Domestic medical news platforms in China are recently awash with stories on corruption crackdowns, such as the notable case of over 150 hospital directors being implicated. Even financial news outlets are talking about the downfall in the pharmaceutical sector stocks, attributing it directly to the ongoing anti-corruption campaign. While Chinese medical media turns its focus to legal issues, international medical news remains largely occupied with typical reports like pharmaceutical companies' financial outcomes. This disparity creates an interesting divide in global perspectives.
However, the pressing concern remains: while many describe the Chinese medical sector as "deeply corrupt," there's little clarity on the extent or nature of this corruption. How can a problem be addressed if its depth and nuances are not fully understood?
Research Breakthrough on Medical Corruption
A recent article published in the February 2023 edition of "Health Policy and Planning," titled "Understanding Medical Corruption in China: a Mixed-Methods Study," brought forward by a collaboration of Chinese and American researchers, sheds light on this issue. The research, interestingly, utilizes verdict information from the Chinese Judicial Document Website, analyzing medical corruption cases from 2013 to 2019. This timeframe provides fresh insights, especially given recent reforms in China's medical insurance procurement.
In addition to this vast database, the study also tapped into a national survey on the infamous "red envelopes" (cash gifts) - a past emblem of medical corruption in China. Alongside this "big data," researchers conducted in-depth interviews with 17 key witnesses from the medical sector, including drug representatives, healthcare managers, doctors, and patients.
What the Numbers Say
The results reveal that the practice of giving "red envelopes" has become a rarity. National surveys from 2011 to 2018 indicate that only 0.4% of outpatient and 1.4% of inpatient patients had given red envelopes. Compared to other developing nations, patients in China are less likely to bribe their doctors directly.
Yet, the previous prevalence of this practice still negatively impacts the public's perception of the medical profession. The trust issues fostered by the red envelope culture haven't faded as swiftly as the practice itself. Why? One reason is the inherent power imbalance between medical providers and patients, which can manifest in various ways. For instance, while patients might never know about the kickbacks a doctor receives from a pharmaceutical company, the mere act of a doctor accepting a small red envelope can directly erode patient trust.
Despite the corruption challenges, it's essential to acknowledge the significant advancements made by China's medical sector over the decades. The decline of the "red envelope" phenomenon is one such progress that more people should be aware of, as it can help mend the strained doctor-patient relationships and bolster public trust in the healthcare system.
Emerging Trends in Medical Corruption
So, if red envelopes are out of the picture, in what form does medical corruption manifest itself now?
There are three main types of corruption in the healthcare sector:
- Theft, such as drug pilfering and embezzlement of public resources.
- Bribery, like kickbacks, which includes the aforementioned red envelopes.
- Fraudulent practices, such as insurance fraud.
From the nearly 4,000 cases of medical corruption identified in the research, the most common corruption form was bribery, comprising a whopping 68.1% of cases. Embezzlement followed at 22.8%, and fraud trailed at 9.1%.
So, if the practice of accepting red envelopes from patients has nearly vanished, who are the new bribe givers? The research points towards medical institutions as the major culprits, with a staggering 79.8% of all bribes originating from them. Government sources account for 14%, while medical insurance entities stand at 6.2%. The leading sectors involved in these bribes are pharmaceuticals (32%), medical equipment (26%), infrastructure (16%), and disposable medical supplies (12%).
This data implies that commercial bribery has now become the most significant issue in medical corruption. Suppliers in the medical industry, be it drug manufacturers or equipment providers, are often bribing hospital staff for a competitive edge.
The research also touched upon embezzlement, noting that while bribery might be seen as something professionals might be forced into due to various pressures, embezzlement was viewed as a straightforward act of unethical behavior with no external pressures involved.
Unmasking the Disparity
The notable variation in corruption levels in hospitals can be attributed to the fact that the primary culprits are often senior hospital officials. These individuals generally enjoy a substantial income and hold significant power within the administrative hierarchy. The fact that they don't force others into corrupt acts is a minor relief, given the gravity of their own actions.
There's growing concern over corruption at this high level. Key informants from the healthcare sector emphasize that these individuals wield considerable influence. If they engage in corrupt practices, it can potentially result in widespread corruption throughout the entire hospital system.
A closer look at commercial bribery cases reveals the role senior officials play in such scenarios. On average, these cases involve sums of 780,000 yuan. However, the median amount is only 200,000 yuan. This suggests that a few large cases dramatically skew the average. In fact, 468 officials or hospital directors have accepted bribes exceeding 10 million yuan. The most egregious case involves a provincial hospital director accepting over 100 million yuan. Today's anti-corruption measures in healthcare primarily address commercial bribery under the guise of market promotion, making it understandable why so many in hospital management are implicated.
A Balanced View on Medical Corruption Amidst the heated anti-corruption drive in healthcare, it's crucial to address medical corruption comprehensively. Despite the gradual decline of the "red envelope" phenomenon (bribes given by patients to doctors), we shouldn't negate the significant progress Chinese healthcare has achieved over the past decades. While bribery in the pharmaceutical industry remains rampant, initiatives like the centralized procurement system have started to curb such practices. The power dynamics of procurement and the substantial drop in drug pricing have significantly reduced the room for commercial bribery in pharmaceuticals.
However, an efficient healthcare system isn't just about integrity and cost-effectiveness; it's about efficacy and results. As the emphasis on price intensifies, there's a growing concern about the skewed assessment of healthcare value, which might not necessarily prioritize public benefit.
Furthermore, even if medical corruption has lessened over time, it doesn't mean the problem is eradicated or its impact has diminished. Research jointly conducted by Chinese and American researchers found that all key informants agreed on the negative repercussions of medical corruption, such as inflated medical costs and potential quality drops due to the use of subpar equipment and drugs.
Additionally, when the pharmaceutical industry's core competency shifts to bribing under the banner of market promotion, the long-term growth of the Chinese pharmaceutical sector is at risk. Recent media attention has shed light on domestic pharmaceutical companies' high marketing costs. In stark contrast, their research and development investments are minimal. This skewed balance raises concerns over the sustainability and competitive edge of these enterprises in a healthy medical market.
Medical corruption also strains the doctor-patient relationship and threatens the longevity of the healthcare industry. No matter how widespread the public perceives corruption to be, it remains a stain on society. Key informants from the healthcare sector emphasize that, even if bribery is common, it's still frowned upon. With such a rampant culture of bribery, how many young professionals will be willing to step into this field?
Sustainable Anti-Corruption Measures are Key While short-term crackdowns may deter potential offenders or block prevalent corrupt practices momentarily, lasting solutions require comprehensive and long-term systemic reforms.
For instance, the distorted reward system in healthcare services keeps the economic pressure of accepting commercial bribes alive. Over the past few decades, we've witnessed the evolution of medical corruption, shifting from accepting bribes from patients to kickbacks from enterprises. These practices have now morphed into sponsorships and service fees for academic conferences and exchanges. Without reforming the incentive structure in healthcare and ensuring reasonable incomes for hardworking doctors, companies might find new ways to exploit the system.
The research on healthcare corruption in China suggests adopting regulations similar to the Sunshine Act in developed countries. The U.S. passed the Physician Payments Sunshine Act in 2010, requiring pharmaceutical companies to annually report their financial interactions with doctors and hospitals for public scrutiny.
Such transparency is vital. Interaction between businesses and healthcare professionals can lead to crucial industry innovations. While financial interactions are a part of these collaborations, the public has every right to oversee such transactions.
Additionally, both internal and external regulatory mechanisms in healthcare institutions need strengthening. On average, cases of bribery and corruption take up to five years to be detected. A well-functioning healthcare system shouldn't wait half a decade to penalize corrupt officials. Effective internal monitoring can identify and rectify violations early on, minimizing corruption and the peer pressure associated with it.
