What makes a hospital Chinese?

In academic circles a lot of work is done trying to understand the concept of “Chineseness”, or “中国情”. In non-academic terms the question being asked is what makes something, like a country or a certain commercial product, or someone, Chinese?

It seems simple – I’m sure more than one of you wants to say, “well, being Chinese makes someone Chinese” – but there’s more to it, or so I’m led to believe here at Michigan’s Chinese studies department. Still, I’m also inclined to believe that the question is a good one from a business point of view. After all, marketers who work with China have built up entire businesses by essentially striving to find better answers to the question than the other guy. The reason that marketers like this can make money is that their client’s customers, who are Chinese, seem to care whether the products they shop for understand what it is that they want to buy.

So isn’t it the case, for those of us concerned with the business of hospitals, that the question of What Makes a Hospital Chinese? is a truly important one to understand?

Generally speaking, there is among would-be hospital investors a conviction that making a hospital work in China takes prior knowledge of how a well-managed modern hospital is supposed to work, abundant political capital, some time to figure out how to navigate all of the regulations one needs to comply with before entering the Chinese market, and baseline awareness of attendant concerns related to workforce and capital shortages of the Chinese market. And to understand all of these matters is, in fact, very important. But, having an understanding of the regulatory and labor force environment one is entering into, as well as the political and capital resources necessary to operate in China is not the same as understanding how to make one’s hospital, once already in country, Chinese. Arguably, mastery of the former gets you up and running in China, while mastery of the latter component will keep you running and have you thriving in China.

This, in any case, one of the lessons I took away from the experiences of the first wave of American hospitals to operate in China, as described in the excellent book, , by Michelle Renshaw.

Ms. Renshaw’s thorough examination deals with how American missionary hospitals, as well as later secular institutions like Peking Union Medical College, found out the hard way that it was not enough to simply bring a good medical product to the Chinese. It was also important to bring a Chinese product to the Chinese (hence the title).

Incorporation of traditional Chinese aesthetic into architecture design, gender division of inpatient departments, assimilation of Western and Chinese notions of health service and proper payment, and the transformation of outpatient departments into stylized versions of traditional Chinese pharmacy fronts, all of these were innovations that resulted from the trial and error misadventures of hundreds of American hospitals in China between the middle of the 19^th century and the beginning of the 1930s.

Most basically the stylization of the modern American hospital, particularly the multi-floored, industrially proportioned and cordoned-off research hospital that started to come into being at the end of the 19^th century had to be adapted for Chinese sensibilities. In some communities this meant that hospital buildings had to be limited to two floors – a traditional aesthetic preference of the period– or risk the sometime violent reprisals of the local community.

But design changes elsewhere had to confirm from less obvious pressures. For example, “Western” doctors, even native Chinese who had studied Western medicine abroad and had come back to China, were perceived as rather cold due to the perceived aloofness of Western medical practices. X-rays and industrial-white hallways were a far cry from the garden-rich veranda offices of traditional Chinese physicians. Harry Hussey, the architect of Peking Union Medical College, incorporated into his design for the Church General Hospital at Wuchang. As described by Michelle Renshaw,

The Church General Hospital at Wuchang

Still an even less obvious pressure was that of payment. The dilemma of the American missionary hospital ‘executive’ in China was (1) whether to charge at all, and (2) how much? And, to whom? The dilemma existed because missionary hospitals were founded with the primary goal of  evangelizing its patients. There were some in the American hospital missionary community who felt that charging for services would make evangelizing impossible, while others felt that it was a necessary evil. Still, without the public health mandate of a colonial government to force patients into their hospitals, it was a dilemma shared by all.

It is tempting perhaps to dismiss these sorts of stylistic and operational concerns as outdated for today’s American or foreign hospitals trying to make good in China. Renshaw’s China is primarily the Qing Dynasty China of the Empress Cixi. The China of the May 4^th movement and the Nationalist Kuomintang government sought to rid itself of much of the Confucian-inspired tradition that gave the American hospital operators of this time so much headache. More recently, the Cultural Revolution and the new China industrial explosion of the last twenty years have also chased away and paved over much of what remained of traditional Chinese values, while “Western” medicine has become by far the dominant provider of acute and long-term care in China.

On the other hand I am also tempted to say that not much has changed at all.  For one thing, like the America missionary forerunners of today’s foreign hospital operators in China, there is no public mandate that requires patients go to certain hospitals: private hospitals run by foreigners are completely outside of the regionalized healthcare system. So the question of how to attract Chinese patients is still relevant. For another thing, those early hospital operators found the greatest source of revenue to be in the sale of pharmaceuticals, which readers will know is still the primary source of revenue for China’s physicians. Is this aspect of healthcare in China a component of “hospital Chineseness”? Or is it an undesired practice that will be successfully defeated by the ongoing healthcare reforms (as coverage of a recent MOH announcement, which we translated, would lead on)?

The debate on this issue will, I think, be very important again. China’s MOH has announced an initiative to have 20% of all available beds in the country be private beds by the end of 2015. The MOH has also stressed that it will strive to differentiate private hospital players from their public counterparts, and at the same time integrate private hospitals with the regionalized healthcare system. This will doubtless increase the number of foreign investors coming into China. The question of what works and what doesn’t in the China hospital context will only get more salient with time as the initial question of how to get in to China at all becomes one that is more easily answered.