The most eye-catching items in Yan Li's nine-square-meter office are piles and piles of case histories on her narrow table and a makeshift bed for patients in this community of 10,150 people from 4,083 households. Yan Li, a 27-year-old doctor in a community health clinic in Xicheng District of downtown Beijing, said 300 of the 1,000 cases were "active," which means the patients visit the clinic regularly as per their doctors' instructions. Yan is so familiar with these documents that people will be amazed by the speed with which she can locate a specific case history.
Of course, Yan knows the patients even better. On a typical working day recently, she saw eight patients in the morning, ranging in age from 55 to 83 years old, and suffering from chronic diseases.
Throughout the morning, Yan talked slowly and loudly to her patients, repeating herself often. Spending 20 to 25 minutes on each patient, she hardly stopped for a break. But, she said, the time she got with every patient is what distinguished her from her peers in big hospitals. "People always complain about doctors' nonchalant three-minute talk in big hospitals, yet I can understand their difficulties; after all, they have long queues of patients waiting outside the door," said Yan Li.
China is ending a 20-year-old medical reform that has been "basically unsuccessful" as concluded by a two-year study by a think tank under the State Council released last July. In 2000, the country bore the humiliation of being ranked 188 among 191 countries by the World Health Organization in terms of the fairness of medical resources. The Chinese Government is changing course toward a community-based health care network consisting of tens of thousands of doctors like Yan Li to serve the health needs of its urban population.
After reading a blood test report, Yan praised a 59-year-old diabetes patient for controlling his blood glucose level well and asked her details of her diet control that she could share with other patients. An 82-year-old victim of heart disease, who came for regular medication for blood pressure control, grumbled about his wife's reluctance to go to hospital for a blood test despite the symptoms of diabetes. Listening to the old man complaining about the tension over disagreements, Yan said the wife might be suffering from depression and suggested she should be taken to see a professional psychiatrist. Lu Fengzhang, 75, who has been suffering from heart disease and diabetes for years, came for a blood test. Based on his weight and height, Yan calculated the amount of rice Lu could take every day and instructed him to eat more vegetables. Before Lu left, Yan told him that she would call to inform him of the time of an upcoming lecture on stroke prevention.
"The characteristic of medicare in China is that it has become both inconvenient and unaffordable," said Li Ling, a professor at the China Center for Economic Research of Peking University, at a symposium last December. She said such a situation was unthinkable in a well-functioning medical system, where expensive health services are always of high quality and convenient while services that people have to queue for are usually inexpensive and even free.
Chen Yude, professor at the School of Public Health of Peking University, pointed out that an important reason for such a situation was that people were rushing to the big, multi-specialty hospitals known for their cutting-edge technology and advanced surgical treatments even for common diseases. Chen said his outpatient surveys in such hospitals in Beijing showed that the most common complaint was upper respiratory tract infection, usually a common cold. As a patient, Chen told Beijing Review, he tried his best to avoid going to The Third Hospital of Peking University, one of the best hospitals in Beijing, despite its proximity to his office. "It is so crowded and I know I will be 'got rid of' in no more than three minutes," said Chen. He said the danger of this "brand-effect" was that patients with a complex disease would not get sufficient time for consultation and check-up.
China embarked on its four-strata national health network in the 1950s. The top three strata comprise comprehensive public hospitals ranked by scale and sophistication of technology while the bottom comprises public clinics at the community level in cities and at the township level in the countryside. Grassroots clinics, amid a market-oriented reform approach and further shrinkage of government subsidies, found themselves short of funds for surgery and development. According to Chen, subsidies have dropped from 30 percent of total medical expenses to around 16 percent. In the process, most people lost confidence in the quality of community medical health.
With the decline of public clinics, private clinics began to mushroom. According to latest figures released by Ministry of Health, China's non-profitable health bodies stand at 134,000 while profitable ones total 152,000. While only the rich can afford to go to private clinics as such treatment is usually not covered by social security, the majority of the urban population has to choose between the overcrowded big hospitals and the crumbling community hospitals. Although the outpatient registration fee for an expert at a big hospital could be more than 25 times that at a community clinic for a similar service, people often choose the former to play it safe.
"The government's new move in medical reform is aimed at trying to dilute the middle level of the system and emphasize the bottom level of grassroots clinics," said Chen. According to the Ministry of Health, by the end of 2005, China had 17,000 community clinics, which is more than a doubling of itself in three years. They serviced 59.4 million outpatients, more than 20 percent of China's urban population.
According to a circular on the development of grassroots clinics issued by the Central Government this August, community clinics have six objectives: disease prevention, health consultation, medical treatment, rehabilitation, health education and family planning.
According to Chen, another important function of the grassroots clinics is to act as a "gatekeeper" of big hospitals, ensuring that critically ill patients can be transferred to big hospitals on time, besides providing quality service for outpatients.
"The development of grassroots clinics is all about making the distribution of medical resources fairer," said Chen, "so that every one can share the achievements of our rapid economic growth."
Statistics from the Ministry of Health for 2005 indicate that doctors at grassroots clinics diagnosed and treated about 13 patients daily on average. This workload keeps doctors busy receiving outpatients and leaves them with little time for other tasks such as disease prevention and health awareness education.
According to the August circular on developing grassroots clinics, they will be staffed with two to three general practitioners, one public health doctor, and three to four nurses for every 10,000 people.
Although Yan Li's 16-person clinic- including six doctors of traditional Chinese medicine, one general practitioner and three nurses-meet the staffing requirement in terms of numbers, she still feels the acute shortage of hands. For a lecture on diabetes care, for example, she has to carefully apportion the work among her 16 staffers for contacting the expert, preparing the conference room and helping senile attendees climb the stairs, besides regular outpatient care.
But what was even worse than inadequate staffing was the lack of professional training, she said. "I hear that community health care has developed to an advanced level in the United States," said Yan. "Their community clinics have professional care managers who have received comprehensive training and even their volunteers can educate the public on health awareness in a professional manner. People in that country can have all their health care and consultation needs met from cradle to grave without leaving their community. We still have a long way to go."
"The quality of the medical staff is the key to a functional community-based clinic network," said Chen. "China has a very small number of general practitioners of international standards. While foreign medical schools offer a major in general practice, it is a relatively new concept in China."
However, as community clinics develop in big cities such as Beijing, Shanghai and Shenzhen, more and more comprehensive hospitals are starting their trial programs to train qualified general practitioners. For example, Fuxing Hospital in Beijing set up a training center for general practitioners in 2005. The training programs include offering clinic staff temporary work opportunities in hospitals and starting a master's course for general practitioners with more than four years' working experience.
Yan Li, who has been working in the clinic since graduation from a medical college in 2002, assumed the position of acting director this April. When asked whether the promotion was a reward for her diligence, the young doctor said, "A better reward would be sending me to a hospital ward for training. I would look forward to it."
(This is the third of the year-ender series.)