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 If you are Chinese, try very hard not to be ill (来源:EnglishCN英语博客基地)

 
Richard McGregor


l will not easily forget the first time I entered a Chinese hospital, a few years ago – and not just because I was ferrying my pregnant wife into the maternity ward in the freezing pre-dawn hours of a Shanghai winter.

The hospital refused to allow us into the ward until I lined up at
what looked like a railway ticket
sales booth and paid Rmb30,000 ($4,000). I was lucky to be able to use a credit card. Most hospitals demand cash up front.

What was an annoyance for me is a matter of life and death for many Chinese people, who cannot get treatment for themselves or their children, even for life-threatening illnesses, until they hand over money.


The health system has become a kind of perfect storm for China's transition from a state to a
market economy. Like most
aspects of the fast-growing Chinese economy, its impact is no
longer confined to China itself.

The fear of being financially crippled by falling ill is an important driver of the country's high savings rates, which in turn feeds the economy's bias towards investment and, more recently, with a large current account surplus, in
favour of exports.

Health (along with education
and pensions) used to be provided through government enterprises in cities and communes in the countryside, both bulwarks of the state that have disintegrated in recent years, leaving a vacuum to be filled by a user-pays system.

In the absence of government funding, hospitals (China has no system of general practitioners) have been turned into pharmacies on steroids, with more than half their recurrent funding from the sale of drugs. Much of the rest comes through diagnostic tests, which explains why some Chinese
hospitals have better equipment than in the west.

The system has in-built incentives for everyone to sell as many drugs as possible, including doctors, whose salaries are tied to prescription targets. As a result, rich China gets good hospitals, while poor China is lucky to get a clinic. It would be
easy to blame the hospitals for shaking down their patients at the front door, but they have to grab money where they can.

It is no coincidence that one of the biggest corruption cases this year centred on Zheng Xiaoyu, former head of the state food and drug administration, who was executed last month for taking bribes of $1m to approve new drugs.

The most common prescription is for antibiotics, with devastating effect. The health ministry announced the results of a survey this week showing about 70 per cent of child pneumonia patients were resistant to drugs used to treat the disease, because of overuse of antibiotics. In three children's hospitals in Beijing, Shanghai and Guangzhou, the country's wealthiest cities, the figure climbed to 90 per cent.

The systemic problems are notorious enough to be the subject of media pranks. A Chinese journalist visited 10 hospitals this year and, pretending to be a patient, provided tea in the place of a requested
urine sample. Six of the hospitals said they had discovered “blood cells” in the “urine” and immediately prescribed drugs.

The government has not been idle (in China, it rarely is) in addressing the health crisis. In rural areas, a new co-operative system is being rolled out, which combines insurance contributions from the local government and individuals with price caps at hospitals. In larger cities, the government has also begun a means-tested health insurance programme for low-income earners and, in May, capped hospital margins from drug sales.

At the national level, the issue has the attention of a committee involving nearly 20 ministries. Officials have panicked at the potential cost of
what many believe was a directive from Hu Jintao, the president, to come up with a blueprint for universal coverage. But the beginnings of a new national system will be rolled out, probably next year.

A country can still prosper, and indeed become a superpower without a fair or exemplary health system, as the US demonstrates, and certainly there is no magic bullet to fix China's problems. The health overhaul, however, will provide a telling template for the broader policy directions, and boldness, of Mr Hu's administration.

The problems of the health system are tangled up in the country's larger policy conflicts. How much of a role should be allowed for the market? (The health ministry, which stands to profit from the industry's growth, is resisting giving too much ground to the private sector.)

Who will regulate the doctors? (China is just starting to build professional bodies with the kind of independence that has so far not thrived in a one-party state.) And how much money will Beijing throw at the issue? (The finance ministry is flush with tax revenues but reluctant to hand them over to provinces and cities without knowing how they will be spent.)

In my case, I received a refund of the balance left over from my down payment after the birth, so I left hospital with a baby in one hand and a heavy brick of cash in the other. Such happy endings, however, are all too rare.

 

 “病不起”的中国人

 
作者:英国《金融时报》马利德(Richard McGregor)


我不会轻易忘掉几年前去一家中国医院的情景,这不仅仅因为那是在上海冬季一个严寒的黎明前,我陪着怀孕的妻子走进产科病房。

这家医院规定,进病房前必须先在看上去像是火车售票处的地方排队,并交纳3万元人民币(合4000美元)。我很幸运,可以使用信用卡。大多数医院要求,必须用现金支付押金。

对我而言,这是件麻烦事;对于许多中国人而言,这可是件生死攸关之事。如果不先交押金,即便是危及生命的疾病,他们自己或孩子就得不到治疗。

在中国从计划经济向市场经济过渡的过程中,医疗体系似乎面临一场大风暴。与迅速增长的中国经济的许多方面一样,其影响已不再仅限于中国自身。

人们担心一旦生病就可能陷入拮据,这成为中国高储蓄率的驱动因素之一,进而促进了中国经济对投资和出口的偏好,最近中国出现了巨大的经常账户盈余。

过去,医疗(以及教育和养老金)由城市中的国有企业和农村公社买单。而最近几年,政府的这两大堡垒已经瓦解,留下了一个由用者自付体系来填补的真空。

由于缺乏政府的资金支持,医院(中国不存在全科医生(GP)体系)已演变为类固醇药品的药房,多一半的经费来自药品销售。其余很大一部分来自诊断化验,这正是中国有些医院拥有比西方国家更先进设备的原因。

这种体系有着某种内在的激励,促使每个人尽可能多的销售药品——其中包括医生,他们的薪资与处方药指标挂钩。因此,中国的有钱人可以去好医院,穷人去个诊所就不错了。指责那些在大门甄别病人的医院很容易,但它们不得不尽力挣钱。

前国家食品药品监督管理局局长郑筱萸一案,是今年最大的腐败案之一,这并非巧合。在7月份,他因收受100万美元贿赂、非法批准新药被执行死刑。

抗生素是最常见的处方,这类药会有严重后果。中国卫生部公布的一项调查结果显示,由于过量使用抗生素,约有70%的儿童肺炎患者对治疗此病的药品产生抗体。在中国最富裕的城市北京、上海和广州的3家儿童医院,这一比例高达90%。

这种结构性的问题广为人知,并成为媒体“恶搞”的对象。今年,一名中国记者去了10家医院,假装成病人,在要求提供尿样时使用茶水。结果,有六家医院表示它们在“尿样”中发现了“血细胞”,并立即给开了药。

在解决卫生危机方面,政府并没有无所作为(那在中国颇为罕见)。在农村地区,中国正启动一个新的合作机制,把地方政府和个人缴纳的保险与各个医院的价格上限结合起来。今年5月,在大城市,政府也开始对低收入群体实行免息医疗保险计划,限制医院药品出售的利润空间。

在国家层面,这个问题引起了一个委员会的关注,这个委员会包括近20家政府部门。官员们对一项全部报销的、据说是国家主席胡锦涛指示的蓝图感到担心。但一项全国新体制的启动即将开始,也许是在明年。

正如美国的情况所表明的那样,即使没有一个公平或值得效仿的医疗制度,一个国家也能繁荣发展,甚至成为一个超级大国。而且,解决中国的问题,肯定没有万全之策。然而,全面医疗改革将提供一个有力的例证,表明胡锦涛政府更广泛的政策方向与勇气。

卫生系统的问题纠结于中国更大的政策冲突之中。应该允许市场发挥多大的作用呢?(将通过该行业增长而获利的卫生部,不愿意给私营领域太大的空间。)

谁来监管医生?(中国刚刚开始建立专业机构,迄今为止,那种机构所具有的独立性还从未在一党制国家发展起来。)中国政府会在这个问题上投入多少资金?(财政部手头掌握着大量的税收收入,但不愿意在不知道钱会怎么花的情况下,把这些钱拨到各省市。)

就我而言,妻子产后,医院还给我押金中剩余的钱款。于是,我一手抱着婴儿,一手拿着厚厚一摞现金,离开了医院。不过,像这样皆大欢喜的结局,终究是少之又少。

 

 

 

 
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