Healthcare in China

I have been an obstetrician at the Beijing United Family Hospital, in Beijing for five years. My former colleagues in North America often ask me about the Chinese healthcare system. Unfortunately, asking about healthcare in China is rather like asking about healthcare in Europe. China is huge. Huge in geographical size (slightly smaller than the US) and in population (1.3 billion). It is also extremely diverse: Beijing in the east and Xin Jiang in the west are as different as Poland and Portugal.

Q: How is the healthcare system organized?

A: A healthcare system tends to reflect the general social and economic mood of a country. At present, the mood in China is one of change. Time has been lost. China has fallen behind the West and is working hard to take up what it feels is its rightful position in the world. The effort to change and modernize is reflected in business, industry, and healthcare. For 50 years the communist government – run according to Chinese Marxist lines – took care of the health needs of the country. It dictated what was necessary and paid for it. The central, provincial, and local governments funded hospitals, and medical care was provided at either no charge or very little charge to patients.

Q: How is healthcare funded?

A: Now that China has moved into a more capitalistic, entrepreneurial era, hospitals have been told that they have to finance some of their own costs. This is not an easy process for hospitals or for patients. Patients are now being asked to pay for some of their care. There is currently no system of private health insurance, although many firms are looking to start such programs.

Q: How is healthcare delivered?

A: The alarming thing in China is the almost total absence of primary care. Even in cities, there are no independent doctors' offices or neighborhood clinics, so people have to go to the hospital for every healthcare need. Since there is little in the way of appointment systems, crowding and confusion occur. An enormous amount of resolve and money would be needed to correct this problem. The math is staggering. In a country of 1.3 billion people, it would require an additional half-million family doctors to provide the services that are available in many Western countries.

Hospital structures are vastly different from place to place. Large cities like Beijing are well served with both general and specialist hospitals. Specialist hospitals, which are equivalent to tertiary care referral centers in the West, have excellent equipment and technology: they routinely perform cardiac surgery, angioplasty, and transplant surgery. In many rural areas, there is a structured system of local and county hospitals with increasing levels of expertise as you go up through the system. However, there are areas of extreme poverty where the level of care leaves much to be desired. In the provinces furthest from Beijing, hospitals have little in the way of modern equipment, or even modern plumbing.

Despite the absence of an official private healthcare system, patients can pay an additional amount of money to see a physician of their choice, at a more convenient time, or to receive individualized care. Some of these payments are official and are set by the hospital, but other payments are of the unofficial variety. The newly affluent Chinese are demanding a better level of service in all areas of life, including healthcare, and hospitals are responding to their demands by building units with comfortable private rooms and special nursing care.

The Beijing United Family Hospital, where I work as an obstetrician, has been open for five years, and is currently the only Western-owned hospital in the country. Initially, the patients were almost exclusively Western expatriates and Chinese who had been living abroad, but recently we have seen an increasing number of local Chinese patients looking for more personal care. Foreign patients who are concerned about the lack of cleanliness in provincial hospitals now fly here from all over the country, even for minor problems. Beijing also has an eye hospital, which was started by a local ophthalmologist who trained in the United States.

Another element of the system is Traditional Chinese Medicine (TCM) – see A Prickly Issue. Many of my Chinese colleagues who practice medicine in a style similar to that in the West use a few TCM techniques and medications, but for the most part the two systems run separately along side each other. There is less antagonism between the two systems than there is in the West. On questioning my Chinese patients, I find that they are often taking traditional medicine in addition to the medication that I have given them. (Playing it both ways!)

Q: What are the current concerns among healthcare workers in the country?

A: Doctors and nurses are very poorly paid, and their level of training varies greatly. Training for doctors ranges from a two-year course to programs that are equivalent to those offered by Western medical schools. Specialists are generally well-trained, but there is no national body that sets standards and assesses competency, such as the American Boards or a Royal College.

Although doctors and nurses have social status similar to their counterparts in the West, many of the younger doctors are discontented. Promotion in the system is very slow. Moving from city to city, or even from hospital to hospital, is rarely an option, in part because it has never been a feature of Chinese life. I have met many former doctors who have given up medicine for better paying jobs. One young woman works as a ticket agent for a Western airline company, another as an office manager for an import company. They feel that the financial and personal rewards are much greater in these areas.

Q: What are the current concerns among patients?

A: The patients are, for the most part, quite content with the system. The Chinese are enormously patient. To wait for hours to buy a train ticket or to see a doctor is accepted as a normal way of doing things. (Although like many things in China, that is changing.) Privacy is not a great preoccupation. Crowded clinics and hospitals are accepted more easily than they would be in the West. This is a very crowded country.

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