centre for Health Protection, to believe that both cases were contracted in the mainland city.
H7N9 has not been shown to spread easily from person to person, meaning the risk of a large-scale epidemic is fairly low. Still, Hong Kong is taking no changes. The city has increased its border checks and the government isolated 17 people who had been in close contact with the first H7N9 victim. To date, none of the quarantined group had tested positive for the virus.

Mainland medical graduates should be used to overcome Hong Kong doctor shortages

by Dr Feng Chi-sun

There is a serious shortage of doctors in Hong Kong and it affects mainly public hospitals. Based on the frequently cited figures, more than 90% of inpatient services are performed in public hospitals, where fewer than 50% of our doctors work.

Since it takes years to train a doctor, the obvious quick remedy is to hire overseas doctors. When Hong Kong was a British colony, all Commonwealth doctors are eligible to practice in Hong Kong; non-Commonwealth ones had to take a qualifying exam. After the handover, all foreign medical graduates have to take the exam, which is notorious for its level of difficulty, with a pass rate of 10% or less.

It's no wonder we continue not to have enough doctors in public hospitals, and waiting time for elective surgeries takes months and years.

To solve the shortage problem, Hong Kong's Hospital Authority has come up with a solution that some argue is flawed. It is giving limited license to selective non-local medical graduates so that they can practice in public hospitals without taking the exam. The candidates must speak Cantonese and hold a valid medical degree. Fair enough. But that's where the transparency and accountability of the selection process ends. By picking candidates based on their paper credentials and not by a more objective method, such as test scores, the authority is inclined to admit only medical graduates from world-renowned schools from Western countries, and exclude those from less prestigious ones, especially those from the mainland.

The difference between an ethnic Chinese from a Canadian medical school and one from a Chinese medical school is the family background. But, unlike family wealth and prestige, medical knowledge is acquired and not inherited. Regardless of their undergraduate medical education, all doctors have an equal chance of being nurtured into a highly competent healer. Doctors learn most of their skills at the postgraduate stage.

Perhaps, a better way for the Hospital Authority to deal with the shortage crisis is to recruit Cantonese-speaking non-local medical graduates from around the world, and lower the entry bar for them to start working in Hong Kong by easing the exam to a level at which the pass rate is at least 50%. The way the current exam is structured, it is suitable only for fresh graduates, but is counter-productive to our goal of recruiting competent doctors. Many of the candidates have already had a few years of practice experience in their own fields, and might have forgotten many didactic facts in other areas. Is there really any need for a future ophthalmologist to also have indepth knowledge of gynecology?

And like in the US, they could start work as an intern, and are allowed a full license only after years of training and passing a more advanced exam in their specialty.

The approach used by the Hospital Authority in picking candidates to work for them is problematic because it is whimsical and non-transparent, and easily perceived to be discriminatory or having a hidden agenda. It invites criticism and possibly lawsuits.

Most of all, the pool of potential medical geniuses is much bigger on the mainland than the small group of Cantonese-speaking doctors who graduated from Western countries. Hong Kong will lose out if this valuable human resource is not tapped.

The author was a consultant pathologist for the Hong Kong government and St. Paul's Hospital before his recent retirement. He was a lecturer at the Medical Faculty of the Chinese University of Hong Kong and a diplomate of the American Board of Pathologists.
Source: China Daily

Bisphosphonate treatment worsens bone health in Chinese patients

Bisphosphonates may cause atypical stress fractures due to deterioration of mineral content of the femur

by Michael Woodhead
The anti-osteoporosis bisphosphonate drugs may prevent bone loss but long term use results in weaker bones that are more prone to fracture, Hong Kong researchers have shown.
In a study to assess the link between long-term bisphosphonate treatment for osteoporosis and atypical fractures, researchers from the  Department of Orthopaedics and Traumatology and Bone Quality and Health Centre at the Chinese University of Hong Kong, studied bone health in 28 elderly patients taking bisphosphonates.
They found that when compared to a control group of 37 elderly people, the total hip bone mineral density was no different in the patients who took bisphosphonates for osteoporosis prevention for four years. However, bisphosphonate-treated patients had lower bone mineral content in the femoral shaft, and they also had a weaker bone structure in the subtrochanteric and mid-diaphyseal regions and thus significantly lower bone strength. CT scans confirmed that there was significantly decreased trabecular density, bone volume ratio, trabecular number but increased trabecular spacing in tibia and distal radius. Other tests confirmed significantly lower stiffness and failure load in tibial bone. Biochemical studies also showed lower bone resorption and severely suppressed bone formation activity following bisphosphonate treatment.
The researchers say that the unchanged total hip bone mineral density between the two groups confirmed the beneficial effects of bisphosphonate on trabecular bone, thus preventing osteoporotic fractures in general. However, the inferior structural, densitometric and biomechanical properties at cortical bones, especially femur midshaft, need  special attention to look into the association between long-term bisphosphonate intake and the occurrence of stress fractures, they suggest. They  recommend that when patients taking bisphosphonates complain of proximal thigh pain or discomfort, X-rays should be used for screening. All patients prescribed bisphosphonates should be informed of the possibility of these potential bone weakness complications, they add.
"In conclusion, inferior biomechanical properties due to structural deterioration and poor bone mineral content at cortical bones of osteoporotic patients, together with the uncoupled bone remodelling process with long-term bisphosphonate intake were depicted in this study. These findings may explain high tension stress in the lateral sides of the subtrochanteric and midshaft regions is prone to stress fracture during normal daily activities. Until the risk factors of developing atypical fractures can be identified, patients under bisphosphonate treatment should be monitored closely to detect the potential problems, and early and prompt treatment should be given accordingly. "
And as the half life of the drug in the bone tissue is around ten years, plain film checking for stress fractures in case upper or mid-thigh pain is [advised], even after the drug is stopped, they suggest.
Source: Chinese Medical Journal

Hong Kong health providers allowed to set up mainland institutions

Hong Kong hospitals will be able to set up health institutions on the mainland next year

Hong Kong and Macao health service providers can set up institutions on the Chinese mainland starting from January 1, 2013, the Ministry of Health said on Friday.
They can set up health institutions wholly-owned by themselves, jointly-invested ones and cooperative ones partnering with mainland health establishments or enterprises.
Except for wholly-owned hospitals or senior houses, other forms of entities established by Hong Kong and Macao investors will be subject to administrative approvals of health authorities at provincial level, rather than national level, meaning simpler procedures, the Ministry of Health said.
The plans are based on agreements of the Closer Economic Partnership Arrangements between the mainland and Hong Kong and Macao. Supplemental agreements were signed this year.
The Ministry of Health said the arrangements signal greater liberation of the health sector on the mainland. It will also provide opportunities for Hong Kong, Macao health professionals to practice on the mainland as well as for the health industries of Hong Kong and Macao.
Source: China Daily