Matriz de consistencia

Three main problem areas have been identified at the hospital level itself. These are examined below.

More patients choosing hospitals at county level or above

Increasing numbers of patients choose to be treated in a hospital where the costs incurred are higher than in another available facility. The cost differential may be due to greater distance or to higher charges. A recent survey (Chen, B.P., 2009) found

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that, of all patients requiring hospital treatment, 35.46 per cent chose the township hospital while 49.36 per cent chose the county hospital^†.

According to the 3^rd National Medical Service Investigation and Analysis Report by the Ministry of Health (2003), the number of rural patients treated in township hospitals has been steadily decreasing while those in the larger, higher level county hospitals continues to increase. Township hospitals accounted for 28.8 per cent, county hospitals for 42.6 per cent, and higher level hospitals for 14.1 per cent.

Compared with 1988, the overall hospitalisation rate in rural areas had decreased by 6 per cent.

In terms of accessibility, the village medical clinic is more convenient for patients than the township hospital, while the county hospital offers better technology and expertise than the township hospital (Chen, 2009a). Accordingly, rural patients with serious illnesses always go to a county hospital, and those with common illnesses always choose the easily accessible village medical centre. In other words, the township hospital is said to have ‘no capability’ for serious illnesses, and ‘no opportunity’ for common illnesses (Chen, B.P., 2009).

This trend - “Seek far and neglect what lies close at hand” - has several negative consequences. Costs are increased while, at the same time, the medical resources of

†Therefore the number of patients at the county hospital was 1.39 times higher than at the township hospital. Those who chose to be treated in an area level hospital, in a provincial hospital, or in other hospitals were 8.3%, 1.76%, and 5.12% respectively.

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the township hospitals are left unused and the demand for county hospitals exceeds supply. In other words, a deficiency of medical resources coexists with wastefulness.

Whereas the structure of the RCMS reflects the intention that “the familiar diseases don’t go out of the village, the complex diseases don’t go out of the township, the serious diseases don’t go out of the county”(Chen, B.P., 2009, p 328), practice clearly is running in the opposite direction.

At the same time, Xia (2010, p 17)records the following account from various provincial delegates at the 2010 National People’s Congress:

Some of the township hospitals, seeking economic benefit, asked the serious disease patients to stay in their hospital, but they did not have the ability to treat them, which made it dangerous for these patients and led to a lot of iatrical entanglement. When a patient had just come into the hospital, the first question the doctor asked was “Are you a new RCMS member? If you are a new RCMS member, the medical expenses will be higher than for a non- member.”

Nevertheless, some township hospitals reimburse outpatients the same as hospitalised patients.

Equipment and facilities

Concern has also been expressed about the standards of equipment and facilities in rural hospitals, as well as the need to improve the standard of medical workers

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through better staff training. There is a significant gap in the distribution of medical resources between rural and urban areas (Jiang, 2008). The urban population, which accounts for about 44 per cent of the total population, consumes about 80 per cent of medical resources. The rural population, by contrast, accounts for about 70 per cent of total population but only 20 per cent of medical resources (Jiang, 2008). In 2002, the Development Research Centre (DRC) of the State Council in China conducted a survey of 26 administrative villages in 15 provinces, municipalities and autonomous regions. It found that there were 98 health centres, of which 68 were privately owned.

Among all 98 organisations there was an average of only 0.96 stethoscopes, 0.81 blood pressure meters and 0.16 refrigerators. As well as this lack of basic medical equipment the centres employed very few trained doctors or nurses (Jiang, 2008). In addition, when equipment and facilities are distributed to rural hospitals, staff training in their use may not be adequate, if it exists at all (Yuan, 2006).

Accessibility and reimbursement

Both the location of healthcare services and the mechanism for reimbursement are crucial to the effectiveness of the system. Currently, patients can only be reimbursed at township hospitals. The difficulties this may pose for unwell people, especially the elderly who tend to have frequent but irregular needs for healthcare that is easily accessible, are illustrated in the following case history compiled by Boguang Xia (2010). Hu Shao Kuang was a retired soldier. He was 81 years old and resided in Yushan village, Shatang town, Xingye County, Guanxi Province. His feet were

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crippled; he suffered from chronic bronchitis and benign prostatic hyperplasia and needed regular transfusions. He was unable to walk properly and could not therefore access a doctor at the township hospital, which was more than 10 kilometres away.

Instead he frequently attended the nearby health clinic, where he paid an average of 600-700 CNY per month for his medical expenses.

The reimbursement system is complicated and often confusing to rural Chinese patients. Additional problems arise from the requirement that a patient must have a doctor’s certificate to be transferred to a higher level hospital for necessary diagnosis and treatment but at the higher level hospital they get a lower rate of reimbursement.

This rule is in direct opposition to the new RCMS’s main aim of meeting the needs of those with serious illnesses. The rural population has expressed great dissatisfaction about this cost differential, which means that patients with serious illnesses pay more and more over time for their own healthcare (Huang, 2010).