China’s super-sized hospitals may not actually be better for nation's health

Just before midnight, the pavement outside the glowing high-rise towers of the First Affiliated Hospital of Zhengzhou University is littered with slumbering bodies. Spread out on colourful mats or tucked into folding cots, these are patients’ relatives. Inside, beds line hallways and crowd elevator lobbies, while relatives share trolleys with patients and doze in brightly lit stairwells. The hospital in Zhengzhou, in central China’s Henan province, is the biggest in the world with about 7,000 beds – but still it is not big enough. My dad paid for a bed but still couldn’t get one Ma Wenxiao, a university student from Wuhan “My dad paid for a bed but still couldn’t get one,” said Ma Wenxiao, a university student from the central city of Wuhan , whose father waited two days for a bed after travelling to Zhengzhou for chemotherapy. Demand for healthcare is booming in China – driven by a growing middle class, improved health insurance coverage and an ageing population. In response, some of the country’s public hospitals are adding beds by the thousand. China now has 16 public hospitals with more than 3,000 beds. However, unlike the rest of the economy, where China wants growth, this expansion has policymakers worried. Hospital expansion in the cities testifies to a lack of public confidence in rural healthcare. They add to local government debt and may not be providing cost-effective care. Last summer, Beijing issued a directive restricting expansion of public hospitals, but hospital administrators appear to be finding ways around it. Hospitals’ building surge, and the government’s response, highlights the dilemmas facing the country’s healthcare system, experts say. Liu Tingfang, a professor at Beijing’s Tsinghua University, said that in China today, “hospitals have to expand if they want to survive”. Despite government efforts to encourage patients to use smaller local hospitals, most Chinese people still feel safer being treated – for everything from earaches to emphysema – in major university-affiliated hospitals in the big cities. Hospital chiefs, too, believe that bigger is better. Government funding provides less than 10 per cent of state hospital operating budgets, and the state holds public hospital fees low to keep care affordable. As China has chipped away at the profits from medicines that they once relied on, many hospitals see expansion as a way to increase revenues. Big hospitals often have the support of local governments, which approve and help fund hospital expansion – in part because they are evaluated on their ability to drive growth. China’s big hospitals are now so large that some have their own police stations. One doctor at the First Affiliated Hospital of Wenzhou Medical University even briefly wore roller skates to get around the wards faster after the hospital’s expansion. But even as patients flock to them, giant hospitals have become magnets for controversy. Patients come to the big hospitals expecting to see leading doctors, said Li Huijuan, a Beijing-based lawyer who handles medical cases. However, rapidly expanding hospitals have to hire less experienced medics, creating a gap between a patient’s expectations and reality that “can cause or exacerbate conflicts between doctors and patients”, Li said. Rapid expansion can also increase pressure on medical personnel because increases in bed numbers may outpace growth in staffing levels. As the recent Middle East respiratory syndrome (Mers) outbreak in South Korea has shown, large and oversubscribed hospitals can be conduits for infection and disease. About half of the nearly 200 cases of Mers in the South Korea were traced to Seoul’s 1,900-bed Samsung Medical Centre, where long waiting times for a bed are common. “When you have a lot of people packed in a small area, it increases the risk of transmission of infectious pathogens,” said Neil Fishman, associate chief medical officer at the University of Pennsylvania Health System, in the US. An official at Zhengzhou First Affiliated said the large volume of patients was a reflection of demand, and that the hospital did daily inspections to ensure patient safety. However, the hospital declined requests for an interview. According to its website, the hospital plans to add 3,000 beds at another location. The problems that giant hospitals create have caused a ripple through China’s healthcare system. Between 60 per cent and 80 per cent of patients visiting to big hospitals could be treated at community medical centres, said Ma Jingdong, associate professor at Huazhong University of Science and Technology in Wuhan . Big hospitals may also have high-cost bases and be poorly suited to providing continuous care for chronic diseases. “We may be spending a lot, but in reality, we may not seeing the same level of returns in terms of public health,” Ma said. Chen Xiaoming, president of the First Affiliated Hospital of Wenzhou Medical University, said that the number of beds at his hospital – currently 3,770 at two locations – might be reduced in the coming years in line with government reforms. Yet the public’s healthy, unswerving faith in big hospitals may be hard to shake. Standing in a swirl of people at the Zhengzhou hospital, a man who would give his name only as Cai said he had not thought twice about rising at 5am and waiting for several hours so that his wife could see a gynaecologist – perhaps for no more than a minute. “This is normal,” Cai said, surveying the crowd. “Chinese people are used to this.”