Bigger than Ben Hur: relaxation of hukou system will provide healthcare for China's 270 million floating population

BY MICHAEL WOODHEAD
If the relaxation of hukou (residence permit) regulations announced by the State Council is actually enacted in practice, this will have a profound effect on healthcare access for a quarter of a billion Chinese.

This week the State Council announced that local governments were being instructed to adopt new regulations that will allow nonresidents to get a household registration. This registration will give the floating rural migrants access to basic public services such as education and healthcare, and family planning services. The changes could potentially affect 270 million internal migrants who have moved from rural areas or regional small towns to the larger and more prosperous cities of China. Until now this floating population has been denied access to healthcare facilities in the cities, leading to the development of many unofficial backstreet clinics. The main problem for migrant workers was that their hukou only entitled them to healthcare in their place of residence registration. This also applied to their children.

However, it pays to read the fine print - this does not mean that city hospitals will be immediately swamped by rural migrants seeking healthcare. The new regulations say that city governments should extend 'basic' services only to nonresidents who qualify for residence via a points test based on factors such as length of residence (as much as seven years) and stable employment. Many rural migrants will only qualify for temporary residence cards in the cities, which may limit their access to healthcare.

According to Xinhua, the State Council made the changes because "if these issues can not be effectively addressed in the long-term, it will trigger a series of social risks and contradictions."

However, some media commentators have been asking whether the legislation is premature because local governments are neither willing nor able to provide additional healthcare services to 'outsiders'

The other questions being asked in the Chinese media are: what are the criteria that will allow a nonresident to acquire city registration? Also, what level of services will the be eligible for? Another important question being posed by analysts is what kind of effect the widening of hukou system will have on current city residents? Will they be crowded out of hospitals and healthcare service by the onrush of outsiders?

One expert from the Renmin University, Beijing, also pointed to a potential problem with the loosening of the hukou system: the degrading of the funding base for rural health services. Professor Yang Junhua said many rural areas had already seen huge migration from the their towns and villages, depleting their tax revenue base, meaning they were unable to support services for the 'left behind' residents who tended to be either older and retired or young children. Allowing rural residents to switch their hukou to cities would further undermine the viability of rural healthcare services, he warned.

Professor Yang also predicted that there would be resistance on the ground from city governments to implementing the new regulations, and thus the central government would have to be strict in monitoring and enforcing the rollout of any hukou reforms.

Nevertheless, if fully implemented the new residency regulations are a 'game changing' step for China and have major implications for healthcare. The 'floating population' have long been neglected in terms of healthcare and many of the rural migrants in cities have poor healthcare as a result: unable to access health services they have missed out on basic services such as vaccination, leading to outbreaks of infections such as measles. The new residency rules could have more of an impact on China's healthcare system than the recent more widely publicised two child policy.

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.

When it comes to health, for China the numbers are staggering

by Michael Woodhead
In western countries hardly a week goes by without some disease condition being put in the spotlight in a press release saying "Condition X affects Y million people a year and costs Z million dollars". 
If industry has a stake in the matter then this is usually followed by a statement saying that the Condition X is underdiagnosed and undertreated and if only we used Drug A or Test B then we would avoid prevent much suffering and save the health budget in the the long run.
This sort of thing is now happening with health conditions in China, except the numbers are bigger by a factor of ten or even a hundred. Take osteoporosis, for example. An analysis published this week shows that there are about 2.3 million osteoporotic fractures a year in China, costing $10 billion in health costs. And if you think that's bad, wait until you see their projection for 2050 - the researchers estimate that with the ageing population there will be 6 million fractures a year costing $25 billion. And as predicted, the report's authors say that "screening and intervention policies must urgently be identified in an attempt to minimize the impact of fractures on the health of the burgeoning population as well as the healthcare budget."

A similar dire warning was made this week for hypertension and diabetes in China. An article in the Journal of the American College of Cardiology said that China was facing a cardiovascular disease epidemic as three out of four Chinese people are in poor cardiovascular shape due unhealthy eating, smoking and obesity. On a similar note, a study from Shenyang showed that 50% of older adults had hypertension and poor cholesterol levels. And a report in The Lancet this week shows that China has 300 million smokers and that tobacco causes 1 million premature deaths a year. The numbers are so big they are incomprehensible. And yet at least the Lancet offers a workable solution: cigarette taxes. It says that if cigarette taxes were raised by 50% this would result in 231 million years of life gained over 50 years and also produce an additional US$703 billion in extra tax revenues from the excise tax. The overall effect would be to relieve financial burden on the poor by avoiding diseases such as lung cancer and the consequent medical bills and time off work. But does Xi Jinping have the gumption to increase cigarette taxes?

For yet another set of mind boggling numbers turn to the example of cervical cancer. With no Pap test screening program, tens of thousands of Chinese women develop this disease and die of it each year, even though it is preventable. Western countries have long had screening programs and are now tackling cervical cancer with the HPV vaccine for young women. Some health economists have crunched the numbers for China and estimated that a national vaccination program of HPV vaccine for 9-15 year old girls, between 2006 and 2012 would have prevented 381,000 cervical cancer cases and 212,000 related deaths. They say that a HPV vaccination program could be implemented in China at a cost of about $50 per girl for the whole set of vaccinations and program costs. In total this would cost China about $160 million, but would ultimately prevent hundreds of thousands of deaths from cervical cancer - and also be cost effective.

A final example: stomach cancer. This causes  hundreds of thousands of deaths in China every year. And yet researchers have found that regular use of low dose aspirin could reduce the risk of stomach cancer (and other common cancers such as colorectal cancer) by as much as 40%. In other words, if Chinese people took a regular dose of aspirin they could avoid many fatal cancers, not to mention the protective cardiovascular benefits against stroke and heart attack. Whether these would be outweihed by increased bleeding risk remains to be seen.

I think what I am trying to say here is that when it comes to ill health in China, the numbers are often too large to be imagined. But that also means that measures that produce only modest reductions in rates of disease can also have major impacts on the absolute numbers of illness.

And while talking of high rates, let's return to my favourite bugbear about healthcare in China - the infusion. I have been guilty in the past of blaming backward thinking among the Chinese masses for insisting on having an infusion for every ailment. I hope I haven't hurt the feelings of the Chinese people and perhaps I owe them an apology. A study from a bog standard Hubei hospital shows that a staggering 96% of antibiotics used in the hospital wee given parenterally (ie by injection or infusion rather than orally). The authors of the report contrast this with the rates of about 30% of IV antibiotic use seen in European hospitals.

However, they blame the profit motive among hospital managers for the widespread use of antibiotic infusions - noting that hospitals depend on drug sales for a major part of their income. Therefore it will be interesting to see what happens when the Chinese government tries to eliminate this source of income for hospital by introducing cost price pharmaceutical billing this year (ie not charging a markup).  How will hospitals  fund their services? The government only covers about 20% of their running costs. There are already predictions that costs will be shifted to medical procedures - and trigger even more overservicing.

At least there is some discussion taking place of these kinds of problems and some in the government are acknowledging that there is still a long way to go in health reform. This week a very frank and bleak account of the ills of rural Chinese health system was published. Doctors and hospital managers said quite bluntly that the rural healthcare system in China is being hollowed out - older doctors are retiring, and nobody is taking their place. Young doctors do not want to work in rural hospitals, partly because the ban on commissions from pharmaceuticals means they can make only a tiny income. And patients do not want to be treated in them. And so the county and township hospitals are becoming ghost hospitals - deserted compared to the overcrowded city hospitals, where rural Chinese flock when they have a serious health problem.

Fact of the week: Chinese primary care (community health centre) doctors earn only 3000-4000 yuan a month. Primary care doctors account for only 4% of doctors in China.

Intern scheme concerns | Telehealth ban sparks backlash | Rural residents too poor to pay for care

Internship scheme will create bottlenecks and headaches
Doctor training moves to a three-year internship system next year but many medics believe the changes will leave hospitals with even worse staffing shortages. The new system which will see newly-graduated doctors rotate through various hospital departments to gain experience is intended to bring China into line with other countries and to create a uniform high standard of medical practitioners. However, critics warn that the additional three years of being a trainee will mean that doctors earn very little and the low income will deter many from entering the medical profession. Another drawback of the new system is that doctors will serve as interns in tertiary 'teaching hospitals' and will then refuse to be 'downgraded' to work in smaller local country and township hospitals.

Ban on telehealth consultations triggers backlash
There has been a major backlash against an announcement that doctors will be banned from conducting online consultations by the National Health and Family Planning Commissioning. The NHFPC said this week that 'remote' consultations are illegal except through accredited medical institutions because all doctor consultations need to be carried out according to the regulations of the NHFPC as currently laid down for hospitals and clinics. The NHFPC said remote consultations should be viewed as no different to any other kind of consultation and therefore all the usual regulations on medical practice apply. However, after a major backlash from health groups and online health providers such as www.haodf.com, the NHFPC said it would look again at the legislation and would 'listen to the opinion of the masses' in interpreting the legislation.

Rural health insurance not working
People who live in remote rural areas of China are so poor they cannot afford to seek medical attention when they are sick,  a study from Hebei has found. More than 50% of people living in the Dabie mountain areas of Hebei said they would not seek medical care if they felt unwell. The main reason (for 38% of people) was financial difficulty. Other reasons included inconvenience and preference to self medicate. Researcher Dr Fang Pengqian and colleagues from the Tongji Medical College, Wuhan said the findings suggested that the universal health coverage from the New Cooperative Medical Scheme (NCMS) was was not working for people in poorer highland areas. They said the locals could not afford to pay the necessary insurance premiums to  cover basic care and the low reimbursement meant they faced high out-of-pocket costs.

Resisting the Japanese invader: the China success story against Japanese encephalitis

by Michael Woodhead
 As China cranks up its media hate campaign against its former enemy Japan, the country can actually celebrate victory in its war against another 'Japanese' invader from the 1940s: Japanese encephalitis. 

This mosquito borne viral disease used to cause about 200,000 cases of severe neurological illness in China every year at its peak in the 1960s and 70s - with about 30% patients dying and many of the survivors  left with lasting neurological disability as a result of the infection.

The name is misleading - the disease did not originate in Japan, but was first identified there in the 19th century. The infection was first recorded in China in the 1940s and became widespread in the 1960s - partly because of the breakdown in public health preventive activities during the chaos of Mao Zedong's Cultural Revolution.

A vaccine against the virus was developed in Japan in 1965, and China started manufacturing its own vaccine a few years later.  Writing in the journal PLOS Neglected Tropical Diseases, Dr Gao Xiaoyan and colleagues at the Chinese Centre for Disease Control and Prevention, Beijing, describe how Japanese encephalitis was brought under control in China.

The initial Chinese vaccine was only available in limited quantities and required many doses. It was expensive and was only available to privileged cadres and Party members, not to the peasants who were most at risk of the disease. With more than half the cases of Japanese encephalitis in the world, China continued to work on improving the vaccine and eventually developed one in 1988 that was more convenient and could be mass produced at relatively low cost, to make it affordable for public health use.

This vaccine was gradually made available at a cost of 1 yuan to rural residents, and was fully subsidised as a free vaccine after the year 2005. Since it was included in the "Expanded Program of Immunisation" this cheap and effective vaccine had reduced the incidence of Japanese encephalitis in China from 21/100,000 people to just a fraction of 1 per 100,000 - a remarkable achievement.

But the vaccine is not the only reason for the drastic reduction in Japanese encephalitis in China. Other public health measures were implemented by local health authorities to reduce mosquito breeding and transmission:  pig farms were moved away from villages,  sewage disposal was improved to reduce mosquito breeding, and mosquito breeding grounds in areas of static water were eliminated.

The threat from Japanese encephalitis has now been markedly reduced in the more prosperous eastern provinces of China but it remains a problem in the poorer parts of southwest China. Nevertheless, Chinese researchers say other developing countries can copy the Chinese model for eliminating Japanese encephalitis: low cost programs using inexpensive vaccine and anti-mosquito measures.

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.

Why China's well-meaning rural health reforms are destroying township hospitals

by Michael Woodhead
In the hierarchy of Chinese healthcare, rural township hospitals occupy the second to bottom rung, below country hospitals, but above village clinics.  They are an essential component of the Chinese health system, especially for rural people on low incomes, but they are collapsing because of ill-planned rural healthcare reforms started in 2008.
The big change that is destroying township hospitals is the attempt by the health ministry to make drugs affordable and stop doctors from profiting from commissions on the sale of medications. To do this, the ministry brought in a new system that restricted township hospitals to using medications on an essential drugs list, all of which are sold at zero commission. This made drugs more affordable to rural people, but it also meant that township hospital doctors lost their main source of income. To compensate, doctors were put on fixed salaries equivalent to those of secondary school teachers. The Chinese government also created an affordable rural health insurance scheme that would provide reimbursement for inpatient care - and less so for outpatient care.
In theory, this sounds like a recipe for affordable and equitable healthcare for rural residents. So what went wrong? The first problem was that the health ministry forgot to consult with rural doctors on the likely impact of the scheme. The unintended consequences of the reforms have meant that they have done the exact opposite of what they were intended to do - they have weakened the township hospital system to the point where it is being abandoned by doctors and patients alike, all of whom are fleeing to the larger and better equipped country hospitals. Why is this?

In a new paper in the journal Social Science and Medicine, China health experts including Dr Theresa Hesketh from the University of London report on a series of interviews with rural health workers and patients, who describe the impact of the health reforms.

1. Essential Drugs List
The main complaint of rural health workers is that the essential drugs list is too narrow, and it prevents them from doing their job properly. Many doctors have found that the drugs they need are simply not available, and as a result patients have to go to a country hospital, where the essential drugs lists (and capped prices) are not enforced. Thus patients end up having to travel long distances for treatment and also have to pay more for their drugs. Another problem with the essential drugs list is that drugs are often not in stock because the low prices mean that drug companies have little incentive to produce them to a good quality standard.

2. Doctor Incomes
A second problem with rural health reforms relates to the switch to fixed salaries of doctors - a return to the 'iron rice bowl' of the Mao years. This means that doctors no longer have an incentive to see more patients or work more flexible hours, such as night shifts or in mornings and evenings when rural residents may be free from farmwork. Doctors now get paid regardless of how hard they work, which is a disincentive. The low level of the fixed salaries is also demoralising because doctors see themselves (rightly or wrongly) as more highly qualified and skilled than secondary school teachers, whose salaries are used as a benchmark.

3. Inadequate health insurance
One of the main anomalies of the New Rural Cooperative Medical Scheme is that patients get more reimbursement for inpatient treatment fees (70%) than outpatient treatment fees (30%). This creates a perverse incentive for patients to get admitted to hospitals, even for minor illness. However, the low ceiling of the health insurance cover (about 200 yuan a year) means that it fails to protect patients who have catastrophic health costs due to serious or chronic illness.

The net result of the reforms has been the demoralisation and de-skilling of rural doctors because they have seen their income drop and their ability to treat patients curtailed. Not surprisingly, many doctors have joined a brain drain from township to county hospitals, where they can earn higher incomes (from drug sales) and have more clinical freedom to prescribe what they want.

Dr Hesketh says the reforms have done some good in the poorest rural areas of China, such as those in Yunnan. There they have made drugs more affordable and guaranteed doctors some income. But in more mainstream parts of China such as Zhejiang the reforms have had a negative impact. The problems might have been averted or minimised if doctors had been consulted about the reform before they were implemented. She suggests that the way forward will have to involve raising doctor's incomes and also expanding the scope of the essential drugs list. Giving rural doctors a 'gatekeeper role' - like primary care physicians may also help, but will prove unpopular with Chinese patients who are used to going direct to the hospital. Dr Hesketh says there is also a need to improve insurance cover and the 'supply side' problems such as overservicing and price gouging.

In the meantime, China is left with a broken health system in need of repair to fix the damage caused by early reforms. Let's hope Health Minister Li Bin is paying attention.

China's rural doctor crisis: the 'barefoot' doctors are reaching retirement age and there's nobody to replace them

by Michael Woodhead
China is facing a crisis in its rural health workforce on three fronts: firstly, most village doctors are nearing retirement and there is no junior workforce to replace them. Secondly, the migrant worker trend means the rural population of half a billion people increasingly consists of older and poorer people who have higher medical needs due to chronic diseases and co-morbidities. And thirdly, government reforms mean that village clinics can no longer make an income from selling drugs and they are now also expected to provide unprofitable public health services. Consequently, young Chinese health professionals are not interested in being a village doctor. Who will fill this role?
This is the gloomy and alarming picture painted by a new snapshot of the rural health workforce, based on a survey of almost 2000 village doctors in five rural areas of China. Many village doctors are the original barefoot doctors recruited in the 1960s and 1970s, and most have only a minimal training in healthcare. Typically they are secondary school leavers who have completed the 'county health assistant' examination. Only about 20% have passed the national 'assistant doctor' certificate. The survey found that half the village doctors are nearing the age of retirement (60 for men, 55 for women). Also worryingly, the survey showed that the doctors nearing retirement tended to offer a wider range of medical services (including 'after hours') presumably due to their greater clinical experience than younger village healthcare workers. The younger village doctors also appeared to charge more and expected a more generous pension than the current measly level of 55 yuan a month.
Study author Dr Xu Huiwen and colleagues from the Beijing Normal University said the Chinese government now expected rural doctors to have a higher qualification, and in theory there was an ample supply of medical graduates to fill these roles. However, in contrast to the old village doctors, young graduates were often outsiders who were not trusted by the local people and they also made a low income. For this reason, village clinics found it hard to attract and retain new clinicians. In the future, rural patients may flock to township and country-level hospitals instead of seeking primary care locally. This will put an added burden on second-level hospitals and also increase the cost of healthcare to both patient and government.
The researchers said the Chinese government had recognised the rural health workforce problem and  had tried to fund rural health clinics. However, the funds were often not released by local country governments. They said the Chinese government must act urgently to address the recruitment of rural doctors by improving financial conditions, and especially by addressing the lack of a decent pension scheme. There also needs to be 'political' support as well as economic, they added.
"Ageing of village doctors is a serious and imperative issue in China, and will have a complex and profound impact on the rural health system," they concluded.
Update: Another study of village doctors has just been published that has come to the same conclusions. Published in the International Journal of Health Planning and Management, it found that 1) The village doctors are ageing 2) Younger people do not want to take on the job because of the poor salary (especially the pension), high workload and difficult working conditions. 3) Rural doctors are unwilling to take on new public health and e-health roles for little pay. The study authors say the government should improve working conditions, salaries and continuing education opportunities for village doctors. Recruitment should encourage local residents to train as doctors rather than trying to attract outsiders in to work in villages.

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.

Undercover patients reveal poor standards of care in rural clinics

by Michael Woodhead
Rural health clinics provide poor medical care because the clinicians working in them have inadequate training, little equipment and poor working practices, a study based on sending 'undercover' patients has revealed.
Researchers at Shaanxi Normal University tested the quality of  care provided at village and township health clinics by measuring the responses to undercover patients who had been trained to mimic patients with angina or dysentery.
In an analysis of the content of  72 patient visits to 36 different clinics, the quality of the consulation was found to be very poor. The average length of each consultation was seven minutes, but only one and a half minutes was spent interacting with the patients - most of the time was spent writing prescriptions.
The village doctors made a correct diagnosis in only 26% of the consultations and were completely wrong in 41% of interactions. The most common incorrect diagnoses were ‘indigestion’ for the dysentery patients and ‘sprain’ for the angina patients.
Village clinicians asked less than 20% of the recommended questions for the health condition and  performed only 15% of the necessary examinations for the condition. Most of the questions were focused on prescribing a medicine. For the patients with chest pain, clinicians did not ask the crucial question about whether pain was radiating, and only 11% measured blood pressure.
Rural clinicians were poorly equipped to deal with conditions such as heart attack. For heart problems,  less than half said  they had the necessary equipment to treat moderate cases. Most had a stethoscope and blood pressure measuring equipment, but few clinics had an ECG monitor.
Medications were prescribed in 75% of consultations, but they were either unnecessary or harmful 64% of the time. The village clinicians often failed to refer serious cases, even when they got the diagnosis right.
The average cost to the patient was between 10 and 15 yuan, with most of this cost being for medicines prescribed.
Only 20% of the village clinicians had completed high school and most had only a rural physician certificate as a qualification. Most of their income was made from selling drugs or devices, with only only 351 yuan per their monthly income of 1355 yuan not coming from sales.
The researchers said it was clear that rural clinicians were not yet ready to act as the front line fighters in China’s primary care system.
"If recent reforms that expand access to rural health care are to lead to actual gains in population health, more attention should be paid to improving the quality of care delivered by the rural health system," they said.
"China has recently made enormous strides in providing access to health care for rural residents; however, efforts focused on improving the quality of care delivered by grassroots providers will be essential for reforms to lead to actual gains in health."
The findings are published in Health Policy and Planning.

China's 60 million "left behind" children face neglect and poor mental health

by Michael Woodhead
More than 60 million Chinese children have been 'left behind' by rural migrants who move to cities and these children suffer from neglect and mental health problems, a new study has shown.
Research conducted by Dr Zhao Xue of the Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University has found that almost 60% of children in the rural areas were 'left behind'. This was a much higher number than expected and reflected China's "explosive growth" and shift to urban centres.
The survey of almost 1700 'left behind' children in rural Anhui found that they had higher levels of neglect, higher levels of social anxiety,  lower family function and poor quality of life compared to  children who lived with their parents. The problems were worse for girls perhaps because in Chinese society they have lower status than boys and thus get little attention, receive less physical and emotional support and have worse lives than boys, the researchers said.
However, left behind children tended to have lower rates of physical abuse than children who lived with thir parents. This might be becuse the escaped the "education by sticks" beatings from parents, the study authors suggested.
"These findings suggest that "left behind children' are currently in a relatively disadvantaged situation in Changfeng county and require more help from the local government and society to improve their life environment," they concluded.
The findings are published in Acta Paediatrica.

A rural doctor's views on China's health reforms

Fengcheng Yuandu Clinic, a hospital in Yuandu township, Jiangxi province, is responsible for the health of 50,000 local residents and has gradually become a medical center serving surrounding areas in recent years.
Hospital Director Zou Huihua said he puts great effort into improving the quality of medical teams and the service of the hospital.
Ensuring the healthcare in townships like Yuandu and rural China is very important, Dr Zou said.
The Chinese government approved a series of proposals to improve the healthcare system in townships and villages during the most recent session of the CPC Central Committee congress held in November.
As an experienced doctor at the grassroots level for nearly 20 years, Zou believes what he has been doing is indeed meaningful.
"There are a lot of doctors in big cities," Zou said. "But in townships and villages they need people like me."

Medical care for rural elderly hampered by 'unfilial' shame and urban migration

Zhu Chengyu strolls around her countryside courtyard as a form of exercise. Old age and illness blight her daily life.
The 78-year-old woman, who lives in Zhuhe village of Dong'e County in eastern China's Shandong Province, has been admitted to hospital five times this year for asthma and heart disease.
Medical expenses costing thousands of yuan was partly covered by basic medical insurance. The remainder, around 2,000 yuan, was a large sum for Zhu.
She has no other source of earnings apart from a monthly pension of 65 yuan (10.5 US dollars) and an annual payment of 800 yuan, which she gets from renting her 2.5 mu (0.17 hectares) of crop land.
What worries Zhu most is when she becomes ill. Nobody is around to take her to hospital.
"My only son and his wife work as migrants in cities and seldom come back home," Zhu said. "I am left alone."

Chinese government acts to improve 'second rate' rural medical insurance plan

Early in November, Chen Ping arrived in Beijing on what was likely to be her last trip to the capital.
The 52-year-old stayed just two days - long enough for her to say a heartfelt farewell to the doctors and nurses in the oncology department of the Chinese PLA General Hospital who have been treating her breast cancer for eight years.
Chen, who comes from a small village in Jilin province, wanted to express her gratitude to the medical staff for helping to extend her life.
She told the staff she was grateful to have lived long enough to see her sons grow up. However, as her illness is now in the terminal stages she has decided to stop receiving treatment.
One man Chen particularly wanted to see was out of town, so she was unable to say a last goodbye to Liu Duanqi, former director of the hospital's oncology department, who supervised her treatment.
Liu, looking tired after a working trip to Gansu province, said of Chen: "She's a peasant woman with a rural hukou (household registration). That means the only public medical insurance available to her is the New Rural Cooperative Medical Scheme."
The hukou system effectively ties a person to their place of birth and registration. It usually means that they are ineligible to claim social benefits or medical insurance if they receive treatment outside the place where they are registered.

China medical research in the journals

No increase in obesity among rural children

There are no signs of an obesity epidemic among rural Chinese children, a study from has shown

Researchers from the Capital Institute of Paediatrics, Beijing, monitored overweight and obesity rates in more than 280,000 children from eight counties in Jiangsu and Zhejiang between 1998 and 2005. They found that the prevalence of overweight was barely changed from 3.7% in 1998 to 3.9% in 2005 and there was no increase in the 0.5% prevalence of obesity.  An increase in overweight/obesity was more likely in boys than girls, especially among those aged over three years. The study also found that the prevalence of stunting decreased dramatically.

Full study: Public Health

IVF conception for 1% of Chinese babies

About one in a hundred Chinese babies is born to women undergoing IVF or other assisted reproductive technology, Beijing researchers have shown. Dr Yang Xiaokui and co-researchers from the Department of Human Reproductive Medicine, Beijing Obstetrics and Gynecology Hospital analysed rates of ART among 112,403 deliveries from 14 provinces and 39 hospitals. They found the proportion of infants born as a result of ART in China was about 1.013% in 2011, compared to 4% in developed countries. Their study also found an increased maternal complications such as multiple gestation, higher cesarean section rate, low birth weight infants, higher infant mortality in women who conceived with the help of ART, compared with spontaneously pregnant women.
Full study: Fertility and Sterility

Urgent action needed on liver fluke infections in Heilongjiang

Liver fluke infestations are a common and increasing problem in China’s north east province of Heilonjiang, a study from Harbin Medical University has shown.

The infections, which are caused by eating undercooked fish,  were  seen commonly throughout Heilongjiang Province and mainly along the Songhua River, according to Dr Han Su and colleagues from the university. In a review of 4951 outpatients with suspected liver fluke infections the overall prevalence of clonorchiasis was 26%.  Rates of infection increased from 22.5% in 2009 to 34% in 2012. Farm labourers accounted for two thirds of cases and consumption of freshwater fish was the strongest risk factor. Cases of re-infection were common.

“The present study revealed that clonorchiasis remains widespread and prevalent in Heilongjiang Province. An integrated control programme is urgently needed to reduce the public health impact of clonorchiasis in this endemic area.”

Full study: PLOS One

Benzodiazepine use linked to benign brain tumours

Benzodiazepines may increase the risk of benign brain tumours, according to Taiwanese researchers. In a review of  62,186 patients who had been prescribed benzodiazepines, they found that rates of benign brain tumours were more than three times higher in patients using benzodiazepines. The risk of benign brain tumours was dose dependent and increased over time with increasing exposure to benzodiazepines. There was no increase seen in risk of malignant brain tumours, but this may have been due to the low number of such tumours in the study group.

Full study: Journal ofthe Neurological Sciences

SMS reminders improve allergy medication compliance

For patients with allergic rhinitis, a daily SMS reminder is an effective way to improve adherence with intranasal corticosteroid treatment medication and treatment outcomes, according to researchers from the Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital.

In a study of 50 patients with allergic rhinitis they showed that adherence to medication was 60% in the SMS group and 28% in the control group. Clinic attendance and allergy symptoms scores were also better for patients who received SMS reminders.

Full study: International Archives of Allergy and Immunology

Salt reduction success in northern China

People in rural northern China reduced their salt intake after participating in a community-based sodium reduction program and having access to salt substitutes, researchers reported in a late-breaking clinical trial at the American Heart Association's Scientific Sessions 2013.  
"We identified a low-cost, practical intervention that was effective in reducing sodium intake," said Nicole Li, Ph.D., study author and research fellow at The George Institute for Global Health in Sydney, Australia. "The WHO and other groups have identified population-based approaches to salt reduction as among the most cost-effective possible strategies for vascular disease prevention in both developed and developing countries."

Researchers with the China Rural Health Initiative - Sodium Reduction Study assessed 120 villages in which the average sodium consumption is 4.7 to 5.9 grams per day—far more than the World Health Organization's recommended 2 grams per day maximum. Americans eat an average of 3.4 grams per day.

Sixty villages receive no intervention and continued with their usual practices.

Citizens of the remaining villages received community health education advising lower sodium intake, with special messages for residents at high risk of heart disease. In addition, a potassium-containing, reduced sodium salt substitute was promoted through a health education program and in village convenience stores. These 60 villages were further divided at random with 30 receiving a price subsidy for the salt substitute, and 30 getting the substitute at full price, which is about twice that of regular salt.

After 18 months, researchers examined 24-hour urine samples of 20 people from each village for sodium and potassium intake.

Those in villages who received the intervention reduced daily sodium intake by 13 mmol (millimoles) compared with non-intervention villages. Seventeen mmol equals about 1 gram of salt.

The intervention also decreased daily sodium by 17 mmol in villages with price-subsidized salt substitutes, increased daily potassium intake by 7 mmol on average across all villages with the intervention and increased daily potassium intake by 9 mmol in villages with price-subsidized salt substitutes.

"The study findings could be applied in similar settings around the world in which salt added during food preparation at home comprises a significant proportion of daily sodium intake," Li said.

The researchers are conducting a larger, five-year study in the same region to determine whether this sodium-reduction intervention impacts incidence of high BP and stroke.

The American Heart Association recommends a diet with less than 1,500 mg (1.5 g) of sodium per day to reduce the risk of cardiovascular diseases. 

Source: Medical Express

Full study: American Heart Journal

Four-fold increase in diabetes rates among rural Chinese

Lifestyle changes have led to increasing incidence of diabetes among China's rural population, a senior medical official warned Friday.
The incidence rate of diabetes among adults in China's rural areas has increased from 1.8 percent in 2002 to 8.4 percent in 2010, said Wang Linhong, a senior official with the Chinese Center for Disease Control and Prevention, at a seminar held in Beijing.
The incidence rate in the countryside increased faster than in cities, though the rate was still lower than that of cities, Wang said, adding that the rural population has become a priority in diabetes control and prevention.
The national incidence rate of diabetes among adults increased from 2.69 percent in 2002 to 9.7 percent in 2010, while the rates for 2011 and 2012 were not available, according to Wang.
With rapid urbanization over the past few decades, rural people's livelihood has improved quickly, while modern agriculture requires less physical labor.
Unhealthy diet and less exercise have caused obesity and higher blood lipid levels among the rural population, which could lead to diabetes, Wang said.
Additionally, rural people are much less aware of diabetes than their urban counterparts, he said.
Nationally, only 36.1 percent of diabetes patients were aware of their condition, and 34.7 percent used medication to control their condition, according to Wang.
"Diabetes has become a major challenge for China's public health and a main task of our programs to control chronic diseases," he said.
In 2012, the Chinese government launched a plan on the control and prevention of chronic diseases from 2012 to 2015, which included efforts to increase the awareness and medication of diabetes. 

Source: Global Times

China medical news roundup for Friday 15 November

 

Village doctors empowered with cloud computing

Doctors serving China’s 900 million people living in rural areas are being helped with cloud computing. In a pilot study, researchers from Taiwan equipped village doctors with Health Information Technology and developing an electronic health record (EHR) system.

The EHR system based on a Cloud-computing architecture was developed and deployed in Xilingol county of Inner Mongolia using various computing resources (hardware and software) to deliver services over the health network using internet when available. From 2008 to 2011 health records were created for 26% (291,087) of 1,108,951 Xilingol residents. There were 10,240 cases of hypertension and 1,152 cases of diabetes diagnosed and registered. Furthermore, 2,945 hypertensive and 305 diabetic patients enrolled in follow-up. Implementing the EHR system revealed a high rate of cholecystectomies leading to investigations and findings of drinking water contaminated with metals. Measures were taken to inform the population and clean drinking water was supplied.

The researchers concluded: “The Cloud-based EHR approach improved the care provision for village doctor in rural China and increased the efficiency of the healthcare system to monitor the health status of the population and to manage preventive care efforts. It also helped discover contaminated water in one of the project areas revealing further benefits if the system is expanded and improved.”

 Full study: Computer Methods and Programs in Biomedicine

Unifying medical insurance is a gradual process: expert

China is attempting to put its three medical insurance systems under one administration, but a healthcare researcher has warned that obstacles still remain, and an effective solution is to merge two of them initially.

The move can only be done step by step, and the first step is to unify the management of the urban resident basic medical insurance and the new rural cooperative medical scheme, Ying Yazhen, of the National Health Development Research Center under the National Health and Family Planning Commission (NHFPC), was quoted as saying in a report carried on Thursday by the China Business News.

Merging the two insurance schemes is feasible as they are similar in terms of fund raising, reimbursement standards and the income of people under their coverage, Ying explained.

She said many places in China, such as parts of the eastern coastal province of Zhejiang and the central province of Anhui, have already merged the two insurances and realized a free capital flow between the two.

Considering its huge population and imbalanced economic development, China implements three separate medical insurances -- the urban workers basic medical insurance for urban employees, the new rural cooperative medical scheme for the rural population, and the urban resident basic medical insurance for people who are not included in the first two insurances, mainly the underage and unemployed residents in cities.

However, the two insurances set for urban residents are managed by the country's Ministry of Human Resources and Social Security, while the scheme for rural people is administrated by the NHFPC. The State Council, or China's cabinet, decided this March to put the three insurances under one administration in order to reduce government redundancy and raise efficiency in medical services. Ying suggested putting all the three insurances under the control of the NHFPC because it is best placed to coordinate the management of the insurances and the medical service fees and quality.

But the researcher insisted that a gradual process is needed for such unified administration.

Compared with the other two systems, the insurance for urban employees is quite different in its participation polices and financing levels, which can be five to seven times higher, Ying told the China Business News.

What's more, its reimbursement percentage for participants, which may reach up to more than 90 percent, is also much higher than the scheme for the rural population and the insurance for unemployed urban residents, according to Ying. The reimbursement percentages of the latter two are often about 55 percent of what patients should pay for medical services.

Ying said there have been rare examples across the country in which the three insurances have been merged for unified management; however, even where this has been attained, administrators have not been able to manage free capital flow among the three insurances.

Source: Global Times

Shanghai to set up China’s first translational medicine centre

The country's first national-level translational medicine center will be established in Shanghai to promote health benefits for individuals and communities.

Translational medicine, also known as translational science, is a discipline within biomedical and public health research. It focuses on translating laboratory findings into diagnostic tools, medicines, procedures, policies and education to improve the health of individuals.

"Translational medicine in China is rapidly growing, though started recently. The establishment of the new center will boost the development of translational medicine in the country," said Zhao Qiang, vice-president of Shanghai Ruijin Hospital.

Covering an area of 60,000 square meters, the research center will have 300 beds for clinical research. And its research will focus on tumors, cardiovascular disease and metabolic diseases among others.

This weekend, the 8th Sino-US Symposium on Medicine in the 21st Century will be held in Shanghai on Nov 16-17, and this year's theme is translational medicine. Medical experts and scholars from both home and abroad will come together to discuss the latest research and the practice's development in the world.

Source: China Daily

Shanghai cracks down on illegal medical practices

At a conference in the Jiading district of the city of Shanghai, on Nov 11, the organizers announced plans to monitor the medical services field in the fight against illegal medical practices.

The related crackdown mainly targets unlicensed practitioners, unnecessary fetal gender tests, and sex-selective abortions.

The district government began its medical monitoring efforts back in 2005 and in the intervening years has developed a governmental management system involving health supervisors and community health service centers. And, things have worked out well, with the discovery of 2,373 illegal activities, with punishment handed out in 742 of the cases, and 54 handed over to the judiciary resulting in 41 people being sentenced.

Source: Jiading District News

Rainbow masks a hit for Hunan surgical staff

Have you ever walked into an operating room fearing the surgeons? Fear not, because rainbow-colored surgical masks and caps designed to ease patients' tension is apparently the latest thing to hit Chinese hospitals.

Allegedly inspired by the hit TV show, Grey's Anatomy, doctors and nurses of Hunan Provincial Maternal and Child care hospital have joined in on the fashion.

With a variety of patterns such as flowers, clouds, animals, Hello Kitty and more, doctors believe the color helps calm the patients and distract them - presumably from the likelihood that they'll lose an ovary during a pelvic operation or get blinded during a nose job. Zing!

Source: Shanghai-ist

Retired doctors urged to work in rural areas

by Laurie Burkitt
China is encouraging doctors to come out of retirement and work in rural areas as part of an effort to tackle a health-care disparity between wealthy cities and the much poorer countryside.
The move is one of a number of initiatives outlined by China's health minister to revamp a health-care system that reinforces the social inequalities now threatening the country's economic growth and stability. China offers progressive medical facilities in large cities such as Beijing and Shanghai, for those who can afford it, but still struggles to provide basic care to large portions of the rural population.
Many medical professionals prefer living in cities, fueling the disparity. On Tuesday, Health Minister Chen Zhu said the ministry is boosting incentives, such as free education, to entice physicians to work in less developed regions.
The ministry is also rolling out a new examination system that will lower the standards required for doctors who aim to work in villages, Dr. Chen said at a briefing with representatives of the World Health Organization on China's health-care reform. Retired doctors from large public hospitals will be invited to return to work in primary-care facilities around the nation, he said. He didn't outline specific details for the new examination system or the programs for retired physicians.
Doctors working in public hospitals follow the national retirement regulations, with men retiring at 60 and women at 55. Private hospitals can hire or retain doctors beyond those age limits.
Health officials will also increase efforts to create more county hospitals and primary health facilities in the countryside to take the strain off large urban hospitals, Dr. Chen said. "This is a critical year" for health reform, he said, adding that there is now more expectation among the general public for better health care.
The world's most populous country is in the midst of one of the largest health-care overhauls the world has ever seen. China has spent $125 billion in recent years to extend public health-insurance coverage to 95% of the population.
The yawning gap between the country's rich and the poor, most obviously between its city and rural dwellers, is an issue facing China's new government that takes power in March at a meeting of the National People's Congress. The median household income of city residents was 28,000 yuan, or roughly $4,500, in 2010, nearly triple that of rural counterparts, according to China's Southwestern University of Finance and Economics.
The rift threatens to unhinge the country's growth and ignite social unrest. And it is widely playing out in the country's health system.
Health officials announced years ago plans to expand hospital networks across China, but village and rural dwellers are still traveling often thousands of miles across the country to city hospitals where they seek treatment when treatment back home either isn't available or isn't up to par with city standards
The result has been overcrowded city hospitals, where the sick spend days, even weeks, waiting for appointments in overflowing waiting rooms.
China's central and western regions remain the country's largest weak spots, said Wang Jin, a partner in consultant firm McKinsey's health-care group in China. "There has been recent investment in those areas and other rural areas, but historically there has been such a deep gap there that the government is still catching up," Ms. Wang said.
While much of the emphasis has been on improving the quantity of hospitals and doctors in rural areas, future leaders will be tasked with a need to improve the quality of care, Ms. Wang said, noting that many rural doctors' skill sets limit their ability to operate on patients and treat certain diseases.
Health officials are also aiming to improve the reimbursement rate for rural families dealing with critical and catastrophic illnesses, Dr. Chen said, adding that the country's national insurance has reimbursement rates of around 70% for rural citizens, but the other 30% is often a huge burden.
Dr. Chen also said that it is expanding sales within counties of pharmaceuticals on China's essential drug list, a list of Western and traditional drugs that cover diseases such as cancer and that are subsidized by provincial governments.
Source: WSJ