Release date: 2015-07-07 For many countries, the first impression of China's health care system is the lack of reference value. China's geopolitical background is too special: more than 1.3 billion people, a vast territory, a large geographical gap, under the control of an authoritative political system, this country is still making rapid progress from the "third world" to the "first world" . However, the above first impression may be wrong. Since its establishment in 1949, the People's Republic of China has carried out a series of large-scale medical system reform experiments, which have guiding significance in many aspects. One of the most interesting lessons we have learned from China's experience is that it reminds us of how important "medical professionalism" is; in other countries this spirit has been firmly established and taken for granted. Because China's health care system is changing rapidly and complexly, it is necessary to briefly review its history here. Since 1949, China's medical system can be divided into four stages. The first stage was from 1949 to 1984. The government imitated other communist countries (such as the Soviet Union and Eastern Europe) to establish a nationwide medical system. The government owns and operates all medical institutions, and all employees are government employees. Medical insurance is not needed at this stage because all medical services are almost free. At this stage, China's medical system has achieved a remarkable achievement: the “community health worker†system has successfully provided basic medical and health services at the village level, (China calls it the “barefoot doctor†system). . From 1952 to 1982, the infant mortality rate in China dropped from 200 to 34, and some ancient infectious diseases such as schistosomiasis were eradicated on a large scale. Since 1984, it has entered the second stage, following China’s fierce free marketization in the economic field, and China’s medical system has begun to turn. Under the leadership of Deng Xiaoping, China has transitioned from a planned economic system to a market economic system. Reforms have reduced government control in the economic and social spheres, including control of the health care system. The government’s financial support to hospitals has plummeted, and many health workers (including barefoot doctors) have lost financial subsidies. The government still owns the property rights of the hospital, but there is little intervention in the behavior of the medical institution. In a market system that lacks rules, these nominal public hospitals are starting to act like profit-seeking companies. Many health practitioners have become “private business ownersâ€. If a doctor employed in a public hospital is profitable for the hospital, he can get a considerable bonus. How should doctors respond when this new economic rule is implemented in the medical industry? Chinese doctors do not have the history and tradition of “professionalism†as their inner support, and no independent industry association can rely on external dependence. After 1949, China was transformed from a local society with a Confucian cultural background into a society guided by communist values, and then turned into a “market-like†society. Confucian culture with thousands of years of history does not predict the emergence of a modern, independent medical profession; communist values ​​believe that doctors are a screw on the entire state machine, and loyalty to the party is the top priority; In a market-oriented society, there are mixed ideas. Whether it is to establish the norms and standards of the "medical professionalism" or to organize independent private industry associations, the mainstream values ​​of these three stages are unable to provide opportunities for Chinese doctors, let alone any external support. (Independent private industry associations exist to promote the establishment, dissemination, and implementation of the “professionalismâ€). In fact, in Chinese, there is no Chinese vocabulary that can correspond to “professionalism†in Western semantics. In this stage, the government only provides medical insurance for some people, and private insurance companies do not exist at all; so that most Chinese do not have medical insurance coverage, which makes the turmoil caused by the experiment of market-oriented medical reform more intense. In 1999, 49% of the urban population had medical insurance (mainly government civil servants and employees of state-owned enterprises), and only 7% of the 900 million rural population had medical insurance. In this way, the contradictions between doctors and patients are very clear: one is a patient who is seriously lacking in medical insurance coverage, and the other is a hospital that concentrates on “creating income and surviving†(the hospital also has no “professional†The spirit of the "medical practitioners"). In fact, the prevailing new economic rules and incentives strongly encourage doctors to act like business owners in the capitalist economy. Does the government not let go of the medical system completely? Do not! It also firmly controls one element: pricing power. We speculate that the government's initial purpose is to reduce the price and ensure that people can get the most basic medical care in the absence of medical insurance. However, in practice, the government-controlled pricing power can really be depressed, leaving only the labor prices of doctors and nurses. Correspondingly, the government has given the drug and technical equipment a fairly "generous" price, such as advanced imaging technology (the bargaining power of doctors and nurses is really comparable to the public relations and bargaining power of drug companies and equipment suppliers). Too low) . The direct result of the government's efforts is that hospitals and medical practitioners have increased the use of drugs and top-level medical equipment, pushing up the cost of medical services, but reducing the quality of medical services, so that people without medical insurance can not look down on the disease. By the late 1990s, this market-oriented reform experiment led to public outrage, distrust of hospitals and medical practitioners, and even the development of widespread, violent attacks against doctors. In some underdeveloped rural areas, the dissatisfaction caused by the lack of disease has led to public protests, which threaten the stability of society. So in 2003, the third phase began. The first step taken by the government is to implement a medical and health insurance system that slightly subsidizes the inpatient medical expenses of the rural population to alleviate social protests. The medical insurance required hospitalization to be reimbursed, reflecting the fact that hospitalization was expensive at the time and many rural families became poor due to illness. However, this emphasis on “hospitalization†also reflects the limitations of policy makers. They do not understand that strengthening primary care is the key to achieving health, treating diseases and controlling costs. The mindset of policy makers is all taken up by how to reduce the cost of expensive hospitalizations, without realizing the really important issues. In the end, the 2003 medical reform did not improve the dilemma of the Chinese medical system. This result is not unexpected. The fourth phase of China's medical reform began in 2008. Policy makers have realized that the medical insurance system and hospitals will undergo major reforms that would otherwise jeopardize social stability. This time, they announced on the official rumors that they would abandon the medical reform experiment based on market principles and promised to provide affordable basic medical services to all the people by 2020. As of 2012, the government-subsidized health insurance system has covered 95% of the population, although the proportion of reimbursement for each visit is still not high. The government is also working on a primary health care system that includes a network of community clinics across the country. The medical reform started in 2008 is still in progress, but many problems have begun to emerge and continue to challenge the leadership of the medical reform, "three-level hospitals" (Annotation: a Chinese hospital-specific grade mark, representing a larger scale and higher The level is the main problem. First, many nominally public (but substantially profit-driven) tertiary hospitals successfully boycotted the latest medical reform. This may reflect a reality: the hospital's game energy in the Chinese political system cannot be underestimated. The result may be that the frustrated leadership may once again turn to market forces to pull the “public†hospitals back into the set orbit. In 2012, the leadership announced that they intend to invite private investors to increase their investment. By 2015, they will have up to 20% of China's hospital assets, a two-fold increase in the past. Second, there is still a large amount of inequality between poor rural areas and rich areas. Third, to form a high-quality, trustworthy, and professional group of doctors in China, we must not do a hard struggle. A major legacy of China's market-oriented medical reform in the past is that the public generally believes that doctors put their economic welfare above the interests of patients, and it is not easy to completely reverse this concept. Although China's health care system is still rapidly evolving, its short history can already provide us with some lessons. First, in low-income countries (or in high-income countries), community health workers like China's “barefoot doctors†can significantly promote the health of the local population. Second, relying mainly on market means to raise funds and guide the flow of medical services will create a crisis in the entire medical system, and must think twice before moving on. It cannot be denied that the government's malformed price control has led to distortions in market behavior, but this is not the whole reason for China's medical difficulties (quality of medical care, difficult medical treatment, expensive medical treatment, etc.). The principles of economics tell us that the medical field is in the strict sense of market failure. Even if there is a completely free medical market system, the information asymmetry between doctors and patients makes it difficult for patients to make a reasonable choice, and the patient's lack of information may be used by doctors . If this leads to the patient's vulnerability, resentment, and distrust, it may become a cause of social instability. When patients are experiencing huge medical expenses, they will seriously intensify the contradiction between doctors and patients - just as it happens in China. Third, the professionalism of doctors, as a cornerstone to ensure the effective operation of the modern medical system, did not receive enough attention. Doctors should strengthen professional norm education during the training and practice stages. The existence of professional organizations can strengthen the implementation of these norms. Only these two articles can not guarantee that doctors will only be supreme in the interests of their patients and in the public interest. On the other hand, in a society that lacks a professionalism tradition, it is really difficult to form a health care group that is trusted by its leadership and the public. Finally, China's medical reform experience shows that reforming the medical insurance system may be easier than reforming the medical supply system; to create an effective medical system, the role of basic medical care cannot be ignored. A historical review of the changes in China's healthcare system shows that its leadership has made some mistakes, but they also demonstrate flexibility and resoluteness in correcting mistakes. China’s willingness to experiment with large-scale medical system reforms has made it a good sample worthy of continuous observation. (Translated by Dr. Zhang Heng, Huaxi, 2015/4/6) Source: Tumor Information
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