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Money Ill Spent

Money is being poured into construction of big hospitals, centers for disease control and intensive care units in the post-Covid-19 era, but experts caution big ticket items come at the cost of the underfunded community healthcare system

By NewsChina Updated Feb.1

On October 30, experts and health professionals from Shanghai and Nanjing gathered at Suzhou No.5 People’s Hospital in Jiangsu Province to discuss a project to expand facilities to treat infectious disease.  

China is splurging on a new round of hospital construction as the country and the wider world admit that the Covid-19 pandemic has revealed the need to normalize epidemic prevention and control. But many medical experts argue that so many new high-end facilities are not needed, particularly as the country lacks enough trained medical professionals to staff them. What is more urgent is to improve community healthcare and preventive medicine for all ages, rather than responding to a crisis or treating patients after they fall ill. 

Nevertheless, Suzhou is moving ahead with plans for an independent facility to treat severe infectious diseases. The city has invited experts to consult on what is needed in terms of construction and a suitable location.  

Elsewhere in China, other health administrations have recognized the need to improve medical and health infrastructure. The No.2 Hospital of Nanjing in Jiangsu broke ground September 25 on a new facility which will include a center for chronic disease, a medical isolation center and an animal laboratory. It is expected to provide an additional 300 hospital beds. 

Authorities in Southwest China’s Sichuan Province approved a three-year plan in July, with planned investment of 13 billion yuan (US$1.98b) for 49 projects to improve disease control facilities and ensure every city in the province has its own infectious disease hospital.  

According to Song Yafeng, president of No.1 People’s Hospital of Ruzhou, a secondary-level hospital in Pingdingshan, Central China’s Henan Province, the hospital also received 5 million yuan (US$764,500) in government support, of which 3 million yuan (US$458,700) is allocated for a P2 laboratory, and 2 million yuan (US$305,800) to purchase ventilators and build negative pressure wards.  

From the most developed coastal provinces in Eastern China to central and western cities with weaker health resources, an unprecedented upsurge in adding medical infrastructure has started. Covid-19 has forced policymakers to fill the medical gaps and ensure they are prepared for the next possible pandemic.

Construction begins of a new tertiary hospital begins in Wuhan, November 6, 2020

Construction Spree
Jiang Mengxi, a researcher at the National Health Commission (NHS)’s Health Development Research Center, told NewsChina that half of the country’s medical infrastructure projects this year were already planned, including specialist hospitals in underdeveloped areas of Southwest China, and hospitals to meet the needs of expanding urbanization in eastern China’s populous cities. But the rest are in response to the ongoing Covid-19 pandemic.  

Construction on six major projects began on the same day in late July in Wuhan, Hubei Province, the original epicenter of the pandemic. Six new tertiary hospitals of 1,000 beds will be built in four districts, aimed at epidemic prevention, control and treatment. The combined cost of these six projects, more than 10 billion yuan (US$1.52b), is the largest investment in medical and healthcare in the city in recent years, the Wuhan Municipal Health Commission said. 

“The Covid-19 pandemic taught authorities at all levels very important lessons, and we must learn from these experiences. In the 14th Five-Year Plan (2021-2025), it is vital that we spend 200 billion to 300 billion yuan (US$30.42b-45.6b) from the central to the local level of governments to fill the gaps in China’s public health system,” wrote Huang Qifan, former Chongqing mayor, in a piece in the China Economic Weekly in February 2020.  

The focus is on infection departments and public health systems. According to a release from China’s top planning body, the National Development and Reform Commission (NDRC) on July 6, the central government allocated 45.66 billion yuan (US$6.95b) to the national health budget for 2020 to strengthen capacity-building in public health disease prevention, control and treatment.  

“I’m sure this round of investment has to be much bigger than after the SARS outbreak,” said Zhao Wei, former head of Nanjing No.2 Hospital, Jiangsu Province. Zhao told NewsChina that the province built several new hospitals for infectious disease treatment after the SARS (severe acute respiratory syndrome) epidemic of 2003. But this time the spending is much greater. Compared to the infrastructure investment of 400 million yuan (US$60.84m) in Suzhou No.5 People’s Hospital, the budget this time for a new negative pressure ward building alone is 800 million yuan (US$121.7m). 

After the SARS epidemic, local governments tried to improve public health provision. But because some infectious disease hospitals were moved to remote locations and there are fewer patients with infectious diseases, these hospitals were operating at low capacity. For example, No.3 People’s Hospital of Yangzhou, the designated infectious diseases hospital of the city in Jiangsu, relocated to a new site in 2008, but it treated less than 100 outpatients daily for the first three years, lower even than a small community clinic in urban areas. A few years ago, the public health center for infectious diseases in Hohhot, capital of Inner Mongolia Autonomous Region, was dismantled because it saw few patients but cost hundreds of millions of yuan annually to run. 

“At present, there is no need to establish new specialist infectious disease hospitals at scale. It is important to transform existing infectious disease hospitals into general hospitals and strengthen their comprehensive treatment capacity,” Wang Guiqiang, chairman of the Infectious Diseases Branch of the Chinese Medical Association and director of the Infectious Diseases Ward of No.1 Hospital of Peking University, told NewsChina.  

Construction of infectious disease hospitals or wards adapted to “both times of peace and times of crisis” is the basic requirement for all such infrastructure post-pandemic. President Cheng Junping of Suzhou No.5 People’s Hospital acknowledged to NewsChina that apart from simple hardware input, there must be subsequent sustainable, high-quality development and training of medical professionals, but there is still a question mark over how this can be achieved.  

Wang Guiqiang suggested that a mechanism is needed so personnel from several departments and disease control departments can interact. That is to say, doctors are also public health experts and have the right to advise on government decisions.
ICU Expansion
Prior to the Covid-19 pandemic, the use of ECMO (extracorporeal membrane oxygenation) machines to give respiratory support varied significantly across the country due to its high price and high risk. They were mostly used in the wealthiest provinces and cities. But now, in many provinces, buying ECMO machines for hospitals is standard. Sichuan stated in its provincial three-year action plan that the province aims to deploy ECMO equipment to all cities currently without it before 2022. But Liu Xiaojun, director of the General ICU with the No.2 Affiliated Hospital of Zhengzhou University in Henan Province, told the reporter that for some provinces, buying hundreds of ECMO machines would not solve anything if they do not train medical workers to use them.  

Hou Xiaotong, chairman of the China Medical Association’s professional committee on in-vitro life support and director of cardiac surgery at Beijing Anzhen Hospital, estimates that many hospitals might only treat around five cases a year with ECMO. At present, there are 260 hospitals in the country which have used this technology and at most 2,000 doctors who can operate ECMO, Hou said.  

“I don’t think we really need so many ECMO machines. We already have more than most developed countries,” Peng Zhiyong, ICU director of Zhongnan Hospital of Wuhan University, told NewsChina. Because training staff in ECMO use and ensuring professional standards is difficult, efforts should be concentrated in certain institutions rather than everywhere, Peng said. 

Some government departments, including the NDRC and NHS, plan to build one to three major epidemic treatment centers in each province. These hospitals would allocate 10 to 15 percent of total hospital beds for ICU wards, in addition to a certain number of negative pressure wards.  

“This is a very astonishing proportion that no hospital can afford,” Huang Erdan from the Health Research and Development Center with the NHS told the reporter. “Such arrangements will end up being unsustainable because of the high maintenance costs.” 

Beijing intends to provide more negative pressure wards in municipal and district general hospitals. By 2022, the city said it will increase the number from the current less than 300 to 700.  

“I don’t know how they got to this number. Now the number of ICU beds in large hospitals accounts for less than 5 percent, so 10 to 15 percent means two or three times more than that,” said Du Bin, ICU director of Beijing Union Hospital. The main problem, Du said, is that there is neither sufficient medical staff to provide high-quality services nor enough potential patients. “They’ll end up empty or treating less severe patients who don’t really need to be hospitalized, leading to excessive medical care,” Du told NewsChina.  

William Hsiao, a professor at the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health in Boston, Massachusetts, and a consultant to the China State Council’s leading group of experts on medical reform, told NewsChina that a drawback of China’s former planned economy is building hardware without considering the availability of software. Building hospitals and public health centers without having prepared professional personnel in position is squandering resources. “Such a mismatched situation between the two may result in a waste of resources,” Hsiao said.  

However, in the opinion of Cai Jiangnan, director of the Center for Health Management and Policy with the China Europe International Business School, China’s medical system does not lack trained professionals, rather they have quit to work in other industries. “The number is amazing. Hundreds of thousands, or even millions of professionals have been lost,” Cai said. 

A patient attends a fever clinic at a township healthcare center in Xiaogan, Hubei Province

The No.1 Hospital Affiliated to Zhengzhou University

Primary Healthcare
Chi-Man Winnie Yip, also a professor at Harvard T.H. Chan School of Public Health, has long studied the Chinese health system. She told NewsChina that many in China simply believe that the public health system is equivalent to the Center for Disease Control and Prevention, but in fact China’s healthcare reform strategy is to let the primary healthcare system assume the main function of public health. According to Yip, China has struck a course for the past 30 years like that of a large ship - developing hospitals to treat patients when they get sick. However, it must now change course and focus on a holistic system for lifelong care by building up and enhancing the grassroots healthcare system.  

In 2015, China put forward its “Healthy China 2030” strategy. “It is hoped that by 2030 China’s health system will be much more focused on preventive measures rather than curing diseases,” the strategy read. To achieve this goal, Yip said that China will need more professionals in primary healthcare or family doctors specializing in elder care.  

Xue Jidong, president of the No.2 People’s Hospital of Jiyuan, Henan Province, told NewsChina that township health centers have been in crisis in recent years. These health centers do not have high standards of treatment or nursing and can only prescribe basic drugs. Salaries are low, so staff are not incentivized, Xue said.  

“Capable healthcare employees from township hospitals all job-hop to city hospitals, leaving behind the least professional staff. If we don’t foster the development of township health centers, I’m afraid most will close,” Xue said.  

Liao Xinbo, deputy director of the former Health Department of Guangdong Province, published an article on medical-focused WeChat account “Vistamed” earlier this year that said: “Looking back on the course of Wuhan’s fight against the Covid-19 pandemic, the improvement of the community-level medical treatment system will be the most economic and effective measure to deal with a pandemic situation. 

“Service capacity-building of primary healthcare institutions should not only be reflected in public health for disease prevention, but also in the diagnosis and treatment of common diseases. Community medical providers should have the ability to deal with certain diseases to avoid overwhelming medical resources,” he said. 

According to an article published in medical journal The Lancet in 2019 titled “10 years of healthcare reform in China: progress and gaps in universal health coverage” co-authored by Professor Yip in China in 2017, approximately 58 percent of resources are concentrated in tertiary hospitals, but “Only 18 percent [is] at primary healthcare facilities. Such resource distribution is inefficient, costly, and does not meet the needs of the population,” the article said. 

“This round of new infrastructure will certainly strengthen the hardware of China’s health system and public health,” Cai Jiangnan said. But overall, Cai admitted that he still did not see any efforts put into particularly weak aspects that already exist and have been identified in the present health system.