Universal health insurance comes one step closer - but who's paying?

by MICHAEL WOODHEAD
The big healthcare news from China this week is that a health insurance safety net for serious illness is being extended nationally. This means that if all goes to plan, poor people who develop catastrophic diseases such as cancer should not be left destitute by medical bills for care. Pilot programs that have been running at provincial level will now be extended to all provinces, according to an announcement by the State Council on July 22.
This will be good news for the many sad and desperate Chinese families who face financial ruin because of medical bills - or who are simply unable to pay and have to watch their loved ones die of treatable diseases. Some of them resort to all kinds of bizarre publicity stunts and begging methods to try raise the money to pay the medical bills. I have recently before about a girl who offered herself as a bride to any man who would pay her brother's medical bills.

According to the China Daily (hardly the most reliable of outlets), the meeting chaired by Premier Li Keqiang, cover for major illnesses will "cover all the subscribers to the urban and rural resident basic medical insurance as of the end of 2015", with full implementation in all 6800 public hospital in China by 2017.

A spokesman for the council said that there were 700 million impoverished people in China, of whom about 10 million are suffering from a chronic disease or major illness.The scheme will cover 50% of expenses initially, but this will be increased over time.

According to state media, the funding for the scheme will come from existing insurance accounts and therefore "will not be a financial burden to the beneficiaries". However, it also slipped in the detail that the safety net scheme will be run by commercial insurance agencies chosen by the government through bidding, with limits of 2-5% on profit margins.

"Introducing the third-party commercial insurance as operators will bring a better inspection performance to control medical fees and prevent waste or ill-designed fees" a government spokesman said.

China's commercial insurance companies are keen to get into the lucrative business of providing private health insurance. However, reading between the lines, it looks like the government has told them that covering the safety net for the impoverished will be a condition of their getting access to this market.

As China Daily, puts it:

Wu Ming, a professor of public health at Peking University, said many insurance companies may compete for the business despite lower profit margins, since it can bring many potential benefits.
"Participation in the program can pave the way for the insurers to enter further into the medical care sector in the future," she said.

However, as the more reliable Caixin magazine reports, commercial insurance companies are worried about the financial implications of taking on serious health insurance policies. The various pilot projects run in places such as Jiangsu and Zhejiang have shown the potential for major cost blowouts for uncapped schemes, and also problems with defining which illnesses are covered and who should pay for what. In some cases local governments, which administer (and fund) health insurance schemes tried to unload all their difficult patients onto the safety net. Or as they told Caixin magazine: "all the risk, none of the power, no voice".

The commercial companies also fear that they will be required to take on patients only after they have gone through the regular health insurance system over which they have not control. They believe that if they have a full package of insurance they would be able to control costs (and potentially prevent patients from developing serious illness) rather than just picking up the pieces.

At the State Council meeting chaired by Premier Li Keqiang, the government said it would be keeping a close watch on the safety net scheme and conducting many checks and inspections to ensure there was no abuse of the scheme.

China's universal health insurance? Well, that depends what province you live in

by MICHAEL WOODHEAD
China's government now claims that something like 90% of the population are covered by health insurance. It's a statistic that's repeated by people who should know better - including the editor of the Lancet.
In reality, the level and breadth of health insurance varies significantly between different provinces. Some have high rates of coverage, some have high rates of investment in their health funds. Some have both, some neither. An interesting analysis in Caixin by Yang Mingyu shows why the patterns of health insurance have emerged.

[Health insurance coverage (left) and investment per person (right) by province]

He divides the provinces into four groups, characterised by their health insurance profile.
Some he describes as ideal, with high rates of cover (80-90%) and investment (100-1800 yuan per person). These tend to be the affluent eastern coast provinces of Guangdong, Zhejiang, Jiangsu. A second group, typified by Beijing, Shanghai, Tianjin, (and weirdly, Tibet) have high rates of investment in their health insurance systems, but coverage isn't so great - sometimes as low as 60%. The third kind of insurance pattern is the 'cover' province: Sichuan, Guangxi, Chongqing, which have high rates of insurance cover but only modest investment in them. And finally we have the poor relations - the low cover and low investment provinces such as Heilongjiang, Jilin, Liaoning.

Yang Mingyu says the  patterns are explained by a combination of economic strength, internal migration and the government's policy to maintain social stability. Investment in healthcare is seen as a major way of preserving social stability. Therefore, the government has invested heavily in health insurance in some of the  provinces where there have been large inflows of migrant labour. Conversely, some of the poorer provinces  have a left behind population of mostly elderly and children with high healthcare requirements but little capacity to contribute to healthcare costs. The government has promoted wider membership of health funds in these areas to reap premiums needed to support the health infrastructure.

However, there have been some 'backward' conservative provinces with few financial resources and also little investment in the health funds.

The article concludes by saying that some provinces need to be encouraged to reform their health insurance systems and provide more cover or investment to suit local needs, even if the local circumstances do not favour it.

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 (看病难, 看病贵 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.

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.

Bound feet, pirate hospitals and frequent flyer patients: just some of the medical news stories out of China this week

Bound feet not all bad for bones

Women who had their feet bound according to feudal Chinese tradition are more prone to osteoprosis but their enhanced balance skills mean they do not have excessive fractures, a study has found. A review of more than 250 elderly women who had bound feet by researchers at Kunming Medical University found that they had higher rates of osteoprosis than women of similar age.
However they did not seem to be in worse health or be more prone to fractures, the study found.
"This might be explained by compensation in physical activity to improve body balance, implying the importance of improving or maintaining body balance in overall prevention strategies against fragility fractures," the researchers said.

Trademarks use to fight pirate hospitals 

The renowned Beijing Tianlun fertility hospital has trademarked its name after finding that other hospitals around China were setting up 'Tianlun' fertility clinics and claiming to be affiliated to the famous clinic.

Frequent flyer patient

A Jiangxi endocrinologist has been called to provide emergency inflight medical help to the same woman twice in a month, according to CAAC News. The doctor treated the women on a flight to Thailand after she fainted. On the return flight he again answered a call for help and found he was helping the same woman with the same problem.

More family doctors for Henan

The Henan government claims to have re-trained almost 10,000 doctors to work as family doctors in community clinics and township-level hospitals. The government said the re-training program meant that Henan could not make family doctors available to 60% of people in rural areas and 100% of people in urban areas.

 Guangdong gets locals to sign up for GP cover

The Guangdong city of Huizhou says it has  got 30% of target patient populations to enrol with a family doctor. The city health authorities want to arrange GP cover for children under five, pregnant women, the elderly and people with chronic diseases. The authorities say they aim to have 50% of people enrolled by the end of the year.

Tianjin hospital gets Dr Weixin

A hospital in Tianjin has set up a smartphone service to allow patients to get advice, information  and book appointments via their phones. However, users said the electronic hospital system was clunky, did not allow access to many departments and they still had to queue to pay for appointments

Serious disease insurance cover to be nationwide.

China's minister for social security has said that his department will fully introduce nationwide social medical insurance for serious diseases within the year. However, critics have saod that hospitals will use the cover to claim rebates for unneccessary treatments while local governments will not have the finances to support the scheme. Meanwhile a group from Renmin University in Beijing have suggested that micro-credit schemes be used to give poor rural people access to funds to pay for their medical bills. The scheme would operate in the same way as micro-credit programs running in developing countries to provides funds for business startups.

Family planning staff become child development aides

The staff of local family planning departments may move into child development work and away from enforcing the single child policy, if a pilot program in Shaanxi is successful. The program sees family planing agency staff assisgned to follow up children up to the age of three to ensure they are meeting basic development goals in care and education, according to Caixin.


And this week's violence against healthcare workers:

Zhejiang: An armed man opened fire in a Zhejiang hospital and had to be disarmed by police after he injured one man and threatened patients and staff in the Haiyang country hospital.

Shanghai: A drunk man took a hostage at knifepoint at the emergency department of Shanghai No. 9 People’s hospital yesterday morning and injured a policeman who intervened.

Hebei: a  gang armed with machetes smashed up the emergency department of Baoding Hospital and severed the hand of a man who was being treated for minor injuries from an earlier attack. The man had been involved in an earlier altercation with the gang and they had come for payback, police said.

Liuzhou: a man got 10 days administrative detention and was fined 200 yuan for attacking a female doctor at a Liuzhou hospital. The man hit the female doctor because he was unhappy with the treatment his father was receiving for a bladder problem.

Beijing: A patient with a grudge over hand surgery assaulted a surgeon at the Jishuitan Hospital. The patient had previously had eight stitches in his  finger and was unhappy because it did not bend the way it did before the injury.

My weekly medical news blog for 7th February

There have been few takers for GP training places in Nanjing. The city's community health centres need to recruit 110 family doctors to fill their positions but have only had 49 applicants. Under new health ministry regulations, all doctors including GPs must have the 5+3 education and training (5 years undergraduate and 3 years postgraduate.) However, despite offering a masters degree and a one month placement with GPs in Taiwan, most medical graduates have given the GP training scheme the cold shoulder. The reason is the low status and poor pay of 'community doctors'. After eight years training, GPs can expect to earn only about 80,000 yuan (US$13,000) a year, which is much lower than hospital-based specialists earn. Also there is no chance of promotion or career progression and GPs are expected to move around many clinics in suburbs and villages. Health educators say the Chinese government needs to put more emphasis and resources into primary care if it is to develop a healthcare gatekeeper system similar to those used successfully in developed countries.

Most of the 'research' published by China's doctors is rubbish and there's a simple reason for this - the publish-for-promotion system. To gain promotion (and often just to stay in the job) all China's doctors have to meet a certain quota of  papers published in medical journals. The problem is that most of China's doctors are way too busy treating patients to be doing research and writing up papers. Many are simply not interested. The result is a thriving industry in academic fakery and plagiarism. It is common knowledge that doctors hire 'publishing agents' and ghostwriters to source the articles that will be published under their name. Ironically, many of the articles are written by medical students, and so there is an inverted system whereby the most knowledgeable and experienced clinicians are publishing articles written by the least knowledgeable. The going rate is about 3000-4000 yuan for a good paper - payment on publication, of course. Experts say the system has become a wasteful farce, and they are calling for reform of the one-size-fits-all quote system, to divide doctors into three categories: 'craftsmen' (no research, just treating patients), physicians (some research) and medical scientists (more  research, fewer patients).

The government says it expects to see a dramatic increase in uptake of private medical insurance before 2020, with new policies encouraging Chinese citizens to take out private cover. Ma Xiaowei, deputy head of the health ministry, the National Health and Family Planning Committee, told a news conference this week that the central and provincial government would "encourage the development of various types of commercial insurance to increase people's ability to deal with risks posed by major diseases." He said private cover was needed to help fund demand for health services, with the number of people over 60 already exceeding 200 million. However Mr Ma didn't explain how people will be enticed to take out private health insurance given that there are currently virtually no private doctors or hospitals and very few services or benefits from having insurance.

Underpaid, overworked and under fire: that's the life of an emergency medicine specialist in Guizhou province, according to a Sina article this week. In China, emergency doctors accompany ambulances and are often first on the scene of trouble, even before police. One doctor said he often had to jump in and stop bleeding in stabbing victims while people were still fighting around him. Another said emergcny doctors were often faced with physical challenges such as getting critically ill patients down stairs of apartment blocks with no lifts. Emergency doctors said they worked 24 hour shifts then had a day off during which they mostly slept, and there was no time for leisure, holidays or study. The stress of daily life as an emergency doctor meant there were high rates of burnout - and doctors were considered grizzled veterans if they lasted three years, they said.

In clinical news, new research shows that older Chinese are consuming more calories - and eating more unhealthy food - than their counterparts of the previous generation. A study from nine provinces found that the average daily energy intake had increased among older Chinese adults from 1379 total kilocalories in 1991 to 1463 kilocalories in 2009. The increases had come from greater consumption of high fat and high carbohydrate foods such as plant oil, wheat buns, and wheat noodles.

Chinese are also consuming more polluted air and it is killing them as much as smoking. A study carried out by the School of Public Health in Peking University found that there were
257,000 premature deaths related to PM2.5 pollution in 31 major Chinese cities. This made air pollution a major killer equivalent to smoking. Conditions such as lung cancer and stroke triggered by air pollution killed about 18,000 people in Beijing alone in 2013, the researchers said.

And finally, a study from Shanghai as shown that the number of cervical cancer diagnoses in the city has increased six fold in the last decade. Data from 13,518 women with gynaecological cancers  from 2003 to 2013 showed that the number of women with diagnosed gynaecological cancers increased by almost sixfold with the increase largely due to the increase of women with newly diagnosed cervical cancer. The study also showed that the age of diagnosis of cervical cancer had increased.

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]."

China's move to promote private hospitals means health system will go from bad to worse: experts

In a scathing critique in the Lancet's special China-themed issue, health economists from Oxford and Harvard say that the Xi Jinping government's recent swing to favouring private sector involvement in the health system will be a retrograde step with 'dismal' consequences for health in China.

Professor Winnie Yip and Professor William Hsiao say the new target of giving private hospitals a 20% market share by 2015 is misguided and will promote wasteful and inequitable care. And most importantly, it will do little to improve China's already rotten public hospital system, which suffers from the worst of both words - state-controlled but with a user-pays private model of financing.

Their conclusion is that if the private hospital system continues: "population health outcomes would suffer; health-care expenditures would escalate, with patients bearing increasing costs; and a two-tiered system would emerge in which access and quality of care are decided by ability to pay."

They say China made a good start to health reform with the landmark 2009 decision to introduce universal and affordable public health insurance cover for both rural and urban residents. However they warn that the limited improvements achieved so far will be negated if the privatisation of an already profit-driven public hospital sector goes ahead.

The article is worth reading for its detailed dissection of the ills of the current hospital system, in which state-owned institutions are driven to maximise revenue by overservicing on unnecessary prescribing, tests and procedures. This sentence sums it up:

"Because physician staff are the residual claimants of profits in public hospitals, they are de facto shareholders of the public hospitals. Hence, public hospitals have neither the motivation nor the incentive to integrate care with primary health-care providers or make treatment decisions based on cost-effectiveness or population health maximisation criteria."

They warn that adding private hospitals into this already toxic situation will create even more problems as state-owned for-profit hospitals enter a "medical arms race" with private hospitals to provide more services at higher cost to patients - especially as private hospitals are already being planned by pharma companies and medical device companies.

"Overall, our assessment suggests that China's prospect of provision of affordable and equitable access to health care with a primary health-care-centred integrated delivery model approach would be relatively dismal. The for-profit motive of large public hospitals would result in escalation of health-care cost, inefficient use of pharmaceutical and high-tech diagnostic tests, and an absence of incentives for public hospitals to integrate care with primary health-care facilities. Entrance of private investment will further exacerbate these trends."

China's rural timebomb: half a billion elderly people with chronic diseases and no care

by Michael Woodhead
A survey of elderly villagers in rural parts of China has revealed some of the monumental healthcare problems the country faces.

Simply put, China is on track to have almost half a billion elderly people by 2050 and most of them will have chronic diseases but no treatment. The research carried out in 4400 households in rural areas of nine provinces found that a staggering 58% of elderly people are illiterate and many of them have been 'left behind' by children who have moved to towns or cities in search of work.

For almost 70% of elderly people their annual income was below 5000 yuan ($810).  And worryingly, they had high rates of chronic diseases: 18% had diagnosed hypertension, 3% had diabetes and 6% had asthma. However, these figures are likely to be underestimates because very few elderly people are getting health checks - only 3% had any kind of health preventive check in the past few weeks. Only 2% of patients had their blood pressure checked.

Not surprising then that substantial proportions of those people with chronic diseases are not receiving any kind of treatment - 25% of people with hypertension and a third of those with diabetes were untreated, the study found.

Published in the journal International Health, the findings show that China has huge numbers of vulnerable people with high health needs who are missing out on basic preventive care and treatment, says the author of the study, Dr Dai Baozhen of the Department of Health Policy and Management at Jiangsu University.

Dr Dai says one of the main reasons for this sorry state of affairs is the lack of funding for preventive health in rural China. Most rural residents are covered by the New Cooperative Medical Insurance Scheme, which provides modest reimbursement for inpatient treatment for acute illness. However, the New Cooperative Medical Insurance Scheme does not cover much outpatient treatment and does not reimburse village clinics for preventive health checks such as measurement of blood pressure or diabetes checks. Even if it did, the scheme also fails to cover the basic 'disease management' approaches needed to curb chronic diseases.

What this means in practice is that many people in rural China have chronic diseases such as hypertension and diabetes that are easily detected and which can be prevented and treated by simple and widely-available therapies. However, most elderly people miss out on the basic preventive and disease management approaches and so their chronic diseases are allowed to progress unchecked until patients develop later stages of disease that are more debilitating and more difficult (and expensive) to treat.

But as Dr Dai points out, there is no point in offering health checks if there is no capacity to provide follow up with early treatment and preventive programs.

"Until now, the New Cooperative Medical Insurance Scheme has not been structured to provide payment for prevention, promotion services and disease management for chronic conditions, and no health intervention (e.g. health education and promotion) is provided for groups at high risk of developing chronic conditions," he writes.

Dr Dai concludes that with adequate funding, the New Cooperative Medical Insurance Scheme could provide early identification and management of chronic conditions and thus help prevent a huge burden of disease in some of China's most vulnerable and deprived people.

Hukou reform: what does it mean for health?

by Michael Woodhead  

The announcement by the Chinese government that it will relax some of the restrictions on the hukou (household registration permit) system will have major implications for the healthcare system.
Access to healthcare in Chinese cities is determined by hukou - if a family or person do not have an urban hukou they are not eligible for social services such as education and health insurance in that city - their hukou only entitles them to health services in the location where their hukou is registered. This means that the millions of migrant workers living in China's cities are denied access to healthcare.
   Actually, it's a bit more complicated than that - rural migrants may be able to attend hospitals, but have to pay full price as their rural-based insurance (if any) will not cover treatment at an urban hospital. With millions of rural migrants locked out of urban schools and hospitals, their demand for education and healthcare has meant that a whole host of 'underground' schools and clinics have sprung up in cities to serve them. As you might expect, the quality of these illegal clinics can be very poor.
   The announcement this week says that the hukou system for some cities will be relaxed to allow rural migrants to switch their hukou to a city. However, the new rules only apply to smaller cities of 1-3 million, not the bigger cities like Beijing, Shanghai and Guangzhou. And as has been pointed out, these changes will not take effect immediately, but will be gradually implemented to create an 'orderly' shift in urbanisation. Furthermore, cities that do not believe they can handle an influx of rural migrants will be entitled to maintain the status quo.
   In theory, the hukou changes will potentially give rural migrants access to urban health services - but this means that urban local governments will face greater demands on their services, and city hospitals will face greater demand. The question is where the extra funding and resources will come from to provide these additional healthcare services. Another cautionary note has come from rural migrants themselves - many have said they will not be willing to relinquish their rural registration because they believe this means they will lose entitlements to land and housing that they may one day want to return to.
   So, to sum up - the hukou changes could potentially fix one of the greatest gaps in Chinese healthcare - the lack of provision of services to the 200 million rural migrant families. The reality, however, is that any change will be a long time coming - and other changes (such as health insurance cover) will be needed too.

The Chinese Dream? A Hangzhou children's hospital tries to help poor families who can't afford to keep their children alive

by Michael Woodhead
An amazing article from a Hangzhou hospital reveals the appalling Dickensian situation that now exists in one of China's wealthiest cities, where sick children of the poorest rural migrant workers literally die in the streets from neglect. 
Dr Zhang Weifang of the Children’s Hospital, Zhejiang University School of Medicine writes about the efforts the hospital puts in to try provide medical treatment for seriously ill children of rural migrant families, most of whom are not covered by urban medical insurance cover. The situation arises because migrant families living in cities are uninsured or only covered by rural medical insurance policies that have meagre payouts and are not 'portable' to the city. The creates a problem when children become seriously ill with conditions such as leukaemia, congenital heart disease and oddly, scalds (the third most common serious problem they treat at the hospital). The hospital tries to treat such children and makes ad-hoc public appeals through the media and relies on donations from 'warm-hearted people'. It also seeks one-off funding from the government and from a handful of medical charities such as "Love Without Borders". The hospital has been modestly successful in soliciting funds in this way - bringing in almost 4 million yuan in donations in 2011. But to put that in perspective, that amount is only about 0.6% of the hospital's budget. And this did not cover the treatment costs of the most seriously ill children - the hospital also waived half a million in unpaid medical bills for the most severe cases. Nevertheless, most poor families are asked to medical fees pay upfront, in advance of treatment, and many simply can't afford this and "abandoned treatment".
As Dr Zhang writes: "At times, the hospital will reduce or remit the treatment cost for these patients. However, the hospital cannot afford to provide all the uncompensated care these children need ... We try to establish a long-term relationship with media and solicit contributions for low-income families. However, the situation is still far from perfect."
This, then, is the stark reality of China's lack of a health and social security safety net for its most vulnerable citizens. It also explains the huge disparities in health outcomes between China's wealthiest and poorest residents - a six-fold difference in child death rates. President Xi Jinping is often quoted in the Chinese media talking about the "Chinese dream". Martin Luther King had a dream of all Americans being equal, in which "the sons of former slaves and the sons of former slave owners will be able to sit down together at the table of brotherhood." Perhaps Xi Jinping could try realise the dream of all sick Chinese children being equal when it comes to getting hospital treatment.

A few fibs about healthcare in China's human rights report

by Michael Woodhead
Don't be too cynical about China's rather self-congratulatory human rights review for 2013. 
 It contains some genuine advances as well as the the usual stuff how much more freedom of speech Chinese citizens enjoy. (The fact that I would not be able to read nor write my blog post or tweet about this report in China because blogspot and Twitter are banned sums it up really). Yes, China has improved human rights if you count lifting citizens out of poverty and providing them with an education and not treating the women like horses. I'll give you that.
But when it comes to the human rights aspects of China's healthcare system, the report is notable for what it leaves out. The report says China has developed a social security system "suitable to China' s current social conditions'. More specifically for health it says that China has established a basic national medical insurance system, that covers than 1.3 billion people, or over 90% of the population. Government subsidies for basic medical insurance for have risen from 40 yuan per person in 2007 to 280 yuan in 2013. It also claims that the reimbursement rate for hospitalisation expenses covered by relevant policies has been raised to around 70%. There are many more figures like this that make it sound as if China now has a functioning health insurance system that covers most of the population. As you will know if you have read many of my previous posts, this simply isn't the case.  The reality is that China's medical insurance scheme coverage of expenses is minimal and fragmented. It's a user pays system and most Chinese people still face high out of pocket expenses for even the most basic hospital treatment. Look at this new report from Guangzhou on the impact of health insurance on the burden of medical fees for Chinese patients. Its conclusion:
"social health insurance participation has a weak negative or even no significant association with the out-of-pocket payments of hospitalized patients. This seems to contradict the principles of social health insurance, which aims to reduce people's out-of-pocket payments and enhance their wellbeing."
Or this study released this week entitled: "The impact of expanded health system reform on governmental contributions and individual co-payments in the new Chinese rural cooperative medical system." It concludes that while co-payments in most rural provinces have been reduced, "a greater financial burden for healthcare persists among persons in the poorest rural regions." The WHO recently reported about the devastating effect that a major illness can have on household impoverishment in China - in other words, low income families are being financially ruined by their medical expenses - they simply can't afford to be sick, and become destitute. And it's not just the low income Chinese who are feeling the healthcare crisis: blogger Zhang Lijia tells of the common experience of middle class urban Chinese:
"The doctor took one cursory look and sent me for an allergy test on an imported machine and then prescribed numerous creams and pills. The total bill was US$800 - more than the average monthly salary in Beijing."
These then are just a few examples of the reality of China's healthcare 'human rights record'. China looks foolish when it publishes reports like this which are so obviously misleading. They have many aspects of their healthcare system of which they can be proud - the good public health services that ensure high vaccination levels and control of infectious diseases such as malaria, for example.
However, if you count universal basic healthcare as a human right China has failed to protect the human rights of its citizens. In this it is in good company - the USA is in much the same boat, as healthcare remains unaffordable for those who cannot get insurance.
Xi Jingping often talks about the 'Chinese Dream' - and that's what this human rights report is when it comes to healthcare - more dream than reality.

Universal health coverage in China - are we there yet?

by Michael Woodhead
An interesting reference article in The Lancet today comparing the progress to universal health coverage in the BRICS countries (Brazil, Russia, India, China, South Africa ...). The section on China I presume is written by Professor Wang Kongde of the School of Public Health at Peking University.
Some of the useful facts in the article, such as China's health expenditure increasing from ¥75 billion in 1990, to ¥1998 billion in 2010. At the same time, average per-head health expenditure increased from ¥65 to ¥1490.

China has four major health insurance schemes:

1. The New Rural Cooperative Medical Scheme (NRCMS) - started in 2003, now covers 812 million farmers (ie 95% of them), financed mainly by the government, with small contributions from farmers

2. The Urban Employee Basic Health Insurance (UEBHI) - covers 30% of population, jointly funded by employers and employees.

3. The Urban Resident Basic Health Insurance (URBHI) - cover urban residents not enrolled in UEBHI.

4. The Medical Financial Assistance system (MFA) - a relief scheme for China's poorest citizens, (70 million people), providing direct aid for the severely disabled and people with serious illness.

According to the Lancet article, the rural and urban health scheme provide 75% reimbursement for inpatient expenses (but I have heard that it actually cover much less than this and patients face high out of pocket expenses even with insurance).
These three systems, NRCMS, URBHI, and MFA, complement each other and greatly expanded the range of health service benefits.
Professor Wang say the Chinese government aims to expand the insurance schemes to reduce health spending to less than 30%. For example, subsidies to rural residents will increase to ¥360 by 2015.
"Meanwhile, efforts will be made to standardise and improve reimbursement plans, enhance inpatient reimbursement, and undertake broad outpatient pooling fund reimbursement continuously to increase the number of people benefiting from the NRCMS," he writes.
However, he acknowledges that China's publicly-subsidised health insurance schemes face many problems in achieving universal coverage.
Like other countries, China faces an ageing population and increasing rates of chronic diseases, not to mention higher expectancy for health services.
He notes that access to health services and resources varies widely between regions. Cost control is also a major problem. Simply increasing government funding may just trigger overservicing with the use of more inappropriate tests and expensive medicines.
Thus measures on cost control are urgently needed, and also a stronger regulatory system and reform of hospital governance. Professor Wang also notes that China is going through a turbulent period of health reform, and that many in the health ministry and government are inexperienced in this area. Therefore, the road to universal health cover for China remains uncertain.

Africans face health discrimination in China | Cochlear implants success | Fake doctor operates on 1500 women | Psychiatrist says 10 words charges 1000 yuan fee

Africans in China face medical discrimination
With the growing economic links between China and Africa there are as many as 100,000 Africans in Guangzhou but they lack access to healthcare, an article in The Lancet this weeks says. Africans in China face racial discrimination, which fuels mental health problems and also is a barrier to them getting access to needed health services and support. Many Chinese people maintain stereotypes toward Africans viewing them as prone to violence and posing risks to public health through spreading diseases, the article says. While China sends medical teams to Africa, it ignores the Africans living within China.
"Providing Africans medical care is consistent with China's health-care reform, but the system has failed to close the treatment gap. Chinese doctors are not trained in culturally adapted care or in the management of specific diseases affecting Africans, and translation services are unavailable," the article concludes.

More Chinese medical tourists
Affluent Chinese are now seeking medical care overseas, according to CCTV. Their report says more Chinese are going to foreign countries for treatment and the trend is blamed on the lack of access to high quality clinics in China.

No takers for dispute insurance
Few people are choosing to take part in a new surgical insurance program that is designed to reduce medical disputes. The new medical insurance scheme pays only in the event of unsatisfactory results caused by medical malpractice not covered by traditional medical indemnity insurance.

Bionic ears work well in China
Cochlear implants have been used successfully in hundreds of Chinese deaf children and have had few complications, according to a new report from Henan. Cochlear implantation is a safe procedure and early postoperative complications are minor, say clinicians from the Department of Otology at the First Affiliated Hospital of Zhengzhou University.

Fake doctor did nearly 1500 operations
A bogus surgeon working at a gynaecology clinic in Henan performed 1485 operations on women and made almost half a million yuan in profit before being caught, Zhengzhou media report. The Pingdangshan court sentenced bogus doctor Ma Juan to nine years in prison and fined him 300,00 yuan for performing minimally invasive surgery on women at the Third Peoples Hospital gynaecology clinic. The manager of the clinic was also jailed for 12 years for employing the fake doctor and encouraging him to exaggerate illness and overtreat women with unnecessary but profitable operations such as cervical cauterisation and nerve blocks.

Psych clinic has few words of comfort
A Chongqing father has complained of extortionate charges and poor doctor-patient communication at a mental health clinic where he took his uncommunicative 'autistic' daughter for treatment. The man told the Chongqing Evening News that he had to pay almost 1000 yuan for antidepressant medicines after a brief consultation with a doctor who did not speak more than ten words to him or his daughter. The father sad the costs for the questionnaire test and brief consultation were excessive. A medical expert said mental health clinics were under a lot of time pressure and were not designed to provide psychotherapy but to treat psychiatric diseases. If patients want to talk more they should visit a psychologist, he suggested.

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.

Tuesday news: The US health model best for China | Food and drug police | SARS victims forgotten | HIV medication non-compliance | Womens' wrinkles vary by region

US healthcare model is the answer to China's problems
The answer to China's health problems is to follow the American model and encourage growth of the private health insurance industry, says an American academic. Harvard's Professor Martin Feldstein, a former economics adviser to Ronald Reagan, says China could boost the growth of private health companies by creating tax breaks for employers and people who pay into them. Expansion of health insurance would also lead to an increase in the provision of hospital services as private insurers will enter the market, Professor Feldstein told Jewish Business News. By encouraging the purchase of health insurance by individuals or employers, the Chinese government could reduce the current trend for household saving to pay for medical bills and free up funds to increase consumer spending, he said.

'Health police' to be set up to catch drug and food crooks
"Watch it, here come the health police ..." - may soon become reality in China.  The Ministry of Public Security is planning to set up a new police division to deal with "food and drug safety crimes" in conjunction with the China Food and Drug Administration (CFDA). At present those who break food and drug regulations are supposed to be dealt with by the CFDA, but  the agency has weak powers and not enough staff to deal with the numerous cases of drug and food violations. The new food and drug police would have more powers, but some people are warning that it will lead to duplication and will not deter back street drug factories or sub-standard food manufacturers.

SARS victims abandoned to ill health
Many of the 5000 people in China who were infected with SARS a decade ago are struggling today under a burden of severe long term complications, clinicians say. SARS victims feel forgotten and abandoned, with may having debilitating lung problems that stop them from working and earning a living, according to an article by Professor Xiang Yutao and colleagues of Capital Medical University in Beijing. Many people who had SARS  developed long term problems and disabilities due to the high dose steroid therapy they were given, according to Professor Xiang. However there is no social or financial support for the many people who need ongoing medical treatment, he says.

HIV patients stop taking their medicines
Antiretroviral medicines are provided free of charge to HIV positive people in China but despite this, many stop taking them, leading to high rates of treatment failure. A new study from Guangzhou of 813 HIV-infected adult 19% had recently missed taking their medication and 7% had had stopped their antiretrovirals for at least a month in the past year). Those most likely to stop tended to be male, living alone, poorly educated and to drink alcohol.

The women with the best skin in China live in ...
If you want beautiful skin, go live near the Yangtze - that's the conclusion of a study of women's skin quality in different areas of China. Dermatologists found that skin quality and appearance depended on the local climate - in the cold, dry smoggy climate of Beijing womens' skin tended to be dry and wrinkled, whereas in the hotter sub-tropical humidity Guangzhou women had finer wrinkles - but more greasy skin due to higher sebum content.  Cities such as Shanghai and Wuhan had a combination of high moisture and moderate temperatures and women's skin had more elasticity.

Will China go bust with new major illness medical insurance scheme?

By Michael Woodhead

In a major feature in today's Beijing News, health economists warn that China faces many problems in widening its medical insurance schemes to cover serious and catastrophic illness. These schemes will cover major illnesses such as cancer where the large medical expenses can often result in families falling into penury. Serious disease medical insurance schemes are currently being pilot tested in 27 provinces and 130 cities, but experts say the existing schemes are very varied in their operation, have mixed results and are often poorly managed, with little commitment from local authorities. The Chinese State Council has recently recommended that implementation be speeded up and has ordered all provinces to have serious illness medical insurance pilot programs up and running by June.
At present, almost 290 million Chinese people are theoretically covered by such catastrophic illness schemes that have funds of more than 600 million yuan. Under existing medical insurance programs the reimbursements for serious illness are meagre and not enough to cover even the most basic costs of treatment. The average reimbursement for urban residents is 258 yuan and for rural residents it is 148 yuan. Health economists say there is a danger that if not managed effectively, a more extensive insurance scheme could simply be like "throwing a cup of water on a blazing woodcart". They point to the widespread 'leakage' in the current medical insurance schemes, in which little of the government funding actually gets to benefit the patient. When the government introduced widespread basic health insurance a few years ago the funding was absorbed by hospitals and practitioners who inflated their fees and carried out unnecessary treatments that would attract reimbursements from the government funds.
Therefore experts say that any new scheme must come with strict supervision and conditions to ensure that providers and insurers do not abuse the scheme. Otherwise there is a danger that any such national scheme would become a bottomless pit into which money was poured but with little benefit.
They say current pilot schemes have proved disappointing, with many of them being incomplete and incompatible with other schemes in neighbouring areas. Many still offer inadequate reimbursement to patients with serious illness and many are underfunded to provide sufficient benefits.
There also needs to be provision for rare and expensive to treat illnesses such as Gaucher's Disease, they warn. Without this, patients and their families will still face ruinous expenses when someone becomes ill.

Doctor attacked for refusing drip | National roaming needed for medical insurance | Community HIV testing | Hand, foot and mouth disease surveyed

Doctor assaulted for refusing to put feverish child on IV drip
China's unscientific obsession with IV infusions for every malady has been brought into focus by an assault on a doctor at a Shenzhen hospital. In a widely reported story, it was said that a family attacked a doctor at a Shenzhen children's hospital when the doctor refused to arrange an IV infusion for a one year old child with a cold. The child had been brought into the hospital by his parents and was given oral medication after it was found to be feverish and diagnosed with a viral respiratory tract infection. However, the family were not satisfied with the oral medication and went back to see the doctor to demand their child be given an 'infusion'. When the doctor refused, the child's father smacked him in the face several times until the doctor was bleeding from the mouth. The attack was only stopped after the intervention of security guards and nurses. The attacker was taken into police custody where he will remain for at least three days while his case is investigated.

Health insurance won't work for floating population
China's goal of providing universal national health insurance is being hampered by the huge 'floating population' of migrant workers, a report has found. While more than 90% of the population are now covered by some kind of medical insurance scheme, the reality is that China's 240 million  'floating population' cannot take advantage of their insurance because it is only valid in their home town or province. This means that many migrant workers and their families from rural and regional areas face large medical bills that they cannot get any compensation for. IN some cases, floating workers will return home to take advantage of medical facilities where they can get some reimbursement, the report said. Integration of China medical insurance schemes is fraught with difficulty because different provinces and cities have different insurance schemes with different premiums and entitlements, the report notes. This means that local hospitals and health insurance schemes are unwilling to deal with 'outside people'. The solution may be some kind of 'national roaming' scheme for health insurance, the report concludes

Community HIV testing a hit
Rapid HIV testing is well accepted and detects many HIV positive people when offered by community clinics in China to high risk patient , a study has shown. In a trial of rapid HIV testing involving 42 sites community health centres in China, 23,609 patients underwent HIV testing. The positive screening prevalence was 0.41%, which is higher than in general hospitals (0.17%). Published in PLOS One, the study findings provide concrete evidence to support the involvement of community health clinics in the expansion of HIV/AIDS testing and case finding, said the researchers from the National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing.

Hand foot and mouth disease surveyed
China's largest ever study of hand, foot, and mouth disease has shown that it is most common in June in north China, whereas southern China has semiannual outbreaks in May and September. The review of seven million cases cases of hand, foot, and mouth disease showed the annual incidence was 1·2 per 1000 person-years, of which 2457 (0·03%) were fatal. The incidence and mortality were highest in children aged 12-23 months, according to the study published in the Lancet Infectious Diseases.

Hypertension more common among Mongolians
A study carried out in northern China has found that hypertension is more common among ethnic Mongolians. Mongolian and Han populations in northeast China. In a study of 4753 Mongolian people and 20,247 Han people, rates of newly diagnosed hypertension over a four year period
were 12.64 per 100 person-years for Mongolians and 9.77 for Han. The rates of awareness of hypertension were low for both Mongolians (36.5%) and Han (42.3%) Likewise, rates of treatment (13.1% vs. 18.2%) and control of hypertension (0.7% vs. 1.3%),were low among both Mongolian and Han population, the study in PLOS One found.

Medical news from China's media

In Shanghai, an ENT specialist has rejected accusations from a former student of of stealing Australian cochlear implant technology, saying the allegations are driven by a grudge held by a colleague after he was refused preferential treatment. Professor Wang Zhengmin, a specialist at Fudan University Eye, Ear, Nose and Throat Hospital has been accused by Dr Wang Yucheng of copying foreign technology to register patents for an artificial cochlea and exaggerating his number of theses.
According to the Shanghai Daily, Professor Wang Zhengmin rejected the accusations, saying they were driven by hatred from a former colleague who was rejected after requests for financial help and preferential treatment were rejected .

Also in the Shanghai Daily,the top complaints from patients relating to hospitals include dirty toilets and the high costs of treatment, according to a survey of local hospitals. Other common complaints included poor food and hygiene problems left many hospitalized patients dissatisfied.
The survey of 6,500 patients by Shanghai Medical Ethos Association, also found that lack of access to a doctor and limited health resources were major reasons for  dissatisfaction. The numbers of doctors shared by 10,000 residents in Shanghai halved in the last 20 years due to an increase in population.

In the China Daily, medical insurance in Beijing has been extended to cover higher costs for severe and chronic diseases for the unemployed.

Meanwhile in Shanghai, an 86-year old man has been diagnosed with avian influenza A(H7N9),  the 145th human case reported from the mainland.

Doctors have worse health than rest of population, CMA survey finds

A survey by the Chinese Medical Association has found that half of doctors have hypertension and a quarter have cardiovascular disease.
The findings of the survey of 4032 doctors also show that the overall rate of health problems among medical practitioners over 40 is twice that of the general population.
The results have been released to publicise a new 'Doctor's Health Fund' that will provide medical insurance coverage specifically for doctors. The CMA says the plan is needed because doctors are more prone to disease through exhaustion and stress as they work long hours in high pressure environment. The plan is aimed to provide care and recupration especially for doctors working at the basic level hospitals and in rural areas, the CMA says.