There was a potentially very revealing piece in the China Daily today, where Sun Zhang, Vice President of the National Development and Reform Commission, the government body responsible for coordinating economic development and the body ultimately in charge of China’s ongoing health reforms.
While the article is ostensibly about the NDRC’s recent move towards recruiting more general physicians to rural areas, this aspect of the article is actually the least interesting from a policy perspective. Nearly every country, if not every country in the world faces a physician shortage in its rural areas, whether or not its healthcare system is socialized, centralized, market based, or some amalgam of all three. Professionally trained physicians everywhere in the world follow career paths that take them to areas where they can gain the most reward for their long years of training, whether that reward be in the form of higher payment, prestige or other intangible life-enhancing benefits. Generalists and primary physicians, in particular, are hard to attract, and even train, due to the rigors and environmental factors that come along with being a primary care provider. In the US the urban/rural disparity in physicians is well documented, as is the shortage of general and primary care physicians. That, by the way, is not a criticism – I think it’s rather reasonable to expect of people who have a smaller career window, post-training, compared to other professions and careerists more generally.
What’s interesting about this article comes at the very end where Zeng Yixin, the president of Peking Union Medical College Hospital, lets it be known that he “suggested that the government should set up a program of ‘visiting general physicians’, and offer them 100,000 yuan ($15,896) a year in addition to their salaries.” This is quite a kingly offer if one considers that top of the line physician salaries are 3500 yuan ($560) per month, in China. Part of the problem with rural practice incentive programs for physicians in the US is that government coffers, no matter how generous, can’t hope to compete with salaries, although increased funding to the under PPACA seems to be having positive effects in recruiting more medical students to America’s Primary Care Health Personnel Shortage Areas (PCHPSAs). This program would go far above that. The salary bonus is two and a half times that of the top salary a physician can hope to receive from the state, and that’s on top of a salary that the rural general physicians would receive under Vice President Zhang’s plan.
If Vice President Zhang has made it known that this number has entered discussions as a target payment level for rural physicians, than that seems like an indication that there have been talks about increasing the pay of urban physicians, as well. Obviously physician compensation, in China, is made up of more than their official government salary alone, but it is nevertheless widely acknowledged that a low base salary is a principal cause of corruption amont China’s healthcare workers. This publicly acknowledged suggestion of Mr. Zhang’s then may have revealed more than just a planned grassroots endeavor. It may in fact signal an upcoming major shift in physician compensation. If a salary boost to physicians everywhere were to be realized, then China’s dire medical student recruitment picture could start to change for the better. Following that, the health reforms may truly start to address the so far unaddressed issue of improper physician incentivization.
China boosts investment in grassroots healthcare
Updated: 2012-11-02 22:03
By Wang Qingyun (chinadaily.com.cn)
China has made a great effort to nurture qualified grassroots healthcare workers, the Minister of Health said on Thursday.
“The central government invested 450 million yuan ($721 million) to help 285 medical institutions train general physicians, and 50,000 grassroots healthcare workers participated in the training,” said Chen Zhu on the opening ceremony of the Second Global Symposium on Health Systems Research.
According to Chen, in the last three years, grassroots healthcare providers have given 10.8 billion consultations.
Grassroots healthcare providers include township-level hospitals, community healthcare centers and village healthcare stations.
The Chinese government started the latest round of healthcare reform in 2009. One of the reform’s goals is to provide affordable and high-quality healthcare services at the grassroots level, so that people don’t have to travel to large urban hospitals, which offer better but more expensive services, and which are limited in number.
“In the past three years, we have established a healthcare network that covers the largest population in the world,” said Sun Zhigang, vice-minister of the National Development and Reform Commission.
“We have strengthened training bases for general physicians, and have gradually developed a healthcare model where grassroots healthcare institutions and urban hospitals are each assigned reasonable and different tasks,” he said.
Zeng Yixin, president of the Peking Union Medical College Hospital, believes that qualified employees are crucial to consolidate healthcare services at the grassroots level.
“The key to improve grassroots healthcare levels is to attract more talent into the local healthcare systems,” said Zeng, who emphasized that being a grassroots healthcare worker is a demanding profession.
“A grassroots healthcare worker is first a general physician. Second, they should pay attention to preventive healthcare. Third, they should provide education on basic health knowledge. Also, those healthcare workers must have good interpersonal skills,” he said.
In July 2011, the State Council issued a guideline to increase grassroots general physicians to two to three qualified general physicians for every 10,000 people by 2020.
The Chinese government requires that a medical graduate should take up a three-year or two-year training program, rotating among different departments, before qualifying as a general physician.
However, grassroots healthcare centers in less developed areas have found it hard to recruit workers who are both willing and able to work there.
Zeng suggested that the government should set up a program of “visiting general physicians”, and offer them100,000 yuan ($15,896) a year in addition to their salaries.
“Hopefully, these people will further educate their colleagues and help to improve the quality of the local grassroots healthcare services,” said Zeng
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About the Author
The article you cited attributes the quote about paying “visiting general physicians” an extra 100,000 RMB to Zeng Yixin, the president of Peking Union Medical College Hospital, not Sun Zhigang (VP of the NDRC). While I’m sure Dr. Zeng is influential in NDRC policy circles, I don’t think his suggestions should be interpreted as agreed-upon policy.
I think this is a good idea, but I’m skeptical that even dishing out such a large amount of money would solve the problem. As you point out, the US has many programs designed to attract physicians to rural areas. Many of them are very generous, yet the problem remains. The money makes it realistic for some people, but most people practice rural medicine for reasons other than money, and it’s difficult to see this changing in the US or China.
In China, however, the quality of life difference between urban centers and rural areas is far greater than in the US, so I think Chinese doctors would be even less likely to move to the countryside, even for such a large amount of money. Imagine growing up and getting educated in Shanghai and then practicing medicine in a place that has open pit toilets, no dating/marriage prospects, no entertainment, and very low prestige. I don’t think 100,000 RMB a year is gonna do it for most urban-dwelling medical students.
Research in the US has found that certain characteristics in medical school students’ backgrounds make them more likely to practice in rural areas. Among them are coming from a rural and/or low socioeconomic background. But if the composition of Chinese medical schools is similar to American ones, these people tend to be very underrepresented, which contributes to the problem to begin with.
Hey Stephen,
1) Good spot on the quote miscue. Fixed it.
2) I did not say this should be viewed as agreed upon policy. Rather, I said that it signals to me that conversations about increasing physician compensation are happening at very high levels.
3) I have to disagree with your assessment of what 100,000 RMB would do for physicians moving to the countryside. While physicians take into consideration intangibles like prestige and lifestyle, the data for US physicians on just how much these factors influence physicians choice of practice area is slim, almost entirely because designing the proper methodology to measure such data is very hard. What we do know is that money influences physicians quite a bit. We saw it when rates of medical students going into primary care spiked with the rise of HMOs in the 1990s, dipping in turn with HMOs downfall later on; we see it with the primary physician shortage in the US today and the corresponding glut of specialists; and as mentioned in the post, we see how even relatively modest contributions from the NHSC is already shaping the decision making of students. This list can go on for pages, since every public health class I’ve ever taken seems to be obsessed with the link between compensation and physician recruitment.
The point about rural-urban disparities in China being greater than in the US is debatable for many areas in the US. When I was doing poverty research in North Carolina, in the mid 2000′s () our surveying took us to places that you may not believe. No running water, no toilets, no grocery stores within a reasonable distance, and all of this smack dab in the middle of the East Coast. The area we were doing work in has demographic and social factors that extend from Virginia down through Florida, comprising something called “the Stroke Belt” due to higher prevalence of heart disease among those populations.
Therefore, I’m not convinced that if we were to look at only environmental factors, recruiting Chinese physicians to China’s rural areas is absolutely harder in every case than doing the same in the US context. It is just as hard in many US areas to recruit rural physicians as it is, in China. China is of course, on the whole poorer, so the result of a 100,000 bonus would not be evenly felt across the continent, but if a bonus could do that than every country in the world would be doing it since there would be little need for further health planning.
Moreover, perception of benefit is relative within a society. A 100,000 RMB bonus, per year, in a society where the average salary is less than half that, would be a big deal. Relatively to others, rural doctors would suddenly be doing very well indeed. Prestige in China, like elsewhere, is based on income, unless the income is taken away in which case prestige becomes tied to other things – like publication in academia. Assuming that medical students would hang on to old notions of prestige in the Chinese medical profession, notions that stem from the fact that everyone’s pay has officially been more or less the same for decades, is not, in my view, a good assumption. Those urban medical students you mention still live in small rooms with many roommates. When they reach senior status, even then, they can expect a small apartment, in a neighborhood that’s maybe close to their place of work but doesn’t have to be, and no real prospects under the current system for an increase in pay. Of course, there are physicians who moonlight in private clinics, hospitals, gray-area home clinics, and after June we will see more physicians opening government supported private clinics in cities. Medical students in urban centers certainly have their eye on these developments. These are all ways that urban doctors can make more money than their rural counterparts. But medical students are also aware that this route is one reserved for a select few, and it is highly risky. Why not take a guaranteed 100,000 per year, more when you count the salary, and move into the grassroots system for a few years?
This is not, by the way, an unprecedented notion. China has recently developed a big problem with medical students all together eschewing practice in supposedly “prestigious” urban hospitals and medical centers, to move into the private sector as sales reps for pharmaceutical companies. Obviously many of these jobs are in urban centers, but not all of them. Grassroots pharmacies are principal distributors of drugs in China, so some of these reps have to be living in rural areas or areas bordering rural markets.
4) Your point about the potential underrepresentation of minorities, geographic and ethnic, in medical schools is an intriguing one. But I just haven’t seen any data on Chinese medical school graduates this to make a comment. Because of the correlations you mentioned new medical schools currently under review for AAMC accreditation, including either 3 or 4 in Michigan (I can’t remember off the top of my head), are being designed to attract students from rural backgrounds with an interest in primary care. I wonder how much of this already goes on, in China – are their medical schools there that focus solely on rural applicants? Applicants from poorer provinces?. The data you point out for the US also strongly correlates with race. So this problem of underrepresentation could, if we were to comparatively extrapolate here, be in play for China’s minority population.
Mr. Denoble,
I wonder if the promise of higher salary upon taking a job in the countryside’s influencing Chinese doctors to leave large urban areas would have a similar effect on English-speaking Chinese doctors who want to move to the USA? The reason I ask is that I want to research the prevalence of Chinese doctors taking the American boards or USMLE exams for the purpose of moving to America to practice.
Do you have any information on that?
Thanks,
Mark W.
Shanghai, China
Mark,
For whatever reason, the brain drain of physicians from China to the US and other countries is very low. I recall seeing something a few weeks ago that puts the number on the order of less than 5% of all physicians in China that graduate from medical school.
That being said, yes. America has traditionally heavily supplemented its primary care physician workforce with physicians trained outside of the US. I think the number in recent years has hovered around 25% of all primary care physicians. Those numbers may shrink with the first introduction of new medical schools and expanded funding for residency programs in nearly thirty years, but it should remain significant. (There are also new requirements for foreign physicians who want to practice in the US. They have to commit to serve two years in a medically underserved area of the United States upon completion of residency, or serve two years in their home country upon completion before they are allowed to practice elsewhere in the United States.)
Why America has been successful at keeping these physicians seems to be pretty straightforward – higher pay. Although primary care physicians in the US make less relative to their non-primary care peers in the US, they still make more than primary physicians elsewhere, on the whole.
So to me the question you pose is a very interesting one if you’re looking at 1) Chinese physicians looking to practice in the US through the USMLE process, 2) who are making the decision between practicing in a rural area versus their home country for two years after residency. Which path will they choose? Why?
Keep me update on this. It sounds like it could develop into a really great question.
Mr. Denoble,
I am trying to determine if there is a market For American medical board test and or other types of certification and medical education computer software in China. A couple of foreign doctors think the only Possibility is for doctors who want to emigrate to the USA to practice and yet they cannot pass the boards because it is too difficult without training services. What do you think?
Thanks,
Mark W.
Given the substantial differences in medical education between the two countries, I think the USMLE still would be prohibitively difficult for the vast majority of Chinese medical school graduates even with training services, but there probably is a market for that.
Page 20 of the report below from USMLE shows that only 3.2% (310) of foreign medical graduates graduated from a Chinese medical school and only 3% (289) were Chinese citizens. (Not sure if this includes Hong Kong and Taiwan since they are not listed separately). Unfortunately, it doesn’t list the passage rate by country, so we don’t know how many Chinese med students took the test and didn’t pass. The overall FMG passage rates are fairly high, but the majority of FMG’s come from English- or Spanish-speaking countries with strong Western medicine influence (India, Pakistan, Philippines, etc). It would seem that passage rates would be much lower for test-takers who were not educated in a Western/English-language educational system. But I’m curious how dramatically those challenges could be reversed with USMLE prep programs.
I’m also very interested in how this develops.
Hello. I am currently a Pre-med student here in the United States. I would like to know why on earth are the salary for doctors and nurses so low in mainland China? Many of my international friends from China always looked down on me because I was planning on going into the medical profession. Why is it such is the medical field so badly represented to the Chiense?