China’s extreme measures in the battle against Covid-19 led to a 90% decline in new infections within the country. Now, 70% of all new cases are outside of China. At the time of writing, there have been over 121 000 confirmed cases in 118 countries – over half now fully recovered - with 4366 deaths since the outbreak began.

This article revisits the first weeks of the emergence of Covid-19 and examines:

China’s system of health care within the context of the outbreak
how Chinese people tend to seek medical attention when sick
the rise of telemedicine as a consequence of the crisis
challenges in China’s system of primary care and public health in general that may have contributed to the Covid-19 death toll, and
how lessons from the outbreak could turn China into a global leader in health.

Chinese health-seeking behaviours: a rejection of Primary Care

One of the biggest uncertainties during the first weeks of the Covid-19 outbreak was how many unconfirmed cases there were. It is now known that the virus had been circulating in Wuhan for weeks before detection. Many people did not seek medical attention with mild symptoms, neither did many with more severe symptoms, and, when they did, they tended to go to a hospital. In the early weeks of crisis, queues of severely infected people at hospitals would have certainly exacerbated the contagion. Many of these were turned away once hospitals became overwhelmed by the third week of January 2020.

With hospitals operating beyond capacity, by mid-February, people in Hubei province were issued with new government rules: those who think they may be infected should inform district officials about the symptoms. Then, they should go to local clinics, instead of directly to a hospital. This reflected a sea-change already underway, especially in Hubei province. As the virus spread, those with other illnesses avoided non-essential hospital visits, operations and treatments were postponed or cancelled and people went to hospitals only in emergency situations.

This new directive imposed a shift on the health-seeking behaviours of many people in China. People across the country favour going directly to specialised hospital services rather than accessing cheaper, local primary care clinics. For example, AAA hospitals receive 50% of all outpatients throughout the country, yet, are only one of 10 types of public healthcare facilities in China.

Traditionally, Chinese people prefer hospitals over primary care services because of a pervasive belief that hospitals offer more professional and more specialised care.

Why is this?

According to the “first law of health economics”, as countries become wealthier, they spend more on health. This has hardly been the case for China, where health care investment lags some way behind that of other Chinese infrastructures. Spending in health care is mostly bestowed upon cities. For example, Wuhan offers half of Hubei’s best medical facilities, but has only one-fifth of the province’s population.

This poor investment is no more apparent than in the Chinese primary care system. Primary care in China is geared to handling minor ailments and then more serious complaints are forwarded to specialists in secondary care. Only 5% of China’s registered doctors serve as GPs, whereas the average of OECD countries is 23%. Half of China’s GPs do not have a bachelor’s degree. In villages and small towns, the number of primary care doctors with degrees drops to 10 to 15% – the remainder are more reminiscent of the ’barefoot doctors’, who offered rudimentary and limited health care provision during the Mao era. Some GPs only practice Chinese traditional medicine, some of which has little scientific basis, but it is a branch of care that receives active promotion from central government.

Another concern with Chinese primary care doctors is whether illnesses are diagnosed and treated properly. A recent study from the World Bank employed the “mystery patient” method, where volunteer patients or actor-patients gave feedback of real GP consultations around the world and, for China, the findings were poor. On average, GP consultations lasted one minute, involved minimal fact-finding other than ‘what is wrong with you?’ and only 26% of Chinese consultations involved correct diagnoses. These findings were on a similar level to India, Paraguay, Senegal and Tanzania.

Switching to telemedicine

Since 2011, smartphone-based telemedicine services have mushroomed in China, with over 1000 Chinese companies, although many online doctors have been found to have little or no medical training. Nonetheless, since the Covid-19 crisis and quarantine measures within China, 10 million people have consulted online medical services, half of them were first-time online patients. This is because hospitals are turning away patients with illnesses other than Covid-19, people are confined to their homes and not attending local clinics for fear of becoming infected.

Prior to the outbreak, Chinese telemedicine services were legally restricted to booking consultations and handling and delivering repeat prescriptions. Since quarantine, telemedical services are now authorised to diagnose and treat. The government is encouraging hospitals to conduct consultations online.

This signals a shift in patient behaviour that occurred over a single month that would otherwise have taken five years. Will this cause a change in health-seeking behaviours in the China of the near future?

Public health challenges

In addition to primary care deficiencies, China has numerous vulnerabilities in the area of public health that have been laid bare during the Covid-19 crisis:

For years, there has been a chronic shortage of nurses in China. In most higher income countries, the nurse-doctor ratio is usually 3:1. In China, this ratio is 1:1. In Wuhan, 14 000 nurses were drafted in from around the country and figure highly amongst the 3200 health workers who were infected by the virus.
Air pollution causes the deaths of 1.6 million Chinese on average each year. Respiratory diseases and damaged lungs caused by pollution would have contributed to the death toll from Covid-19 in cities across China. A similar picture is emerging in Teheran.
China has the largest number of smokers in the world, accounting for 40% of tobacco consumption worldwide. As we gain a clearer picture of the nature of fatalities from the virus, long-term smokers are prominent amongst the victims.
At the beginning of the Covid-19 crisis, Xinhua, the government-ran news service, promoted the use of the traditional oral preparation, Shuang huan lian, to prevent the virus. This falls in line with the Chinese government’s keenness to promote traditional Chinese medicine. This advice was false, was challenged by the Chinese medical community, caused panic buying and the preparation offered no protection against Covid-19.

The (second) Great Leap Forward: Health care provision in China post-Covid-19

A country’s GDP is linked to the life expectancy of its people. In most countries where there have been continued economic growth, this tended to happen two decades after bringing infectious disease and infant mortality under control. In China, between 1960 and 1976, life expectancy increased by over 20 years, in spite of the Great Famine and the Cultural Revolution that left tens of millions dead.

Now an important global power, children born in China today have a life expectancy that is 30 years longer than children born in China 50 years ago. This is something that higher income countries took twice as long to achieve. China made this happen by launching sustained campaigns around fighting infectious disease, programmes of immunisation, rural hygiene, health education and improved sanitation.

Furthermore, China is in the process of an epidemiological transition, moving from fighting infectious disease, primarily in children, to managing chronic diseases in older people. This is symptomatic of a nation becoming richer and its inhabitants living longer. The fact that this transition is in its early stages is reflected in the country’s health expenditure: more money is spent on preventing infectious disease than chronic disease management, which receives only 2% of the health budget.

Experiences with Covid-19 could be a catalyst for positive change to China’s health system. It can no longer lag behind other Chinese infrastructure. Health-seeking behaviours of those infected exposed a lack of confidence in the Chinese Primary Care system, leading to the virus being spread further when hospitals became overwhelmed. Primary Care in China is in urgent need of an overhaul, as do disparities in the quality of health care provision in rural settings.

China could develop a more balanced expenditure with regard to chronic disease management. Health promotion activities around smoking cessation could become a priority, as should efforts to tackle air pollution to reduce the pulmonary damage through respiratory diseases that contributed to the death statistics during the Covid-19 outbreak.

Finally, China could become a global leader in unlocking the potential of telemedicine to bolster primary and secondary care, as well as to support sustained health promotion. This could be China’s second Great Leap Forward.

By Mark Gibson, Health Communication Specialist, 11th March 2020.

References:

Bollyky T, Health without Wealth: The worrying paradox of modern medical miracles, Foreign Affairs, November/December 2018
McDermott J, An affordable necessity, The Economist, April 28th 2018
Pearce F, How a ‘Toxic Cocktail’ Is Posing a Troubling Health Risk in China’s Cities, YaleEnvironment360, April 17 2018 https://e360.yale.edu/features/how-a-toxic-cocktail-is-posing-a-troubling-health-risk-in-chinese-cities
Sealed off, The Economist, February 1st 2020
The Smartphone will see you now, The Economist, March 7th 2020
Tracking the stealthy killer, The Economist, March 7th 2020
The Wuhan crisis, The Economist, January 25th 2020
Under observation, The Economist, February 8th 2020
Yiwei Z, Ying X, Ailing Market, The China Report, Vol. no. 67, December 2018
Yunpeng Ji, Potential association between COVID-19 mortality and health-care resource availability, The Lancet, February 25th 2020, https://doi.org/10.1016/S2214-109X(20)30068-1

Covid-19: changes in health-seeking behaviours in China