Análisis estático

The existence of both public and private healthcare institutions in the study site (and elsewhere) is part of the historical legacy of various healthcare reforms in China.

After the implementation of household responsibility for day-to-day economic production in rural areas in 1978, the collective economy no longer existed. The old rural cooperative medical services (RCMS) were replaced by private clinics and hospitals. Clinics charged patients based on state regulations but they were responsible for their own profits and losses. Collective funding for hospitals was progressively reduced. The cheap medical services agricultural workers used to have in the past were no longer available. There was no guarantee for the health care of agricultural workers. At the same time, the government only invested minimally in disease prevention, for example, through vaccinations for children or to prevent some diseases endemic to a particular area, such as snail fever (schistosomiasis).

Older Miao People and Rural Health Policy in China Lin Yuan, University of Sydney, 2012

Table 6.1: Sociodemographic characteristics of health professional participants (2008)

Participant Age Gender Marital

10,000~20,000 1,500~3,000 Han None Motorcycle

Y2# 37 M D Village Clinic doctor

(private)

17 Nursing

school

9,500~10,000 1,420~1,500 Miao None Motorcycle

Y3# 24 M S Village Clinic doctor

10,000~20,000 1,500~3,000 Han Buddhism Motorcycle

Y5# 37 M M County Hospital doctor

Older Miao People and Rural Health Policy in China

Undeclared Undeclared Han None Bus

Y10# 43 M M County Hospital

12,000~15,000 1,792~2,240 Han Buddhism Motorcycle

Y13* 64 M M Village Clinic doctor

1M=Married, D=Divorced, S=Single, W=Widowed # Participant in semi-structured individual interview

* Participant in focus group discussion *# Participant in both semi-structured individual interview and focus group discussion

Older Miao People and Rural Health Policy in China Lin Yuan, University of Sydney, 2012

In the mid-1980s, there was reform of the free medical services in state-owned firms and government institutions. The reimbursement system was abolished and Government employees had to use their social security fund to pay their medical expenses. Government reduced its funding of public hospitals. Only 60 per cent of wages were now funded by the government, with hospitals themselves responsible for all other wages and expenses. In some public hospitals, medical staff enjoyed few benefits because the hospital had to pay pensions to retired employees and ancillary workers. At “Xinghua” People’s Hospital, for instance, “there were many retirees and extra workers” [Participant Y5]. Some people quit the public hospitals and opened their own private clinics. Others set up private hospitals by jointly contracting with the state-owned and collectively-owned hospitals. The government did not provide any funds for these private hospitals, which were registered with local business administration authorities.

“Jiaren” private hospital and “Baixing” private hospital in “Dujuan” County were established by doctors who quit public hospitals, as participants explained:

Doctors here quit their formal jobs from public hospitals and no longer received a wage from them. I resigned from the county hospital. We have doctors from the health-care hospital and the traditional Chinese medicine hospital. The doctor working in the radiation department resigned from the township hospital. The government did not invest a penny in our hospital. We set up the hospital on our own. [Y10, “Baixing”private hospital, “Dujuan” County]

Older Miao People and Rural Health Policy in China Lin Yuan, University of Sydney, 2012

I was the president of the traditional Chinese medical hospital. I quit in 1993 because I had different opinions from the public health bureau over the expansion of our hospital. I opened a private clinic. After accumulating some assets, I turned the clinic into a hospital. […] There are many preferential policies for the public hospitals. They have funds allocated by the government for construction, renovation, wages and equipment. They don’t need to pay tax. But we, private hospitals, have to pay tax. We have to support ourselves. We have to invest our own money for wages, equipment, buildings and future development. [Y9, “Jiaren” private hospital,

“Dujuan” County]

The surge of private hospitals and clinics broke the monopoly of state-owned and collectively-owned hospitals. China’s medical system became more and more market-oriented (Dummer and Cook, 2007). The Chinese government claims that private hospitals and clinics create competition for their public counterparts, ostensibly providing more choice for patients and maximum use of society’s resources. Such an arrangement, it is expected, will deliver improved quality and efficiency of medical services to patients. Some participants supported this argument, as the following comment suggests:

Based on my working experience of several decades, and my observation of the society, a society without competition lacks vigour. I think every sector, including the medical service sector, should have a competition mechanism. We hire doctors from other places with high salaries. We have doctors from many provinces. We have to pay more to them. Generally each doctor gets over 2000 CNY per month. Their services to the local people are the contributions to “Dujuan” County. Public hospitals do not attract these doctors because they pay lower salaries. [Y9, “Jiaren”

private hospital, “Dujuan” County]

Others, however, expressed a different view. According to Participant Y5 [a 37-year-old vice-president and physician at “Xinghua” County Public Hospital], because there

Older Miao People and Rural Health Policy in China Lin Yuan, University of Sydney, 2012

are many retirees and support staff in the public hospitals, they carry a heavy financial burden. For the sake of survival, they may deviate from providing a public good and focus instead on financial matters. Some are even profit-oriented. Since people have strong trust in public hospitals, these hospitals may charge them more for operations and medical expenses than private hospitals, as the following comment suggests:

Because of the existence of the private hospitals, such as D Private Hospital where I work, the cost of operations is lower. For example, a Caesarian section operation cost 2000 to 3000 CNY in the past. Now we only charge over 1000 CNY. It costs only 65 CNY to do a comprehensive physical exam, while the public hospitals would charge over 100 CNY. It costs 30 CNY to do the x-ray exam here, while they charge 35 CNY. We charge over 10 CNY to have a biochemical test, while they charge over 20 CNY. The technician doing the biochemical test has a bachelor’s degree from Chongqing Medical University. He has five years of working experience. We have better equipment. We use MIRI 2800. Of course, their colour ultrasound machine is better than ours. [Y9, President of a private hospital]

The public hospital would charge 1800 to 2000 CNY to have an appendix operation, while we only charge 1100 to 1300 CNY. They charge even higher, say, 2000 to 3000 CNY, if the patient suffers from appendicular perforation, while we only charge 1300 CNY. [Y10, President of a private hospital]

Market-oriented reform of the medical system makes resources from society available, which to some extent solves the problem of inadequate medical resources in China today. However, driven by profit-seeking, many resources pour into cities.

There is intense competition among hospitals. Some even engage in unfair competition (Eggleston et al., 2010; Zhang et al., 2011), as my participants acknowledged:

Older Miao People and Rural Health Policy in China Lin Yuan, University of Sydney, 2012

There is much unfair competition. Private hospitals are flexible and are not constrained by [government] policy. For example, public hospitals can only improve their attitude to the patients and improve services. Private hospitals are different.

Private hospitals may give some commissions to the doctors in township hospitals and village clinics. If there are patients with severe diseases, the patients would be directly transferred to those hospitals. The patients don’t know what’s going on.

They don’t know which hospital is better. Public hospitals cannot do this. Moreover, private hospitals do not need to invest in infrastructure. They don’t have retired employees whose pensions must be paid. Their main goal is to keep the hospitals in business. Although public hospitals are also market-oriented, they are ultimately service-oriented. Private hospitals only need to rent a building and pay the rent.

Many doctors in private hospitals are retirees from public hospitals. They have retirees’ pensions from the government. So they may charge less to the patients. [Y5, Vice-president in a county level public hospital]

It is important to remember that there are three main levels of health services provision for Chinese rural residents. In regional centres close to rural areas, the main form of health care is the county hospital.^†† Rural townships are the site of the second tier of health care provision, while village clinics provide basic health care for those living in remote rural locations. The market-oriented reform of the medical system has concentrated limited medical resources in cities. Urban residents can enjoy the benefits of good quality services and competition among hospitals. However, there is a severe shortage of medical staff and services in rural areas. The introduction of the new RCMS, as the following analysis of interview data demonstrates, appears to have done little to improve this division. While there have been some improvements to rural healthcare provision since the introduction of the new RCMS, these have been unequally distributed and concentrated in regional centres of rural areas.