Image: A hospital’s cashier window in China, picture author's own

In May 2014, a Chinese farmer in Anhui Province cut off his own feet when they deteriorated into severe necrosis, causing unbearable pain. In 2012, a peasant in Hebei province amputated his festering leg using a saw and a fruit knife. Both patients were unable to pay high medical fees for treatment. These incidents illustrate a much broader issue of unmet health care needs in post-reform China. Since the 1980s, when China began to adopt market reforms, its health system has shifted from a fully state run and financed system toward more private financing and delivery of health care. These changes have led to soaring medical fees and poor access to affordable medical services. Effectively, the government has withdrawn from its responsibility to preserve health.

As a result, individual families have become the main source of health care support. But their capacity is varied. It is not uncommon to hear cases of patients committing suicide because they do not want to become a ‘burden’ to their family. Patients do not dare to go to hospital, but seek to self-mediate or manage at home. If they are taken to hospital as an emergency case, they face demands to pay up front. Numerous reports show patients being rejected by hospitals, or ambulances leaving patients unattended, after hearing they were unable to pay. In early 2013 a migrant worker was left to die under a bridge, even though an ambulance had been called several days before his death. These examples of ‘letting patients die’ violate both universal medical ethics and the socialist ideology of ‘serving the people’ – and have created considerable resentment against both professionals and hospitals amongst ordinary people.

However, the need to consider ability to pay is also a troubling issue for Chinese doctors. Before the 1980s, government assumed most of the financial burden of public hospitals, and would cover hospitals’ annual deficits at the end of each year. After the market reform, public hospitals were asked to become self-sufficient or manage with much reduced state investment. Research shows that in 2006, 93.6 percent of the income of general hospitals under the Ministry of Health was earned from patients, not from government subsidies. In this situation the costs of services became the focus of intense scrutiny and hospitals transferred the pressure of securing up-front payments to health professionals. If patients evaded medical bills, the doctors who treated the patient could be punished.

These new demands thus complicated clinical work. Health professionals have responded to institutional pressure by demanding that patients pay cash to be admitted or to ensure that treatment starts or is continued. In many hospitals, the unspoken rule about intervention has been based on informed consent. If a patient’s family decided to give up treatment or the patient was conscious and decided to give up treatment for him or herself, health professionals might not intervene. Though the law and official regulation  required that emergency care should be offered immediately when a patient was alone and unconscious, hospital staff might try to contact the patient’s family, and deny treatment until reassured about ability to pay. The doctors making these decisions were caught between the interests of the hospital and patients’ interests. If they saved the patient, and the patient failed to pay the fees, they could be held responsible  for the hospital loss. But if they did not rescue the patient, they violated their professional integrity and faced criticism from the patient’s family.

The situation has forced Chinese government to respond. The government has initiated a new round of health care reform since 2009 that aims at rebuilding a state-sponsored health system and providing health insurance for all. Recent research shows that 95 percent of the Chinese population had health insurance by the end of 2011. Hospitals have become ‘bolder’ in treating patients, whose medical bills are partly covered by the insurance. The Ministry of Health has also issued guidance to public hospitals to adopt a  ‘treatment first payment later’. After the migrant worker incident mentioned above, the state has initiated an emergency medical aid system to help emergency patients receive health care. In addition, the state has issued new decree on hospitals’ and doctors’ obligation to save lives.


It is common to see begging with the ‘excuse’ of unaffordable medical fees (‘excuse’ because many people suspect some cases may not be real), Image: Author’s own

Even so, patients’ families still feel the burden of major illnesses. Recent research by Chen Gao and his colleagues, and by Kai Liu and his colleagues both show that the new health insurance schemes have not significantly reduced patients’ medical expenditures. Many treatments, checks and drugs are not on the coverage list. The actual insurance reimbursement rates are not very high. Although government spending on healthcare has increased rapidly, most of the money goes on health insurance, public health, community and township medical institutions, not directly to public hospitals at or above the county level. Public hospitals still have to work under the business mode, focusing on maximizing profit. Doctors are encouraged to prescribe heavily for insured patients, and hospitals make claims for services that were medically unnecessary or never provided, leading to a rapid escalation of overall health expenditure. For major illnesses, patients still pay large amount of money out-of-pocket after insurance reimbursement. Without enough money, tragedies such as self-amputation still occur, and doctors continue to face the dilemma of ‘to save or let die’.

About the Author: Jiong Tu is a PhD candidate in Department of Sociology, University of Cambridge. Her work explores people’s moral experience of health care transformation in China.