A wave of Covid-19 infections reveals the flaws of the Chinese health system

The Chinese regime cannot guarantee the care of those citizens who contract coronavirus

In the coming month, Chinese medical institutions will face their “darkest hour.” This warning from Zhang Wenhong, a leading infectious disease expert, has been broadcast by state media. It reflects a view that not long ago would have been considered heresy in “Covid-zero” China. But now that the virus is spreading across the country, including hospitals, talk of crushing it has stopped. People queue for hours at fever clinics. Medical personnel sick en masse. In the coming weeks, deaths will increase rapidly as the disease takes its toll on an under-vaccinated population.

For much of the past three years, since cases of Covid-19 were first detected in the central city of Wuhan, the government has considered its handling of the pandemic with pride. It had managed to keep Covid at bay and deaths to a staggeringly small number compared to many other countries. He had also managed to profit propaganda from it. At least until later this year, when the virus began to spread and protests over the often brutally enforced lockdowns erupted, many seemed to buy the official line that China’s achievements were the product of a superior political system, of which it was said to be the only one capable of mobilizing people and resources on the scale necessary to prevent the spread of the virus.

With the Covid-zero policy practically abandoned and the streets almost empty, not because of the closures, but because of fear, the attention of the population is directed to the health system. In recent days, calls to 120, the medical emergency number, have multiplied by five or six. “Covid chaos” has broken out in hospitals, as one Beijing newspaper called it. People from many cities have flocked to them, terrified of even a mild infection with the virus. Before, they were told that it posed a serious threat to their lives. Now, contemptuously, the authorities call the current Omicron variant the flu. But immunity to the coronavirus is low in China, so the rising number of cases will lead to many deaths: about 1.5 million in the coming months, according to The Economist’s worst estimate.

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In proportion to the population, this number of deaths would still be lower than that registered in many other countries as a result of Covid. But they will raise questions in China about the shortcomings of the country’s health system and whether they may have contributed to the suffering of the population and the ordeal of medical personnel.

It would not be the first time that an examination of conscience of this type has been carried out. An outbreak of sars, which was first detected in China in 2002 and killed hundreds of people, mostly inside the country, sparked much debate about the failures of the system. After initially concealing the appearance of sars, officials became more outspoken. Henk Bekedam, then chief representative of the World Health Organization in Beijing, recalls a study by Chinese government researchers, funded by the WHO, that ended in 2005. China Youth Daily, a state-controlled newspaper, revealed details of the himself with a striking headline: “China’s healthcare reforms have failed.” According to Bekedam, seeing those words was “something incredible.”

With Xi Jinping becoming China’s leader a decade ago, public acknowledgment of a political mistake would be harder to imagine. Perhaps, in his opinion, it is less necessary. Much has been done to remedy the problems that SARS highlighted.

One of the main ones was the population’s fear of any contact with the health system due to the high cost of treatment. Before SARS, community care had fallen apart. Many state companies and “people’s communes” that previously provided sanitation services had been dismantled. The hospitals were still under state control, but had become market oriented. To swell their budgets and the wallets of their staff, they could set their own prices for drugs and treatments. In the cities, only people with formal employment contracts had access to insurance. Most of China’s 900 million rural people had to pay their own medical bills.

After the war on SARS, the authorities intensified efforts to enroll rural residents in a government-funded health insurance plan. In 2007 they did the same in the cities among those without formal employment. Two years later, the government presented a health reform plan that aimed to offer affordable basic care to everyone (“universal health coverage”, as the WHO calls it) by 2020. It implied a huge increase in public spending. According to the WHO, annual public spending on health, as a percentage of GDP, tripled to around 3% compared to the amount spent at the time of the epidemic (see figure 1). In 2011, more than 95% of the Chinese population had some form of government-funded health insurance. In 2017, the number of healthcare workers per person had increased by more than 85% and the number of hospital beds by almost 145%.

Lessons from Wuhan

A lot, then, to crow about. But the outbreak of Covid in 2019 showed that much remained to be done. The SARS outbreak, minuscule by comparison, had revealed woeful deficiencies in China’s disease surveillance apparatus. With US help, China tried to remedy this by training hundreds of people on how to respond to such events. But by the time the head of the Chinese Center for Disease Control and Prevention, George Gao, reportedly found out about the virus in Wuhan, it had already wreaked havoc.

What happened in Wuhan in 2020 highlighted broader problems in the healthcare system. Government efforts to rebuild community care and make it a gateway to hospitals, such as British GP clinics, had made very little progress. Terrified Wuhanans, often with mild symptoms of Covid, rushed directly to hospitals, dismissive (like many Chinese) of neighborhood health centers, where doctors are often less well trained and less well equipped. In the Chinese Journal of Health Policy, four Wuhan academics described the situation as “chaotic,” like a bank run. Community health centers were of little use. Their doctors were called to help in the hospitals. A national health care development plan had called for community clinics to have 3.5 health workers for every 1,000 residents served by 2020. At the start of the pandemic, Wuhan clinics had just 2.7, experts said. . Stripped of their few staff, some dispensaries had to close as the virus swept through the city.

Days after the first coronavirus-related death was announced, the situation began to change. A lockdown was imposed on the entire city. The city government began requiring citizens with symptoms to be accompanied to community health centers for checkups. This helped take some of the pressure off the hospitals. But the clinics were not enough. Many people with chronic diseases, such as high blood pressure or diabetes, received their medicines and check-ups in hospitals. When hospitals stopped providing these services to limit the flow of people, community centers were supposed to take over. They weren’t ready. “Across the city, chronically ill outpatients found it difficult to see a doctor or get their medicines,” the scholars explain.

Now that the virus is raging again, the authorities are trying to show that they are better prepared. The Beijing city government claims that by the end of November – a week before the main zero-covid mechanisms were dismantled – 240 of the capital’s community health centers had set up fever clinics. After a few days, the remaining 110 had also been opened.

But until recently they had not bothered to vaccinate people. Amy, a vlogger from the city of Kunming, says she was fully vaccinated at her local clinic six months ago, but she hasn’t heard from a booster since. (Vaccines made in China, the only ones allowed in the country, are less effective than those commonly used in rich countries.) She just tested positive, with mild symptoms. If she does get aggravated, the official advice is for her to go to her community clinic first. But she Amy insists that she would go to the hospital, despite the queues and the brevity of the consultations. The quality of care is better there, she says.

Trick or treat?

Amy’s opinion is not surprising. China’s health system, and the ability of its health institutions to respond to emergencies like Covid, continue to suffer from many of the same problems that were revealed during SARS. In 2017, the government stopped allowing hospitals to sell essential medicines at a premium as a way to generate revenue, a practice that had caused enormous public resentment. But hospitals keep finding other ways to make money, like prescribing unnecessary treatments, including expensive hospital care. To attract customers, they buy shiny imported MRI scanners and other diagnostic tools, and charge patients exorbitant prices for tests, while neglecting less glamorous but important areas of care.

Since 2001, thanks to government insurance schemes, out-of-pocket payments for health care have fallen from about 60% of household health spending to 30%, according to “Healthy China,” a 2019 report by the WHO, the World Bank and the Chinese government. But this figure was still higher than the OECD average of around 20%, a club of rich countries.

The profit motive in hospitals has created a blizzard of distortions. One of them is evident in the shortage of intensive care beds in the country, a problem that will worsen as severe Covid cases increase. Before the pandemic, hospitals had considered their usefulness. Why spend money setting them up and training specialized staff when a much more stable revenue stream could be created by focusing on the foreseeable needs of patients with non-communicable diseases such as cancer and heart disease? These diseases are growing rapidly as the population ages, lifestyle changes and pollution undermines health.

In early December, the government ordered hospitals to make sure their intensive care beds were ready for use by Covid patients, including beds for other illnesses. Earlier this month, the government stated that there were now about 10 per 100,000 inhabitants, a large increase from recent official figures of around four.

However, The Economist’s models suggest that this number is still only a third of what is needed to deal with the surge of coronavirus. The shortage of intensive care capacity had been one of the main reasons for maintaining a zero covid policy. Increasing it now will not help the chronic shortage of nurses with the necessary qualifications. Those who will suffer the most from the intensive care deficit will be the inhabitants of places other than the big cities, where the most luxurious hospitals are concentrated. In the countryside, many village “doctors” do not even have a university degree.

The government is clearly aware of the problem. Its latest health reform plan, published in 2016, emphasizes the need for an effective primary care system. He has spent billions of dollars to bolster community centers. But hiring doctors is hard enough: Salaries are relatively low, as is public respect for doctors. Violence against medical personnel is common, often triggered by the high prices for their services. Convincing doctors to practice general medicine outside of hospitals is even more difficult. With fewer expensive facilities and medicines at their disposal, community centers have fewer opportunities to raise their salaries.

Neither they nor the hospital doctors have much incentive to make the system work better. Ideally, primary care centers would refer people who need special care to hospitals, which in turn should send patients back for routine follow-up treatment. But referrals can deprive those who make them of clients, and doctors are loath to lose business. George Liu, from Melbourne’s La Trobe University, notes that the volume of care provided by community health workers in China has increased over the past decade, but their share of the total has decreased. “That’s because they continue to compete with the hospitals,” he says.

As Covid cases rise and local governments rush to beef up primary care centers to divert patients from overflowing hospitals, some see a glimmer of hope. On WeChat, Health News, the spokesperson for the Ministry of Health, says that the shift of care to community clinics has created an “opportunity”. He suggests that his fever departments become a permanent fixture, not just related to covids, so that people with high fevers no longer feel the need to go to the hospital.

It is surprising that China, a country that has hosted two Olympic Games and boasts of having landed spacecraft on the moon, continues to debate how to build community health clinics that patients trust and want to use. If the coronavirus pandemic succeeds in accelerating long-needed change, some of the suffering it is causing will not have been wasted.