Former Director of West China (Huaxi) Hospital, Vice President of the Chinese Medical Association, State Council Leading Group for Medical Reform expert advisory committee member, Professor Dr. Shi Ying-Kang passed away in the afternoon of 11th May 2016. It was reported that Dr. Shi was so disheartened that he jumped down from the twentieth floor of a building. The death of Dr. Shi shocked medical societies in China. People feel sorrowful and mourn his death. As a medical worker in China, I also feel very sad upon this regretful news. Maybe it will offend many people; still hereby I like to express the views which have been held deep in my heart. I hope this article will benefit the health care reform in China.
Firstly, I like to point out that I have never met Dr. Shi. He would never know the sort of a person I am. I only got to know of him since his biography is widely available. It is with my great respect for Dr. Shi and also with great grief, but not personal grudges, I hereby say some harsh words in the article. I look deep into the accomplishments as well as the errors made by the public hospital system directors in China in the past 20 years.
Dr. Shi held the post of director of Huaxi Hospital for about twenty years since mid-1990s. After the reform and the opening up of the country for more than 10 years, in the mid-1990s China’s social economic situation generally improved; while the development of China’s hospitals was both facing new opportunities and new challenges. Ordinary people’s demand for the healthcare increased, while hospitals were equipped with only outdated equipment and facilities, and capacities were also relatively small. The hospitals were in urgent need to be improved. On the other hand, local government had only tight budget, and the main tasks of government leaders were to develop the local economy, livelihood issues such as the hospitals were generally overlooked. Against this background, leaders of public hospitals, including Dr. Shi, as representatives of the medical staffs as well as the government and health authorities, obtained full and broad mandates, and began rounds of vigorous competitive expansions of major public hospitals in China.
The appointment of a hospital directorship in China has been confined to limited durations, i.e., by terms of usually 4-year each. In order to develop a hospital in a short period, the quickest way is to expand its scale and buy more hardware. The expansion of a hospital often leads to a ‘prosperous’ development momentum for a period of time. The succeeding hospital directors, being exampled by the preceding directors, continue expansive policies. For the past two decades, nearly all public hospitals took similar measures. The reality turned out to be that the vast majority of the hospitals which expanded all developed well; while for those which did not catch up with the speed of expansion even their survival become under threat. However, quick expansion of hospitals resulted in unexpected negative outcomes.
One of the consequences was skilled doctors left primary care sectors. Since the expansion of hospitals requires a lot of manpower and it takes a long time to train skilled doctors, and in addition China lacked sufficient well-trained doctors from the start, experienced doctors moved from communities, township, and county-level hospitals to city-level and provincial capital hospitals. Experienced doctors also moved from economically backward areas to more developed areas. This leads to a serious loss of grassroots doctors. Then there has been deterioration in the grassroots hospitals’ function. Because of the big hospitals’ expansion and therefore a substantial increase in the number of beds, how to fill out the newly added beds became an issue. The “successful” hospital directors have powerful says, and the also resources to influence both the Ministry of Health as well as the local governments. They took advantage of these powers to impose many policies of restriction of patient admission on primary care clinics, township hospitals, and small specialty hospitals, and also imposed on the policy that surgery of different sizes has to be conducted in hospitals of according sizes. Certain types of examinations and treatments have to be conducted in hospitals of sufficient sizes. These policies not only speeded up the outstanding doctors in grassroots clinics to flee, and also blocked primary care doctors to improve their skills and their enthusiasm towards work (1). Together with the rapid development and expansion of big hospitals in big cities, the patient care capability in smaller hospitals deteriorated (2).
Over-examination and over-treatment are increasingly excessive. Expansive hospital development absorbs a lot of money, but the government can only provide limited financial support. When hospital is expanded or new hospital is built, hospital’s debt immediately turns out to be a pressing problem. To repay the bank loan becomes one of the core tasks of hospital directors. Though the scale of the hospitals was expanded, cost-control and efficient management were not closely followed-up and monitored, the hospital profit margins revenue usually did not get enough lift due to the hospital expansion. Since the fee per particular examination or per particular medication is regulated by the government, the hospitals can only increase revenue by over-examine and over-treat patients.
The other consequences of hospital expansion include a shocking waste of resources. As the hospital expansion intensified, various problems surfaced such as low efficiency and struggling for power inside the hospitals which Dr. Shi should have experienced this personally. With the imbalance of centralization of resources towards major hospitals, small clinics and primary cares sectors have been hit badly.
The points that I mention above are only the tip of iceberg. In addition, these negative consequences were not apparently related to its causes as many people could not see them clearly in this way. Quite a few of professionals even cheered for the hospital expansion.
I understand that some people may not appreciate what I am saying, even disagree with my point of views. Next, I will further explain some details of public hospital management in China during last 20 years.
- The size of a hospital is considered equivalent to the skill of a hospital. Due to this wrong concept, public hospital directors often focus their main efforts and resources to expand the hospital size. Now when many friends recall Dr. Shi, the rapid expansion of Huaxi hospital is considered as one of his major achievements. Of course, certain scale or size is necessary. However, what size of hospital would lead to the best efficiency? If answer to this problem is not clear, why the size of a hospital equals the skills of a hospital? Why do not we simply look outside of China? These questions have not been clarified;
- A lack of self cost-control. Public hospital directors are constantly talking about cost-control, but the actual effectiveness is ignored. Some marveled at Huaxi hospital’s cost-control measure for re-use of hands-wash water. This is of course good. However, the core of hospital management for cost-control is to control drug prescription and its associated cost. The cost of drugs themselves is controlled by the procurement policy intervention of the government (3). Currently, in more than 40 OECD countries, drug cost is controlled in less than 20% of the total budget. It has been estimated that in China the drug cost can also be controlled to be less than 20% of the total cost in the current framework. In May 2015, the State issued regulations to reduce drug expenditure to be in less than 30% of the total cost by 2017. Currently, drug cost is generally around 40% in public hospitals in China. This is likely associated with over-examination and over-treatment. As long as the proportion of drug usage in public hospitals cannot be effectively controlled, an overall cost-control can not be successful (4-6). Lack of cost-control leads to excessive treatment without following evidence-based guidelines (7). These are direct threats to the future health of the general population;
- What is correct and what is wrong are often confused. In the last 20 years, many strange phenomena appeared, such as a confrontation between healthcare providers and patients (8). In the current days the medical resources remain limited, consumer-style relationship between doctors and patients and the option for patients choose their doctors lead further to the tension between doctors and patients, and results in the breeding bed for middlemen (9-12). Public hospitals even provide platforms for some ill-regulated practice of private sectors. A lack of supervision provides fertile soil for these distortions. The directors of the public hospitals surely know what has been going on. Some of the measures increase procurement costs, affect operating efficiency, breed corruption, suppress market force configuration. The public hospital doctors could have done a better job in dealing with these issues;
- Hospital income is largely dependent on the income from prescription drugs’ profit. For the last two decades, public hospitals rely on this profit to support the burden of excessive capital cost of infrastructures expansion, equipment purchasing and recruiting more manpower. Because sufficient remuneration could not be offered to doctors transparently, things such as pharmaceutical company’s kickback to doctor as an incentive to prescribe unnecessary drugs or expensive drugs are widespread (12). Public hospital’s directors are partially responsible for these;
- The doctor’s dignity is ignored. When doctors seek gray income, their dignity is eroded (13). While healthcare staff’s safety is violated, most public directors choose to silence the incidences. This is the biggest failure of public hospital management, and may lead to systemic disaster in China’s healthcare environment (13-15).
The five points above are sufficient to summarize Chinese hospital management’s failures. While people memorize Dr. Shi with praising words, almost none had analyzed the problems of hospital management critically. While the late point is probably even more worrying. Since the uncontrolled expansion requires money and public policy to support, and the inherent problems existing in the management need money and policy to cover up, public hospital management ultimately lost their moral high ground. They have to consistently ask for more money, more projects and more cover-ups. The tragedy of Dr. Shi is only an example of the extreme. The lost public confidence will require long time to recover.
Medical community elite were pioneers in the healthcare reform in China with Dr. Shi being of them. With the loss of public supports, healthcare reformers’ hands are further tightened. Nowadays who are leading healthcare reforms China? They include medical reform program drafter Professor Li Ling (a healthcare economist and a political star, and a party secretary), ‘San-Ming’ Healthcare reformer, Governor of Anhui province Mr. Zhan Ji-Fu, etc. I certainly do not regard healthcare reform can only be explored by medical experts, and also do not regard the healthcare reform explored by non-medical experts will necessarily be less useful. However, it is also possible that the healthcare policies proposed by governmental officials and non-clinical academics may contain flaws. Government regulation of the healthcare system requires the active participation from frontline medical staffs. With the hospital directors lost the public support, how much enthusiasm and confidence the medical community can keep? Without the active participation of the medical profession, how the fragile regulation can enforce the policies? Fake drugs, deceptive medicine, and overtreatment will naturally widespread. The complexity of healthcare problems is well known. If public hospital directors lost their rights to voice their concerns, then it will be difficult for general public to identify which policies are the best interests for them. Currently the concerns voiced are certainly mixed and also confusing.
Chinese healthcare reform may have a long way to go. Last year, I heard a reminder of the critical situation. In a city in Henan province, 48 orthopedic specialists were sentenced by court. Perhaps it was the tragedy of institutional corruption. In my opinion, it was what public hospital directors did during the past twenty years lead to institutional corruption in the health sector possible. Hereby I dare to assert that unless this harm is removed, the doctors in China can not have the dignity back, and there will be no breakthrough in China’s healthcare reform.
I regard today’s healthcare system in China is just the darkness before dawn. I very much hope that, one day, in the entire healthcare system in China, there will be no drug rebate, excessive medical treatment, or medical frauds. All of us will be concerned about improving management, standardizing technical specifications, and information exchanges. More importantly, big hospitals will have beds available for patients, and patients do not have to compete fiercely for their beds. I believe that such a day will come. Till now the public hospital directors have made many efforts. Their successes or failures will become valuable assets to learn from for the next generation hospital administration. The death of Dr. Shi necessarily leads to an in-depth reflection of medical profession in China.
While drafting this essay to such point, I feel tired. Facing the reality, my heart is bleeding. I am only an ordinary member of Chinese doctors. My cry can only go so far. I express heartfelt tribute to Dr. Shi, and to all other public hospital directors in China.
Dr. Yi-Xiáng Wáng at the Chinese University of Hong Kong, Hong Kong SAR, and Dr. Hairil Rashmizal Abdul Razak at Universiti Teknologi MARA, Malaysia, helped with the English translation of this article from a Chinese version.
Funding: This work was supported by a special fund for Innovative Methods of the Ministry of Science and Technology of China (No. 2015IM030200).
Conflicts of Interest: The author has no conflicts of interest to declare.
- Wáng YX. On the training of young doctors in China. Quant Imaging Med Surg 2015;5:182-5. [PubMed]
- Wáng YX. Introduce fair competition mechanism in China healthcare system. Quant Imaging Med Surg 2014;4:498-9. [PubMed]
- Yu X, Li C, Shi Y, Yu M. Pharmaceutical supply chain in China: current issues and implications for health system reform. Health Policy 2010;97:8-15. [Crossref] [PubMed]
- Zhang H, Hu H, Wu C, Yu H, Dong H. Impact of China's Public Hospital Reform on Healthcare Expenditures and Utilization: A Case Study in ZJ Province. PLoS One 2015;10:e0143130. [Crossref] [PubMed]
- Chen M, Wang L, Chen W, Zhang L, Jiang H, Mao W. Does economic incentive matter for rational use of medicine? China's experience from the essential medicines program. Pharmacoeconomics 2014;32:245-55. [Crossref] [PubMed]
- Hellerstein S, Feldman S, Duan T. China's 50% caesarean delivery rate: is it too high? BJOG 2015;122:160-4. [Crossref] [PubMed]
- Liu Y, Congdon N, Chen W, Jiang Y. China's overuse of inpatient treatment and routine preoperative testing. BMJ 2015;350:h2918. [Crossref] [PubMed]
- Shi J, Wang S, Zhou P, Shi L, Zhang Y, Bai F, Xue D, Zhang X. The frequency of patient-initiated violence and its psychological impact on physicians in china: a cross-sectional study. PLoS One 2015;10:e0128394. [Crossref] [PubMed]
- Pan J, Liu D, Ali S. Patient dissatisfaction in China: What matters. Soc Sci Med 2015;143:145-53. [Crossref] [PubMed]
- Wáng YX, Li YT. AME survey-003 A2: on the attractiveness of an medicine career in current China with a survey of 7,508 medical professionals and 443 non-medical professionals. Quant Imaging Med Surg 2016;6:84-102. [PubMed]
- Wáng YX, Li YT. AME survey-003 A1-part1: in current China, do you regret you joined the medical profession. Quant Imaging Med Surg 2015;5:765-73. [PubMed]
- Wáng YX, Káplár Z, Li YT. AME survey-003 A1-part 2: the motivation factors of medical doctors in China. Quant Imaging Med Surg 2015;5:917-24. [PubMed]
- Yang Z, Fan D. How to solve the crisis behind Bribegate for Chinese doctors. Lancet 2012;379:e13-5. [Crossref] [PubMed]
- Li H, Zhang H. Ways out of the crisis behind Bribegate for Chinese doctors. Lancet 2012;379:e16. [Crossref] [PubMed]
- Zhang H, Wu J. Ways out of the crisis behind Bribegate for Chinese doctors. Lancet 2012;379:e16. [Crossref] [PubMed]