Giving birth in Shanghai

by MICHAEL WOODHEAD

China has one of the highest rates of caesarean section in the world, and China's health ministry has for years been paying lip service to the idea that this is not such a good thing and that vaginal births should be encouraged.

However a recent in-depth investigation of birth practices in Shanghai by a joint team of US and Chinese obstetrics researchers found that the practice of caesarean section has become entrenched in the system as the norm and little effort is being made to tackle the situation.

The investigation, led by Dr Susan Hellerstein of Harvard Medical School and Brigham and Women's Hospital, found that caesarean section was being encouraged by the hospitals as a way of coping with the huge workload of birthing mothers (16 million babies are born in China every year, 200,000 in Shanghai alone). The high rates of caesarean section were also being driven by mothers wanting a quick and 'safe' birth on a lucky day, and also driven by hospitals wanting to avoid medical disputes with patients.

The end result is that China's hospitals are simply not set up to allow women to have vaginal births - the obstetric hospitals do not have labour rooms and do not have the staff to allow women to give birth by labour rather than by caesarean.

As part of their investigation the team, which included Professor Tao Duan, Director of Shanghai Woman's Healthcare Institute, visited five public hospitals and one private (VIP) hospital in Shanghai. They asked many questions both of women and of the medical staff.

They found that Shanghai has a three tier obstetrics system. The highest tier is the so-called VIP private system, which functions at the one top end private hospital with exhorbitant fees by Chinese and international standards (about US$19,000 for a caesarean section birth).

The second - and largest - tier is the Shanghai public hospital system for city residents. This offered a basic obstetrics package, which usually involved a scheduled caesarean and two days of recovery, for a cost of about $1000. Most of this was in theory claimable on the health insurance that is provided by employers. (Some public hospitals offered 'VIP packages' and add-ons at a cost of $5000).

The third tier is the migrant workers' obstetric hospital network. These basic clinics offer a minimal obstetrics service for about $300.


The investigators found that women have to pay upfront for all services and then claim back what they can from any insurance that they have. In practice, this often means women have to queue for long periods to register and pay for each of their antenatal visits.

One of the most striking things the US researchers noticed about the Chinese maternity hospital system was the high number of patients and low numbers of staff. It was quite normal for a single obstetrics outpatient clinic to have 80-120 women scheduled in one eight hour day. Even the "VIP" services saw 40-60 patients a day. Although women got to have very little time to spend talking with the doctor, the researchers noticed that they tended to have more tests and investigations, which they found to be part of a 'defensive medicine' trend.

The high number of patients also put pressure on women to have caesarean sections - a typical birthing unit could expect to deliver eight babies in an eight hour shift, with each caesarean section taking about 30 minutes ( in contrast to vaginal birth taking from 4-24 hours). The average caesarean section rate observed in the Shanghai hospitals was 66%. The women who did have a vaginal birth did so alone (family are not permitted to be present at the birth) and without the aid of analgesics - no epidurals! Women usually had to share a maternity ward with up to four other women and did not have any personal or emotional support from either nurses or doctors.

New mothers are allowed to stay in the hospital for two days of postnatal care after a caesarean section and four days after a vaginal birth. This time was deemed important to Chinese families so that the new mothers could avoid 'hot and cold', rest and consume traditional soups, the researchers found.

When the researchers interviewed mothers and doctors at the hospital they found several factors that encouraged caesarean sections. Firstly there was maternal preference - Chinese women did not want to go though the pain of vaginal birth and feared this would spoil their health and sexual function. They also preferred the convenience and speed of caesarean section, especially as it could allow them to have a baby on a lucky day. Most believed that caesarean section was safer.

The doctors interviewed also said that pressure from women and their families was a major factor in encouraging caesarean sections to be the norm. Most doctors expressed strong feelings about the risk of disputes with patients and their families over medical events, with more than 60% having had experience of serious medical disputes with patients - often physical. Doctors also conceded that there were 'system' pressures on them to provide caesarean sections - it was more efficient and financially lucrative for the hospital, and doctors' salaries were based on the number of women who were managed though birth every day.

It was also noticeable that obstetrics medical staff were very concerned about maintaining their high reputation and did not want to discuss errors and problems with their peers and certainly not with patients.

"The concept of protected open medical discussion of errors or poor outcomes, transparency with patients, and patient apology were neither well developed nor deemed culturally acceptable by most chiefs of services," they noted.

The researchers found that hospitals were geared up to provide caesarean sections as the main method of delivery - the ratio of operating suites to labour suites was 2:1, in contrast to maternity hospitals western countries where the ration is heavily in favour of labour units over operating theatres.

While the main part of the investigation was carried out in 2012, the US researchers returned in 2015 and found there had been no change to the maternity hospital setup.

"We observed that ... most public obstetric care did not meet rising patient expectations with ward style labor and delivery suites, lacking family involvement, pain control, and emotional support in labor. In the cosmopolitan environment in Shanghai, with advanced public transportation and ubiquitous high tech consumerism, the public health care system lagged significantly in development and appeared out of synch with other aspects of society."

They concluded that the high rate of caesarean sections is likely to continue in China's hospitals due to the high throughput' of women in the maternity system and the institutional factors that promote an 'efficient' rate of births. The high caesarean rate is also reinforced by societal and institutional pressures that put the emphasis on convenience and control in contrast to the untidyness and unpredictable nature of a spontaneous vaginal birth.

The full article is published in the journal Birth.

How pharma companies get their drugs prescribed in Chinese hospitals

by MICHAEL WOODHEAD

I wouldn't be exactly "leaking state secrets" by revealing that China's hospitals expect bribes from pharma companies in order to stock and prescribe their drugs. The practice is so well embedded and accepted that it has its own name: "pharmaceuticals feed the hospitals". And this month there is an excellent article from UK-based Chinese researcher Dr Yang Wei, from the University of Kent, which explains how the whole process works from pharma company via hospital pharmacy to the prescribing doctor. To explore the details, Dr Yang interviewed four doctors, five hospital managers and four pharmaceutical industry managers from Shanghai. Broadly speaking, the problem of overprescribing and corruption in prescribing arises because China's hospitals get very little or no financial support from local government. They are essentially self supporting. Despite its increasing prosperity, China spends only a tiny proportion of its GDP on health (about 5%, less than Afghanistan) , and hospitals see very little of that money. As one manager told Yang:

"I think the biggest problem is that there is not enough money for healthcare sector. It is
also related to whether health care is a policy focus of the local government. I remember
that in the past the government would allocate certain percentages (of their budget) to
subsidise healthcare sector, but now it seems there is no such policy… At least in my
district, hospitals are almost financially independent."

Hospitals face rising costs, rising demand for services and yet the fees they can charge for services are capped by order of the central government. This means many hospitals are in serious financial difficulty, running into debt and unable to pay their bills for supplies. The problem is especially bad for regional and rural hospitals faced with the double whammy of wealthier patients preferring to go to city hospitals, while the local government is starved of funds due to migration of the working population to the cities.

The hospitals must therefore obtain revenue from the sales of pharmaceuticals and medical services. To ensure they receive a fixed and predictable income, the senior managers set financial and servicing targets for each hospital department. These department managers in turn set targets for individual doctors.

As one hospital department manager said:

"We have targets for each quarter, and we have to fulfil it to generate enough profits. There are regular meetings in the hospital. We discuss which medical department is not doing well in terms of meeting targets. We, doctors, all want to generate profits, and the hospital wants to generate more profits as well."

The financial revenue performance targets are thus written into the doctors' contracts, with a financial bonus dependent on meeting those quotas. According to the doctors interviewed by Yang, a typical bonus for a junior doctor is around Y2500 quarter, for a doctor whose basic salary is 5000 a month.

However, the bonuses depend on the level of seniority and also on the speciality. Doctors working in surgery and orthopaedics can earn much higher bonuses because they see more patients and can offer more interventions and services, Yang notes. Conversely, doctors in specialities such as paediatrics have a lower income from bonuses as they tend to prescribe less.

Doctors see nothing wrong with earning bonuses for overprescribing or overservicing, because their basic salaries are so pitiful for their high workload and high level of expertise:

"(Being a doctor) is a job that requires years of training and deals with lots of risks. But
their salaries, compared with their foreign counterparts are quite low…People laughed at
them and said, ‘scalpels do not even value as much as a barber’s scissors’. Do you think
this is fair?"

As well as receiving their hospital bonus for prescribing, doctors also receive kickbacks from pharmaceutical companies, based on their level of prescribing. Drugs have high profits margins for pharma companies - and some of this is passed on to the prescribers.

"The profit for the pharmaceutical company is around 5-15% of the wholesale price, and 10-30% for the hospital." - pharma industry manager.

This is where it gets interesting. According to Yang, the pharma companies have promotional budgets that they disburse to hospital in the form of bribes (incentive payments/commissions) to the doctors - but more importantly to the hospital pharmacy committee. This committee, which includes the director of the pharmacy department, the vice hospital president, directors from various medical departments, and some other specialists, decides which drugs are purchased and used by the hospital.

The committee members are targeted by pharma industry representatives, who develop personal relationships with them and offer bribes.

"The most important thing is to know who are the key persons in the Hospital
Pharmaceutical Committee …targeting the right persons is the key. The second step is to
persuade the persons to speak for you at the meeting. We offer money…It is possible that
the first time they will reject you… in the end, they will accept your money ... Some
medicines need a lot of money to get listed in a hospital, especially for Chinese medicines."

Once a hospital has agreed to stock the drug, the pharma company must then target individual doctors with offers of commissions to prescribe their particular drug. Doctors may be offered a commission of 15-20% of the drug price. This encourages doctors to prescribe the most expensive drugs and for long periods. Sometimes doctors are paid indirectly, with the drug company paying them 'lecture fees' or 'travel fees'. "

"Sometimes, a doctor does not need to give a lecture. We issue a receipt under a title of ‘fees or academic lectures’. We will transfer the money to the doctor as a way to pay for drug remunerations. This way, everything is legal."

This was seen in the major crackdown on GlaxoSmithKline in Shanghai, which resulted in a hefty fine. But according to Yang, such payments have been standard practice for all drug companies.

" Drug remunerations are paid monthly based on how much the doctor prescribes. In Shanghai, a doctor work in outpatient clinics in a Class III hospital can earn up to 50,000RMB a month from pharmaceutical companies," said one pharmaceutical representative.

As in other countries, pharmaceutical reps develop close and friendly relations with doctors in order for them to prescribe their drugs. They take the out for dinner and may also support them in informal ways such as by giving them lifts.

Because of the commissions, doctors are encouraged to look at the price of the drug first and foremost, rather than whether it is the most appropriate drug - or the best value for the patient. Doctors are also encouraged to prescribe worthless 'tonics', which have a generous markup and which they know they can offer to patients without fear of too many side effects:

"The most widely used medicine in my company is X. It could be used on a lot of diseases, for recovery. Drug remuneration is around 20% of the retail price…You may not need it, but anyway, it will not kill you (so doctors will prescribe it)…"

In the concluding remarks, Yang Wei notes that the Chinese government is now trying to move away from the commission system for drugs in hospitals. It has encouraged 'zero markup' policies for hospital pharmacies and has also introduced lowest price tenders to ensure that inexpensive drugs get first priority. However, Yang notes that faced with the need to generate revenue, hospitals simply sidestep these reforms by creative accounting and supply deals in collusion with the pharma companies. And when barred from generating income from drug sales, hospital simply switch to profiteering from other services such as medical devices such as cardiac stents (Y2000 each) - or offering unnecessary checkups and tests.

"If pharmaceutical revenues are cut down, then we have to increase other fees or increase the use of other services, such as the use of various diagnostic procedures. This is what is
happening now, and the healthcare costs will continue increase and remain high ... In order to follow the policy and to keep the profit of the hospital, hospitals may promote use of high-tech diagnostic procedures, special wards and other methods to increase non-pharmaceutical expense…"

Yang concludes that the problem of overprescribing and/or overservicing will remain until the Chinese central government and the Ministry of Health solves the problem of adequate resourcing for hospitals. Local governments have no incentive to enforce curbs on their local hospital revenue - and the central government has little enforcement clout at the local government level.

Link to full article: Health Economics, Policy and Law

China's Top 10 Lei Feng medics (the 2016 Noble Prize for Doctors Working While Conspicuously Sick)

About two years ago China's health minister Li Bin had a problem. The masses were not happy with her privatisation reforms of China's healthcare system. Prices of medical treatment were going up, service levels were way down and there was a widespread and justified suspicion among the public that they were being ripped off by a corrupt and dysfunctional health system centred around the state-owned monopoly of for profit 'public' hospitals. It was hard to see a doctor, expensive to see a doctor and the treatment was brief, perfunctory and often inappropriate.  Patients were being prescribed expensive drugs they didn't need, just so the doctor and the hospital could generate more income.

Unable to vent their frustration on the Party, the public started attacking healthcare staff. Doctors and nurses were abused for being on the take, and sometimes assaulted - even stabbed and killed. Hospitals were disrupted by family members unhappy with their treatment -  doctors were blamed - sometime even held hostage. There was a widespread feeling that doctors were useless, arrogant and often on the take in he form of commissions and hongbao (red envelopes).

So what did health minister Li Bin do? As usual in China, "moulding public opinion" (propaganda) was one of the standard methods for managing the masses. Li Bin turned to propaganda chief Liu Qibao (刘奇葆) head of the Party's 'publicity' department. His solution to restore confidence in China's healthcare system was a campaign to portray doctors as heroic, selfless martyrs, serving the people. The order was passed down through regional propaganda channels for media outlets at provincial, city and township levels to feature prominent stories of heroic doctors. "Capture the Lei Feng spirit of the heroes and angels in white coats" was the decree. 

[If you don't know, Lei Feng was a fictitious PLA soldier character invented during the 1960s, who was portrayed as selfless, virtuous and totally devoted to serving the Party through helping others. Lei Feng was the Communist version of a saint.]

Each TV & radio station, newspaper and magazine was given a quota of at least one 'Lei Feng doctor' story every quarter. Unable to find many real-life saintly doctors,  editors and reporters racked their brains to come up with ideas. One of them in Yunnan came up with the idea of a selfless doctor turning up for work even when they were sick. In China sickness and tiredness are taken very seriously, with constant exhortations from family and friends to rest, take it easy and eat some medicine/wrap up warm when sick. So the image of a doctor ignoring all this folksy advice and going to work was a very powerful one. To ram home the message, the doctor was portrayed as being rigged up with an intravenous infusion via a cannula in the arm. Again in image-conscious China this is the bog standard visual standard that says "I am sick".

The article about the selfless and noble doctor working despite being sick was very successful and generated a lot of sympathy via social media.  And as with most successful ventures in China, it quickly spawned  imitators. Other media outlets began to run their own copycat versions of the "Sick Doctor Still Working" story and they have become a regular weekly feature of the Chinese media since since 2014. And in a case of life imitates art, it has now become fashionable for medical staff to do self portraits of themselves working while sick.

And so to celebrate this ongoing selfless doctor I'm-Sick-But-Still-Turning-Up-For-Work schtick (Dai Bing Shang Ban in Chinese), China Medical News present this year's inaugural China's Top 10 Lei Feng Medics awards.


Number 10: Dr Feng Wei, Shaanxi

Our first entrant is a Dr Feng, 42, a neurologist from Shaanxi. He was photographed working with a drip stuck in his arm. His patients were reported as saying he had a wonderful, dedicated attitude to his work and would not go home despite having a nasty cough. Get well soon Dr Feng! (but you lose marks because a drip is now so unoriginal).



Number 9: Beijing Children's Hospital

Not to be outdone by provincial upstarts, Beijing's propaganda team felt that just having one doctor with an infusion at work was not enough. The capital had to do better so they found a pair of female doctors on duty - one with 'phlebitis' requiring IV antibiotics, while the other had asthma that required constant use of a nebuliser. Never mind that anyone needing that much inhaled drug likely has very poorly controlled asthma, setting a poor example of asthma management. Tut tut. Amateurs.

Number 8: Unnamed doctor, Suzhou Second Affiliate Hospital

Not sick, exactly. but dead on his feet. This unknown cardiac surgeon assistant was photographed by a journalist while napping next to a patient. in the ICU. According to the blurb the young doc was so exhausted after doing several hours of surgery that he had to catch up with some sleep while on the job. In some countries this would be condemned as working unsafe excessive hours. In China it is lauded as being a noble example of overwork.


Number 7:  Dr Wu Xiaoqing, Guilin

Infections and fatigue are for wimps. Real doctors go to work with broken bones. Just ask Dr Wu, an orthopaedic surgeon, from the beautiful city of Guilin. He was pictured hobbling round the Guilin Medical University Hospital on crutches, having allegedly fractured his ankle in a motorbike accident. The patients thought his presence at the hospital was a reassuring sign of devotion. We think it is a sign of stupidity - especially from an orthopod, showing a bad example to his patients.



Number 6: Dr Li Ming, Jiangsu

 Never mind crutches, Dr Li of Jiangsu showed that the smart doctor with mobility problems gets some wheels. She turned up for work, allegedly, at the stomatology  department of the Xuzhou No 1 Hospital. Bonus points for the mask Dr Li - you don't want to get sick from patients, it might mean you have to take time off work!



Number 5: Dr Zhao Hongyan, Tianjin 

When it comes to mobility, the military always do things better. When her injured leg meant she could not walk to work,  Dr Zhao Hongyan  of the  Armed Police Force Logistics College Affiliated Hospital in Tianjin spurned a wheelchair in favour of the electric variety. Working while sick and also promoting the Four Modernisations!Top marks for efficiency Dr Zhao, but a fail for your blinged up wheelchair lacking the pity factor for eliciting sympathy from the masses.



Number 4: Nurse Chen, Harbin

 This one isn't a doctor, but the so called "Angel of the Hospital" was celebrated in the media for her selfless attitude to healthcare work when she worked despite having a slipped spinal disc. Allegedly in severe pain, Nurse Chen nevertheless was determined to persevere with the paperwork, so she lay down on some chairs. Thanks for taking the strain of your colleagues - as well as your back -  Hero Nurse Chen.



Number 3: Dr Zhang Hong, Hubei

OK pregnancy is not a sickness, but ultrasonographer Dr Zhang Hong of Wuhan is portrayed as the 'Beautiful Doctor and Beautiful Mother' in the local media for working right up until the term of her pregnancy. Dr Zhang said she felt tired and dizzy but did not want to let down her colleagues or her patients. Not sure if this is genuine or posed.



Number 2. Dr Li Zhengyong, Sichuan

Most of our nominees so far have had temporary sickness that should have prevented them from working. Dr Li Zhengyong of Jiulong, Sichuan has a permanent disability from losing a leg after being hit by a truck  decade ago. Despite having only one leg the 35 year old  dedicates himself to working in the village. It may be propaganda but you've got to admire him.

Number 1: Li Juhong, Hechuan

And the winner is .... drumroll ... the ultimate prize for working while sick must go to this noble lady doctor of Hechuan village near Chongqing. An amputee since the age of four, Dr Li worked her way though rural medical collage to become a township medic serving about 1000 patients. Yes, it's a propaganda piece, but Dr Li deserves all the kudos  - and the Golden Lei Feng Award - for her super service.

Now, who's got the nerve to be nasty to doctors?

Meanwhile, here's a few thoughts for the Health Minister and Propaganda Minister to mull over:

* If you're sick enough to need an IV drip in your arm, perhaps you are not well enough to perform your medical duties to a safe level. You are putting patients at risk.

* If you have an infection that requires antibiotics, it must be serious. Why are you putting at risk vulnerable patients and colleagues through transmitting this infection in the hospital environment?

* IV antibiotics are not appropriate for routine infections. It's bad medicine. What kind of example are you setting to your patients (and to junior colleagues)?

* Would you advise your patients to continue working while seriously ill? No, because it delays recovery. So don't lead by bad example.

* Doctor's health is important. Doctors need to be healthy. By showing up for work while sick you are normalising and encouraging unhealthy behaviour. You may be putting pressure on other staff to do the same.

* Patients aren't stupid. They know that seriously ill people should not be working. By making an ostentatious show of working while sick, you are eroding trust in the medical profession and the judgement of doctors.

Why Beijing's war on hospital ticket scalpers is doomed to fail: top cardiologist says jail sentences won't fix supply & demand problem

by MICHAEL WOODHEAD
This week a Beijing court sentenced 15 hospital ticket scalpers to prison sentences varying from 19 months to two years in jail. It's all part of a very public crackdown on the practice of 'entrepreneurs' buying up the hospital clinic reservation numbers (guahao, 挂号) that are needed to gain access to see a doctor. Typically, these hospital tickets cost 20 yuan at the front desk but are bought up and sold for ten or more times their face value by scalpers (piao fanzi, 票贩子) who operate in gangs around the foyers of public hospitals.

In theory, China's hospital clinics operate on a first come, first served basis. Whoever is prepared to queue up early at the hospital ticket window in the morning gets the tickets. In practice, the scalper gangs either send their agents to stand in line and book an appointment - or they have inside connections with hospital staff to procure the tickets through the back door. The corrupt practice has been going on for years, but made headlines in January when a video emerged showing a young rural migrant woman ranting about the scalpers at a Beijing obstetrics hospital. The video went viral on China's social media channels and there was soon public pressure for 'something to be done'.



As in the past, the hospitals and the Beijing health department announced yet another "get tough" campaign on scalpers. They sent in the PSB to round up the usual suspects. They also issued a series of "Five Musts" measures that included real name registration procedures and an end to collusion between hospital staff and scalpers. And as usual, an example has been made of a few offenders in the media. The Party has listened to the masses and taken action. Never mind that the 15 offenders sent to jail weren't actually scalpers, but fraudsters. They had hired hospital rooms in which they used bogus doctors to swindle unsuspecting out-of-towners into jumping the queue and paying for dodgy TCM treatments.

But even if the authorities had enacted a serious and enduring action against hospital ticket scalpers, it still would not make any difference, according to one leading cardiologist.

Professor Yang Qing, has worked at the cardiology department at the Sichuan University Huaxi Hospital for 20 years. He says the problem is not due to the scalpers, who are only the symptoms of a monopolistic system. Professor Yang says it is important also not to blame doctors, who are also constrained by the system.

According to Professor Yang, every day his hospital cardiology clinic in Chengdu is besieged by patients from far and wide, seeking a consultation. Patients come not only from Chengdu, but also from across the province and even from overseas. A typical clinic has 20 allocated slots to see patients with an average consult duration of 6 minutes - but most will actually fit in 30 patients by running over time. Every day at the front desk he is mobbed by people saying: "Professor Yang can you add an extra place for me?" Some are very deserving patients who have traveled a long distance to see him - even renting rooms near the hospital. Others are former patients who want continuity of care and to be followed up by the same treating doctor. And there are also 'insiders' - acquaintances, connections and people who work in the hospital who seek an appointment with him.

Professor Yang says the demand for 'tickets' is inexhaustible and he only has a finite amount of time in a working day. On a typical day he works right through an after noon clinic without a break even to go to the bathroom. He is supposed to finish at 5pm, but usually does not actually finish until at least 6pm. If there is a chance he will add a few extra places, but he says he feels bad for not being able to accept all the requests. And his colleagues all feel the same way. They are not heartless, but they have other responsibilities and things to do - not to mention family life. Professor Yang says that in addition to attending to patients in the outpatient clinic he must also do surgery, supervise junior staff, take part in research and write reports. He must attend medical conferences and teach students.

Professor Yang says that the demand for hospital tickets is high, but the price is low and does not reflect the 'economic value' of the doctors' skill and experience. The scalpers are simply selling the doctor's appointment at a price the market is prepared to pay, he says. And the 'profit' is going to criminal gangs instead of to the hospitals.

Professor Yang says that what the scalpers do is an unsatisfactory and unfair situation, but he believes it is inevitable under a monopoly system. It would be unrealistic to expect them to be stamped out - and even if all the ticket scalpers were removed there would still be an imbalance between supply and demand of medical appointments, he says.

"When a resource is scarce, and when everyone wants to have this resource, the authorities' fight against ticket brokers is meaningless," he says.


Professor Yang says that in theory a system that guarantees low prices is good because it makes treatment affordable for everyone. However, in practice he says low prices enforced within a monopoly lead to low quality care and also to the 'detestable' practice of scalping.
 
Professor Yang's solution is a free market one - free up the doctors to set their own prices and let them manage their own patients. In this way, there will be competition between doctors that will keep prices low and affordable while raising levels of service and quality, he believes.

[Editor's note: Given that they have been given prominent place in the state media, Professor Yang's pro-market comments are presumably endorsed by the government and China's minister for health. It's notable that the learned professor suggests a new model based on the US free market healthcare system, and makes no mention of other more successful models such as the gatekeeper' system of Britain's NHS. 

The kind of problems that Professor Yang describes do not occur in the UK  because that country (like many others) has an efficient primary care gatekeeper system that ensure that patients do not go straight to hospital. To see a hospital specialist, patients in countries such as the UK and Australia must first go to see a community-based general practitioner, who decides if and where they should be referred. This means that patients with minor illness and chronic disease can be managed in the community' rather than clogging up the overloaded hospital system. It also means that patients are sent to the most appropriate specialist. 

Of course the system isn't perfect because financial restraints mean that public hospital patients often have to wait months for an appointment to see the doctor. In countries such as Australia, patients can jump this queue if they have private health insurance (but they still need a GP referral) But if any patient needs urgent care, they can receive it. 

Interestingly, China is pursuing both these options. It is loosening the monopoly of public (actually state-owned for-profit monopoly) hospitals. China is also moving towards a community/family doctor system. However the progress is glacial because of the entrenched financial interests of local governments [and managers] in their local hospital monopoly. So is the solution to hospital scalpers a crackdown, free-market healthcare or a gatekeeper system? You decide ...]

China's pediatrician shortage to worsen with two child policy

by MICHAEL WOODHEAD

In Guilin's main children's hospital this New Year there were only three doctors on call to cover more than 30 beds for children - and a long waiting list - around the clock. Last year there were seven doctors but four have resigned.

Doctors at the hospital say there is a vicious circle - as more paediatricians resign, the pressure on the remaining doctors gets worse, and the speciality becomes even less attractive to other medical graduates. Speaking to local media, paediatricians say there problem is an increasing one for the whole of China. Paediatrics is an unpopular branch of medicine that finds few takers.

One of the reasons is the low income compared to other branches of medicine - paediatricians don't get the opportunity to make extra bonuses or commissions from surgical operations, prescribing drugs or providing medical devices.

Secondly there is the intolerable pressure from pushy parents of Little Emperors. Children with only minor illness are brought in by neurotic parents who demand attention and excessive or inappropriate treatment for their child. Doctors working with children say their parents and grandparents can be obnoxious - expecting immediate treatment and instant miracles for their spoiled child. This often leads to abuse, disputes, complaints and legal action between doctors and families.

Thirdly, paediatricians also struggle with what they call the "dumb patient" problem - unlike adults, children cannot explain their problem well, and therefore doctors need much greater clinical skills to be able to diagnose their illness.

The low income, high pressure and lack of respect means that paediatricians get little satisfaction from their work. Not surprisingly, many vote with their feet and leave.

The lack of child specialists means that the remaining doctors face 12 hour shifts every day - and have to work as many as 10 night shifts a month. Paediatricians are already exhausted and demoralised  - and they expect the situation to become even worse as two child regulations come into effect in 2016.

Hospital gangster siege reveals the murky side of China's healthcare management

by MICHAEL WOODHEAD
The bizarre 22-day occupation by mobsters of a hospital in Zhengzhou, Henan, is a revealing example of the murky finances and power arrangements behind China's hospitals. 

In late December almost 100 unidentified men invaded the Zhengzhou Meixin Chinese Medicine Hospital and disrupted its operations for more than three weeks. According to Chinese media, the men  - many wearing masks - obstructed the lobby, harrassed medical staff, put up banners and drove patients away. The hospital was thus put under siege by local thugs who stayed in the building playing cards and intimidating anyone who entered.

However, this was not the result of a medical dispute by aggrieved family members of a sick patient, but an extortion attempt to try recoup huge unpaid debts owed by the hospital manager, Wang Guangyu. According to Chinese media reports, the mob had been sent in to force Wang to make good on 17 million RMB funds that he owed to a distant relative, Li Jing. Her husband had previously invested more than 40 million in the hospital via Wang Guanyu, but after the husband died last year, the funds were not repaid in full. After several rebuffs, Li Jing called in the rest of her family to put some muscle on Wang.

In any other country a dispute like this would be settled by the police and the civil courts. However in Henan, amazingly, the ringleader of the occupation gang, Guo Zhiyang, was himself the leader of the local justice department and a former senior policeman.

For someone who is supposed to be upholding the rule of law, Gui Zhiyong appears to be a pretty lawless and criminal character. During his occupation of the hospital staff were threatened by men bearing knives and poles. One pregnant member of staff was so terrorised that she went into premature labour.

The incident ended on 9 Feb after provincial media became interested. When outside journalists first visited the hospital they were rebuffed, but were able to make some reports and take pictures. When this made the news beyond Zhengzhou, the occupiers slipped away, leaving the hospital deserted.

Guo Zhiyong could not be found but he issued statements saying he had been trying in a reasonable and lawful manner to handle personal matters with family. He accused the media of slander through their portrayal of him as a gangster and said he would take appropriate action to defend his reputation.

The whole saga may be an instructive lesson for any foreign companies contemplating running a hospital in China!

[Note: this incident is also reported by a "Gloria Chan" of the SCMP . However, the article so sanitised and anodyne as to be incomprehensible. Presumably this is the SCMP's way of trying to please the Chinese government by not washing China's dirty linen in public.]

Why are China's doctors dropping dead?

by MICHAEL WOODHEAD
 In a single week in 2013, four doctors died suddenly of cardiac arrest. Meanwhile in the last two years it has been reported that fifteen anesthetists in their thirties and forties had sudden cardiac deaths. There have even been premature deaths among distinguished surgeons. What's going on?

According to Dr Huang Weimin, an orthopaedic surgeon at the General Hospital of Jinan Military Region in Shandong, doctors are simply being worked to death. It's the Chinese medical equivalent of karoshi (death from overwork). The Chinese and Japanese characters are the same: "过劳死" (Guolaosi).

Writing in the International Journal of Cardiology this month, Dr Huang says there are four main factors that are driving Chinese doctors to an early grave:

1. Excessive hours and work intensity. Doctors work up to 12 hours a day and in general at least 50 hours a week.

2. Extra non-clinical duties. Doctors are required to publish a quota of scientific articles every year to remain qualified and to be eligible for promotion. This requires research, finding funds, and doing the necessary paperwork for publication. All this work must be carried out in addition to their general clinical work, often in their own time.

3. Doctors must attend many meeting and medical conferences and also have a heavy teaching and supervision burden.

4. The excessive workload and lack of time contributes to a deteriorating doctor-patient relationship, which results in more pressure on doctors and also doctor-patient disputes, litigation against doctors and violence against doctors.

Dr Huang says that all these factors have been highlighted by the doctors' trade union, the Chinese Medical Doctor Association (CMDA). In May 2015 the CMDA issued a “White Paper on the Practice of Chinese Doctors” which called for an easing of pressure on doctors.

It noted that more pressure on doctors can be expected with China's ageing population, the increase in prosperity and consumer expectations, and the widening of medical insurance coverage.

"The growing rates of sudden death indicate that doctors in China are already exhausted and they need alleviation of the heavy burdens. It is high time to concern the health of doctors," writes Dr Huang.

"On one hand, the government should optimize the allocation of medical resources, improve medical evaluation systems, and legislate to protect the health of medical staffs. On the other hand, the society should give more understanding to doctors and create a favorable working conditions."

Chinese media cranks up "Heroic, Selfless Doctor" propaganda

by MICHAEL WOODHEAD
For the last year there has been a steady drip-drip of doctor-as-hero stories appearing in the Chinese media. A typical (and recurrent) one is the story of the sick doctor who keeps on working despite being ill enough to require an infusion line stuck in his or her arm. This is presumably intended show show how dedicated the doctor is in the spirit of that selfless icon Lei Feng.

In reality these stories make the doctor and the health service look foolish and backward. No professional doctor would turn up at the hospital if they have an infectious disease. And no self respecting doctor would believe that an infusion is the right treatment for an ambulant patient. If you're sick enough to require IV antibiotics then your place is in a hospital bed, not the doctor's seat.

The fact that these stories appear on a regular basis in the Chinese media suggests that there is some ongoing propaganda edict from on high to publicise selfless healthcare staff.

Until now, these doctor-as-Lei-Feng stories have just been an occasional eyebrow-raising oddity. However in the last month or so there have been more and more such stories appearing in the media. Last week there was a story of a doctor who was so busy that his son resorted to booking an appointment as a patient so that he could get to see his father. In a family-focused society such as China this 'heart-rending' story was no doubt intended to show how overworked and noble the Chinese doctor is.

This week the selfless medic story of the moment is one concerning Zhejiang doctors who have reportedly been lending money to poor patients so that they can pay for their medical treatment.

According to the local media, a female doctor Yang Yonghong, chief physician at Zhejiang Taizhou Municipal Hospital of Infectious Diseases lent 500 yuan to a patient who said he could not afford to pay for the antibiotics he had been prescribed. Dr Yang insisted that the man take the money to pay for an IV infusion for his sepsis. According to Dr Yang, the man had a life threatening infection that needed immediate treatment. When he wavered about paying, Dr Yang handed over the money and said he could repay her later.



The man reportedly left and did not return for his infusion. But Dr Yang said it was better to offer money and lose it than to risk a patient dying. Fortunately for this doctor the story had a happy ending when the patient returned two days later to repay her. He said he had sought treatment at a local clinic because it was too late to return to the hospital. The patient then allegedly made a full recovery.

Dr Yang has since become a local hero on social media for her generous and selfless action - especially as she was very self deprecating, saying it was nothing, and that many doctors performed similar acts of generosity every day.

"I often ask patients about their economic circumstances and if they are not rich I try to prescribe cheaper drugs and treatment. Last year I lent several hundred yuan to patients who could not afford treatment - I did not hear back and I hope they are well," she is quoted as saying.

The whole sounds very fishy and too good to be true. Is this Xi Jinping's way of sugar coating the medical reforms that will require patients to pay higher fees for medical care?

Freelance "Doctor Groups" - the first sign of workforce reforms in China

by MICHAEL WOODHEAD

The creation of some 30 independent "physician groups" (Yisheng Shoutuan, 医生集团) is the first sign of the Chinese government's 2015 relaxation of working regulations for the hospital system. The rules have been relaxed to allow "workforce fluidity" - in other words to allow doctors to work where they wish rather than being bound to a single hospital ( a legacy of the old danwei work unit system).
 he Chinese Nationa Health and Family Planning Commission (NHFPC) wishes to create a more flexible workforce and to allow doctors to work in a more more market-oriented system, supposedly to free up medical talent and overcome the current mismatch in supply and demand for medical services.

It is still early days for these doctor groups, which face problems such as how to engage with hospitals, how ensure high quality medical standards and how to take on medicolegal risk (and insurance). These are things that are usually the responsibility of hospitals and something that doctors have not had to worry about in the past.

To try tackle these issue the Beijing Henghe Hospital has set up a "doctor group collaboration model platform" to try work with doctors towards new ways of working. The group has already started to look towards the US for business and working models for doctors. Initial discussions have revealed that 55% of hospitals have doctors doing some form of 'moonlighting' - and therefore the doctor groups may formalise this working model.

Another survey found that many talented young doctors were leaving the hospital system because of the long hours, high pressure and low pay. A new freelance model may help retain the skills of these doctors, the collaboration discussion group said.

However, other doctors have pointed to the fact that the vast majority of doctors continue to work  in the public hospital system, and they say this system (and its workforce) is already stretched to breaking point. They ask how the public system will cope if many of its 'backbone' doctors reduce their commitment to practising in the hospitals - and also the reduced input in areas such as teaching and mentoring.

The group heard from some leading doctors saying there now had to be a pragmatic approach to developing Doctor-Hospital Partnerships to ensure optimum allocation of medical resources and also recognise the true value of doctors.

In one Doctor Group forum, vascular surgeon Dr Zhang Qiang said there were 10 issues facing doctor groups:
1. Doctor groups are a very vaguely defined concept.
2. Policies have to be open, pragmatic and work with the health ministry and hospitals.
3. What size should doctor groups be? How much will they be worth? And what disciplines will the consist of?
4. How will doctor groups be organised? As private companies? Co-operatives/ Joint ventures?
5. Where will doctor groups be located? In private hospitals? In large institutions or be in stand-alone clinics? Or as flexible visiting doctors?
6. If doctors join freelance groups [how] will they maintain their participation in academia, teaching and research?
7. How will doctor hierarchy and work assignments/responsibilities be arranged in private groups? In the public system there is a clear structure and system of rosters, promotion and responsibility - how will this translate in private groups?
8. How will private doctors interact and communicate online and digitally, if they do not have the support of the government and hospital system? Will there be referrals and shared care?
9. How will freelance doctor groups be financed and where will they find their start up capital from? If there is a share ownership, who will own the shares and control the doctors?
10. Will private doctor groups have clout? For example, in medical insurance will doctor groups have enough buying power and negotiating strength to be able to arrange medicolegal cover, settle medical disputes and influence policy?

The top three medical stories from China this week

Medical exam fraud: A medical examination cheating ring has been uncovered in Hebei after a 29 year old woman was found to be taking a postgraduate exam in place of someone else. The woman was arrested after it was found the ID card did not match the details of the doctor who was supposed to be taking the test, who was from Chengdu. The woman said she was paid 60,000 yuan (about US$9000) to take the test on behalf of another person. The woman, who was originally a doctor, said she had given up her job in 2013 after she discovered she could make more money through exam fraud.

Influenza deaths: There have been three severe cases including one death from severe H5N6 influenza in Guangdong and a further death of an overseas visitor from H1N1 influenza, according to media reports. Chinese media said that a a 25-year-old man from Shenzhen, was in a serious condition in hospital. A 26 year old woman died of the same infection in Shenzhen last week, while a third person in Zhaoqing, Guangdong was in a serious condition. Meanwhile a Guyanese man has died of H1N1 influenza in a Miami hospital after returning from China. The infections are presumed to have come from exposure to live poultry and it is not thought there is a high risk of human-to-human transmission.

Air pollution harms fetus: Pregnant women who are exposed to the high level of air pollution in China are likely to have low birth weight babies, a study shows. Exposure to high levels of PM2.5 particles, as found in China's smogs, was linked to a decrease in birth weight and an increased risk of low birth weight, according to a study by specialists at the Guangdong Women and Children Hospital, Guangzhou. The doctors said the effect of air pollution on fetal growth was similar to that seen with cigarette smoke, and was due to immature fetuses being more susceptible to air pollution because they are in critical periods of organogenesis.

Actress Li Bingbing disparages Australian medical system, flies back to China for tonsillitis treatment

by MICHAEL WOODHEAD

Chinese star Li Bingbing has lit up social media with scathing criticism of Australia's healthcare system, claiming in a Weibo post that Australian doctors had been inept and unable to treat her severe tonsillitis. The actress eventually flew back to China where she received intravenous antibiotic treatment at the Peking Union Medical College Hospital and was said to be recovering. The actress claimed she was relieved  to be back in the "good care of the motherland", but her Weibo post triggered an online debate about the merits of China's healthcare system, overuse of antibiotics and how the privileged can jump the queue.

The star of such critically-acclaimed films such as Resident Evil: Retribution had been in Australia filming the scifi movie 'Nest' (about a labyrinth of man-eating funnel web spiders, apparently) when she became feverish with a temperature of 39 degrees. On her blog she said she went to the hospital but was forced to wait two hours to see a doctor, who finally agreed to do blood tests as she suspected she had SARS. However the tests were negative and she was discharged. Li Bingbing said her temperature fluctuated and she 'burned for two weeks', although the photos she posted showed only a temperature of 37.5 degrees.

On December 6 she posted photos on Weibo showing her in the bed of an unnamed hospital, which she claimed was in Australia, with blood stains on the bedsheets which she said was from a botched attempt to insert an IV line. She wrote that the nurse had been unable to insert a needle into a vein despite three attempts and compared her poor technique to the superior skills  of Chinese medical staff. The superstar complained that she had been to three different hospitals without getting any satisfactory treatment for her fever and had therefore returned to China for medical care.

[UPDATE: I have been told that some of Li Bingbing's photos do not match those of an Australian hospital - the equipment is not that used by Australian hospitals. Also, Australian hospital policies require linen to be changed immediately if soiled by blood.]

The Weibo post elicited  a response from an ethnic Chinese  doctor working in Australia, who said that Li Bingbing's claims suggested that she did not understand Australia's medical system and how to seek help. The doctor explained how Australia had a gatekeeper system of GPs, and that unlike China, hospitals in Australia were not the place to seek initial treatment for fevers. He said GPs would usually advise rest and fluids for fevers rather than antibiotics, but he also questioned why the star had a fever for 14 days before seeking treatment. He was unable to explain why Australian doctors might have missed severe tonsillitis and said he did not have the full medical details due to hospital confidentiality regulations.

However, Li Bingbing's management then issued a legal letter demanding that media retract and delete this doctor's article because it was based on inaccuracies. The star claimed to have followed the Australian system rules for seeking medical care  and said she had consulted a "famous" Australian doctor and two other doctors - including GPs. The star's management also strongly denied that Li Bingbing had sought preferential treatment or had been unable to understand English properly.

The saga triggered a wide ranging debate in China's social media, with some netizens saying that the episode was a lesson for Chinese not to "blindly worship" foreign countries and their healthcare systems. Some said it showed that China's doctors and nurses were more skilled, and also that Australian doctors had little experience in treating common illnesses for Chinese patients.

However, other online commenters said that the incident revealed the differences between Chinese and foreign hospital attitudes to use of antibiotics and infusions. They said it showed that foreign hospitals were more strict about antibiotic overuse, and also that they had more careful treatment pathways and did not give in to public pressure for inappropriate treatment. Some critics said Li Bingbing's praise for the "care of the motherland" sounded like government propaganda. However, others used a play on a Chinese saying: "the moon isn't rounder in foreign skies" to assert that  medical care should not be assumed to be better in foreign countries.

Li Bingbing's social media criticism may be a setback for the many countries hoping to cash in on Chinese medical tourists. However, Li Bingbing is not exactly a trusted expert in evidence-based healthcare. According to Wikipedia, she has a qigong practitioner for a 'godfather' who claims to be able to conjure up snakes from thin air and cured her mother of a mysterious disease.

Are China's doctors happy? A national survey of job satisfaction provides some unexpected results

by MICHAEL WOODHEAD

China's doctors have a lot to be unhappy about. Low pay, long hours, medical disputes that trigger abuse and violence from the public - and daft regulations that force them to publish a quota of 'scientific articles'  every year even when they have no interest in research. 

There has been a lot of talk about poor morale among China's medical profession in recent years, but very little actual research to back these claims up. To address this, the medical online portal DXY conducted a survey in September 2015 that asked a simple question: "do you regret becoming a doctor?"

Responses were obtained from 2,356 doctors, three quarters of whom were male and most were working in tertiary (teaching) hospitals in eastern China (not surprising given that DXY is a medical portal used predominantly by younger and more online-savvy medics).

The survey found that overall almost half of doctors (1146) said they had regrets about becoming a doctor. There was no significant difference between male and female doctors, but there were some interesting trends by speciality and location.

Emergency department doctors had by far the lowest morale, with almost three quarters regretting their choice of career. This is perhaps not surprising as emergency doctors are at the sharp end, doing exhausting shifts dealing with trauma - and being assaulted by stressed out patients and their families with complaints.  Other specialities with poor morale included paediatrics (low pay, high stress when dealing with pushy parents of ailing Little Emperors), obstetrics and gynaecology and oncology.

The specialities with the highest degree of job satisfaction (or least worst morale if you're a glass half empty person) were radiology, TCM and anaesthestics.  The survey also showed that community clinic physicians  also had less regret about medicine as a career - the study authors say this is presumably because they see less sick patients and are more likely to have an ongoing doctor-patient relationship in the community.

Interestingly, doctors in teaching hospitals tended to have better job satisfaction - possibly because the top hospitals have better career prospects and are more professionally stimulating. The doctors in the middle tier hospitals - level 2 - had the worse morale.

Trainee doctors and senior doctors also tended to have better morale whereas mid-career doctors in their 30s and 40s had the worst morale.

On a geographic basis, doctors in the more remote provinces such as Yunnan, Gansu, and Shanxi reported better morale. The survey authors said this was an unexpected results and suggested that salaries were not as important as once thought in job satisfaction.

The study authors say they now plan to publish a more in-depth analysis of the reasons given by the doctors for poor morale.

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.

Shanghai hospitals to ban antibiotic infusions for coughs and colds

by MICHAEL WOODHEAD
Not before time, some of the more advanced and enlightened provinces of China are to ban the widespread practice of giving patients antibiotic infusions for common colds.

Visit any emergency department or outpatient department in a major Chinese hospital and you will see row after row of patients hooked up to IV infusion lines. These are people who have coughs, cold and fevers and are given intravenous antibiotics as routine therapy. In most other countries this would be seen as an absurd, unscientific and harmful overtreatment, but in China it is the norm. There is an almost superstitious belief among Chinese people that an infusion is a panacea.

Many doctors have spoken out against the practice but until now hospitals and health authorities have done nothing to curb the practice. That may be all about to change. The Jiangsu health department has put hospitals on notice by saying that from 1 July 2016 infusions will no longer be permitted as routine therapy in outpatient departments of major hospitals (2nd and 3rd level). This will include city hospitals in cities such as Shanghai.

In a recent interview with People's Daily, Xuzhou Medical College Professor Wu Yunming said the most appropriate treatment for a cold was to take a simple antipyretic such as aspirin, rest and drink plenty of fluid.

"Sick people going to hospital for an infusion has become a long established bad habit, which is one of the important factors for antibiotic drug misuse," he said.

Professor Wu said it was a practice that must be stopped but it would require a change of thinking among the public as well as among the medical profession.

He said strict rules were needed to ban infusions because although doctors were aware that they were inappropriate, self regulation and guidelines had failed to curb their use. Professor Wu said it was typical for an outpatient department to have 200 patients in a morning having infusions - and not unknown for up to 700 patients a day receive such treatment. This was highly profitable for hospitals, which charged 100-200 per infusion, he said.

"Hospitals are businesses and infusions represent a significant source of revenue for them," he noted.

A reporter who visited a major hospital found that healthcare staff were sceptical about the planned ban. They say their was widespread patient expectation and demand for infusions, and if tertiary hospitals did not offer them then patients would simply go to smaller hospitals or local community health clinics that would still provide them.

Professor Wu said rational use of antibiotics was an important issue because antibiotic infusions could cause anaphylactic reactions, increase resistance and also cause other major side effects on the kidney and liver. Infusions also wasted a lot of workforce capacity and resources as nurses had to set up and monitor infusions. He said there needed to be a system-wide plan and implementation of the infusion ban, with an emphasis on social responsibility for hospitals and professional responsibility for doctors.

A spokesman for the Jiangsu department of health said it would be issuing a 'blacklist' of more than 50 medical conditions for which infusion was not permitted.

China's pharma companies take a stake in public hospitals. What could possibly go wrong?

by MICHAEL WOODHEAD
China's not-very communist health minister Li Bin wants to see hospitals turn to "social capital"(ie private investors). And it is slowly starting to happen. China's 'public' hospitals are currently in a strange place - they are essentially state-owned for-profit enterprises, but bound by an odd mix of rules and regulations that keep some prices in check and yet which allow rampant price gouging and overservicing in areas such as pharmaceuticals. Not for nothing are pharmacies know as the 'gold mine' of hospitals.

To try get rid of the obvious incentives for hospital doctors to overprescribe the government is currently phasing in a ban on drug commissions. They are trying to de-link income from drug sales and hospital revenue.

However it's not clear to me how this squares with the trend for China's pharmaceutical companies to go into partnership with hospitals, and essentially to become their operators. Take the recent deal by the Guangzhou Baiyunshan Pharmaceutical Group to invest in six hospitals in the obscure Shandong city of Jining. The joint venture covers six main hospitals with around 6000 beds and a total annual revenue of 2 billion yuan.

The local health department has 49% stake in the new Jining health provider company, while the pharma company has a 33% stake in return for 5 billion yuan investment. Other stakeholders include investment companies, with between 15% and 2% interests.

Analysts say the new joint venture will allow industrial groups to make profits from controlling supplies of pharmaceuticals as well as medical devices, supplies and equipment. I'm no health economist but I can't see how allowing a pharma company to own and operate all of a city's hospitals is good for the patient. Who decides which drugs are made available at the hospital - and what happens to the competitor products? Also what is to stop overservicing, as we have seen so evidently a problem in the current system?

As a commentator in Caixin magazine concludes:

"With deals like this we need to first be clear what is the purpose of the restructuring of public hospitals, and through the restructuring of what kind of results you want to achieve? These issues need further study and discussion. "

China is crazy for medical apps

The latest medical app craze in China is iBaby, developed by an entrepreneur from Harbin to provide antenatal, childbirth and childcare advice to Chinese women. The creator Lu Guotao featured on a recent Apprentice-style TV show on which he demonstrated how his app can link women up to advice via video and online help from obstetricians. Lu turned down offers from investors and went it alone to market the app, which he says now has tens of thousands of users in 31 provinces. Lu says he has had 10,000 obstetricians sign up to provide medical advice online via the app. The one stop platform for pregnancy advice also links women up with local clinics and offers links with merchandisers for pregnancy wares.

Lu says he was already a successful businessman when his wife became pregnant, but they were so busy attending to their work that she lost the baby through a miscarriage. Lu turned his grief into an energetic mission to help avoid such incidents again, by providing accessible information, advice and contacts for prospective parents.

He says the huge success of the app is not surprising given China's move towards relaxing the one child policy and also the opening up of the healthcare system to private investment and more flexibility in doctor roles.

The app has received backing from national obstetric experts including Professor Liu Xinghui, director of the West China Second Hospital, Sichuan University, Chengdu. Professor Liu offers weekly online lectures via the app. She says women can access a wide range of obstetric experience via the app.

Medical news from China: 7 stories that made the headlines this week

1. Nurses in Wuxi are being taught lessons in etiquette by air hostesses. The aim of the program is to make the nurses more customer focused and dispel their image as unfriendly.

2. Acute kidney injury is common in China with 700,000 deaths a year. Researchers from the Medical College of Nantong University found that acute renal impairment went undiagnosed in more than 70% of cases, and was often caused by patients taking nephrotoxic drugs or TCM.

3. A female neurologist in Wuhan is suing a woman for slander and damage to her reputation after the women mounted a four year campaign to blame her for her mother's death. Dr Mei Bin is suing the woman for 5000 yuan in compensation and apology after the woman spread false stories about her and claimed she was unqualified for her post. Dr Mei Bin said she had nothing to do with the care of the women's mother and the allegations against her were false, probably related to a doctor with a similar name in another province.

4. Researchers from Zhejiiang report a case of human to human transmission of H7N9 influenza in hospital from Feb 2015. Both men died, according to a report in the BMJ.

5. Health inequalities: hospital mortality rates are 40% higher in rural areas compared to the cities, a new study shows.

6. About 44% of Chinese women take Traditional Chinese Medicines during pregnancy, the most common being Angelica sinsensis (29%), Ziziphus jujuba (21%) and Dioscorea opposita (13%). Most women used TCM on the advice of their mother or mother-in-la, according to the survey of 700 women in Sichuan. The researchers warned that TCM may cause fatal hepatic and renal effects and some are adulterated with lead or pesticides.

7. A Beijing medical school has started a program to train more psychiatrists to help overcome China's widespread lack of mental health clinicians. The Beijing Huilongguan Hospital Clinical School of Peking University aims to help train several hundred psychiatrists over the next decade. China currently only has 20,000 psychiatrists and needs at least three times that number to match other countries.

Antibiotics in China: not quite there yet

by MICHAEL WOODHEAD
Regular readers of this blog will know that antibiotic misuse is one of my real bugbears about medicine in China. Seeing rows of patients in emergency departments routinely hooked up to infusions of broad spectrum antibiotics for fevers is a symbol of everything that is wrong with healthcare in the PRC.

Well it seems that I'm in good company in deploring this unwelcome practice. As part of Antibiotic Resistance Awareness Week, the World Health Organisation has taken China to task for its misuse of antibiotics. In a new global report it singles out China for having particularly poor usage and knowledge of antibacterials. A survey reveals that more than 60% of Chinese think, incorrectly, that colds and flu can be treated by antibiotics. A similar proportion have used antibiotics in the past few months and one in four bought them over the counter rather than obtain them on prescription. And while 67% were aware of the term ‘antibiotic resistance, few realised that cutting down on antibiotic use was the way to tackle it.

The WHO states that China is one of the worst offenders for antibiotic misuse and blames the lack of awareness among the citizenry for this problem. For a country that prides itself on such a good education system, how can Chinese be so badly informed about such an important matter?

The head of the pharmacy department at the Beijing Union Medical College Hospital, Zhang Jichun, says many Chinese demand antibiotics as a "quick fix". At the hospital if doctors say that antibiotics are inappropriate for patients with a fever or a cough they are rebuked with: "my illness so bad, why don't you give me an infusion for it?" Doctors say patients accuse them of not taking their illness seriously and demand "give me an infusion quickly so I will recover quickly and can get back to work!"

The WHO says it hopes the new report will raise awareness about antibiotic overuse and the risk of resistance in China. I'm not holding my breath.