Inequality in China healthcare - fixing it isn't easy

by MICHAEL WOODHEAD
The Chinese government acknowledges that serious inequalities exist in the country's healthcare provision - rural areas are seriously under-serviced compared to the cities. 

More than a decade ago the government announced a grand plan to try address some of these inequalities - by sharing the expertise of big city hospitals with rural areas. The plan was for medical personnel from tertiary hospitals in prosperous eastern China to spend time in placements and long-term exchanges in disadvantaged rural hospitals and clinics in poorer parts of western China.

However, the so-called "Myriad Doctors Supporting Rural Health Care Project" has not been a complete success (to put it mildly), according to a letter in the Lancet this month from Dr Wang Tao of the Shanghai Jiaotong University Sixth Affiliated Hospital.

After touring western districts to see the progress of the project in its 10th year, Dr Wang found that it had helped bring medical personnel and technology to some poorer areas. However, the project was also under-resourced for such a major undertaking. Lack of funding meant that hospitals struggled to pay their seconded medical workers an adequate wage. The transfer of five senior doctors from each supporting [eastern China] hospital to a disadvantaged hospital on six-month shifts also proved impractical.

"These long-term arrangements create a huge burden for hospitals in eastern provinces and can cause personal difficulties for medical staff," he writes.

Another problem was that medical resources were allocated by government bureaucrats rather than determined by need.

"Coordinating this huge project that involves thousands of hospitals and medical workers according to strict policy guidelines is extremely tough, and inefficiencies and repetitive allocation of resources inevitably arise," says Dr Wang.

The project has not done much to address inequalities in healthcare, he reports. Latest figures show that eastern China areas have average annual healthcare funding levels of 1067 yuan per person, whereas in western China hospitals have only half that level of resources (about 500 yuan per person). Inequalities also exist in the numbers of hospitals, doctors, nurses and beds between eastern and western China.

"Healthcare inequalities remain a serious problem and necessitate support projects for the foreseeable future," Dr Wang suggests.

He asks whether market forces could succeed by encouraging hospitals in eastern provinces to open public or private amenities in the western provinces.

"New sources of income might provide sufficient motivation to create efficient, high-quality services. The fear is that new sources of income might cause new problems, counteracting the government's attempts to reduce inequality. Nevertheless, the consistent provision of an excellent level of health care in China, particularly in less developed areas, still has a long way to go."

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]."

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.