“I’m not even going to talk about the money problem … the utmost concern is toensure stability,” said Gao. Yet, most of the challenges raised by the reform have to do withmoney.
Internal half-year self-assessments provided to China Daily show that 13 of the 32pilot sites listed limited finances as the foremost barrier to further reforms.
Some also complained about the mounting debts of township health clinics due toover-expansion in recent years, an issue that has not been addressed by the reform.
“Grassroots health institutions in the 32 pilot sites carry a debt of more than 400million yuan. Across Anhui, that figure is about 1.4 billion yuan,” said Gao.
“The issue still hasn’t been addressed well but we’re looking into it,” he said, beforestressing that the initiative for the entire province “will be proven effective in half a year”.
Fall in patients
Health chiefs in all 32 pilot sites signed responsibility agreements in late June thatbind them to “achieving comprehensive reform tasks” by March 31, 2011.
Bi Pumin, director of the city health bureau in Huangshan, said the most importantindicator of success is whether or not people in towns and villages get cheaper access tohealthcare.
However, this cannot be done quickly, he warned.
“Medical reforms in the 1990s and early 2000s attracted a great deal of money frompatients and boosted health departments, but officials realized that if we left healthcaresolely to the market, the people would suffer,” said Bi. “That’s why we must rebuilda public-purpose system led by the government. The problem becomes how we canintroduce a competition mechanism to motivate workers.”
The reform has reduced revenue considerably for a third of Huangshan’s townshipclinics. Overall, the number of outpatients fell more than 60 percent during the first halfof 2010 compared to the same period in 2009, which in turn has led to sharp decreases inthe incomes of grassroots physicians.
Although township clinics have been stopped from profiting from drug sales,government subsidies have not yet caught up in many areas, posing a dilemma formanagers.
Xincheng Community Health Center, Huangshan’s highest-rated town clinic in termsof performance, made 800,000 yuan in 2009 but has witnessed a dramatic decline inrevenue following the reform.
Striking a balance between covering costs and providing public services is a challenge,said its director Cheng Libin.
“With minimal subsidies, we’re still pretty much on our own with operating costs,”
said the 37-year-old. “We can probably earn 400,000 yuan in 2010, provided each of our30 or so staffers brings in about 15,000 yuan in revenue.
“Any more would be a stretch, unless we’re determined to make profits again. There’sstill room for profit,” he added, referring to the unnecessary infusions ordered by doctorslooking to make extra money.
On average, about six out of 10 inpatients at town clinics are given infusions,according to Ye Lianggui, Xincheng’s deputy health director. His bureau has ordered allclinics to cut inpatient infusion rates by 70 percent in 2010.
Even Cheng’s center still gives infusions to half of its patients, however.
“It’s a conflict,” said the health center boss. “If they want us to meet the revenuerequirements, this is how we’re going to do it. We would’ve been much better off had thesemissions not been assigned but that would be a great financial burden on the government.”
In response, Ye acknowledged infusion rates are difficult to contain under thecircumstances but insisted the reform is on the right track.
“If we just let it go and allow them to make profit, the tasks of grassroots healthworkers would’ve been extremely simple: Just go catch patients and butcher them,” headded. “Without this reform, medical costs would only go up year after year.”
Doctors’ fears
In rural areas, problems generated by previous market-driven reforms are causing freshheadaches as officials try to restructure village clinics into public health facilities.
Under the new initiative, provincial health authorities pay annual compensation of8,000 yuan to each clinic in a village with a population of more than 1,200.
However, 17 of the 32 pilot sites said in their assessment that the earnings of ruraldoctors had gone down exponentially and needed immediate intervention.
Dongzhi, one of the pilot counties, reported that its doctors on average made20,000 yuan a year before the reform - 70 to 80 percent coming from drug profits. Theregulation of drug prices will cut estimated incomes in 2010 to just 35 percent of that,according to the submitted assessment.
Zhang Gongyong has been the only doctor in the mountainous Qianshan villagesince 1974 but is not qualified to receive the 8,000 yuan compensation as he serves only400 people.
The 56-year-old made 8,000 yuan at his clinic in 2009, as well as 2,000 yuan fromgrowing tea and oranges and 1,200 yuan from government subsidies. However, the latestdrug pricing regulations mean his total net income will fall by 5,000 yuan in 2010.
For the time being, Zhang is fine with the changes. “If other people can survive, socan I. Somebody’s going to have to work for public health in villages,” he said.
Rural youngsters have become much less motivated to join village clinics in recentyears and more than half of the 400 village doctors in Shexian county are older than 50.
“Fewer kids are studying medicine,” said the veteran medic. “People can make at least 30to 40 yuan a day as migrant workers. That’s not the pay you can expect as a village doctor.”
He added: “I’ll be here until I’m too old for it. There’s no retirement.”
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A clandestine market for unregistered weapons still exists despite crackdown.
Hu Yinan reports from Hunan.