Physician Behavior Analysis under a Free Health Care System: An Empirical Research on Surmang Charity Clinic in Qinghai Tibetan Area Abstract: Based on the data of systematic medical institutions investigation and in-depth interviews of their responsible persons and practitioners in Qinghai Province undertaken in 2009, the paper focused on description and analysis of physician behaviors in treatment strategies and drug selections provided by a charity clinic compared with public medical institutions. The results show that physician behaviors in treatment strategies and drug selections provided by the charity clinic were markedly different from that by the public, primary medical institutions. The charity clinic provided better primary health care services than public, primary medical institutions. The rational physician behaviors of the charity clinic were built on physician’s high income, excellent professional training, and good professional reputation. Key words: Tibetan Area; clinic; free health care; health service; physician behavior
The Chinese government has always been focusing on the input in and development of rural primary level health care service. Many reform measures in the new cooperative medical scheme are related to primary medical institutions, such as the implementation of primary drug system, duel lines of income and expenditure, elimination of price rise of drugs and improvement of the public health function. The government is attempting to improve the conditions of primary medical institutions, enhance the physician behaviors through rational incentive mechanism and increase the welfare of farmers. Unfortunately, these measures have failed to completely exempt the farmers from the medical burdens; under the new cooperative medical scheme (NCMS), individuals still have to pay the major part of the medical expenses and costs of the drug. The surveyed Tibetan Area in Qinghai is located in the remote, impoverished and less-developed mid-western part of China. In this area, people suffer weak health conditions and less access to health services. Under the current medical care system, the public, primary medical institutions play a crucial role in improving the health of local farmers. However, there are problems in service efficiency, service access and service quality. Overtreatment, shortage of health promotion and health service provision also occur to physicians. So, if completely free medical service and drugs are provided by the public, primary medical institutions, will the physician behaviors and the health of the farmers be different? The Surmang charity clinic surveyed provides us with a chance to know about the physician behaviors under the free health care system.
The Surmang charity clinic is a primary clinic providing free medical and health care service founded by Surmang Foundation (the Foundation) in Surmang Dutsi-til, a Tibetan region in Qinghai in 1996. After starting its operation, the clinic served over 70,000 patients with its core services (from 2000 to late July, 2009), and the number of patients it receives sees a rapid annual soar. It has contributed remarkably to the improvement of the basic health conditions of the local residents. This study provides an analysis of the behavior of physicians in Surmang charity clinic in providing health services and its distinction from that of public, primary medical institutions, in the anticipation of providing reference for reform of primary health care system and solving more health care problems in the regions of ethnic minorities and impoverished regions in Western China.
1. Source of statistics
From July to August, 2009, we conducted a systematic institutional survey on how health services are provided in public, primary medical institutions and Surmang Charity Clinic in Yushu Tibetan Area in Qinghai Province. In-depth interviews on responsible person of the institutions concerned and medical practitioners were arranged, and open-end interviews were given on key cases. There are 21 interviews in all. Contents of the survey include service provision by different kinds of service-providers, resource-reserves and capacity of services, with emphasis put on the physician behaviors of Surmang charity clinic and its influence on the covered areas.
2. The model of free health care implemented by Surmang charity clinic
The model of free medical care in Surmang charity clinic is featured by: provide drugs and health care service free of charge, hire full-time physicians with high pay and provide quality training and train community health workers for free to promote health education for people.
Surmang charity clinic hired one full-time general practitioner when it started formal operation in 2000, and recruited one more in 2003. Besides, the Foundation recruits volunteers from abroad irregularly each year and the doctors will bring drugs and provide service in the clinic, frequently holds health-promotions programs and trains the community health workers. Surmang charity clinic offers pay and lodgings for the full time general practitioners, and dispatches one doctor to Beijing for at least one-month vocational training each year. When volunteers arrive each summer, they will select health workers from the local community and provide training for them. They will also provide professional trainings for doctors in Surmang charity clinic.
Doctors of Surmang charity clinic provide general medical services through the years and have basically met the general medical demand of the local residents. In 2000, there were over 6000 persons received and treated and over 16000 in 2008. The number of received patients, in the first half of 2009, topped 10000. Over 80% of its patients are from Yushu County, a majority of whom are local— from Surmang Dutsi-til (with a population of around 7000). The second main source of patients is Chamdo County which neighbors Modi Village where the clinic is located. The survey reveals that there are also patients from Xialaxiu over 150 km away from the clinic, which shows that the clinic’s service covers a comparatively large area. Surmang charity clinic has created a health record for every treated local villager. A number of community health workers trained by Surmang charity clinic have become a vital force in providing health services to the local community.
While providing free health car services, Surmang charity clinic actively set up a practical operating model in line with the reality in the remote areas, such as practical and feasible management model, methods for training health care staff, and health education for local residents, which has achieved positive effect.
3. Major Discoveries 3.1 Surmang charity clinic has a strong capacity in providing primary health services
The survey reveals that common diseases treated in Surmang charity clinic are gastro-enteritis,
arthritis, hypertension, common cold, cholecystitis, ocular diseases, stomatopathy, etc. Common diseases of pediatrics are diarrhea, verminosis, etc, and diseases commonly encountered in gynecology are adnexitis, etc. Common diseases that need doctor visit are hypertension, bone fracture, dystocia, etc. Surmang charity clinic not only treats a diversity of diseases commonly found in rural Qinghai Province, but also demonstrates a stronger capability in ophthalmology and otorhinolaryngology, dermatology, and women’s health care, than the public, primary medical institutions. Compared with outpatient clinic service of county-level hospitals, it also performs well in providing primary health care services and alleviates the workload of county-level hospitals (see table 1).
3.2 Doctors of Surmang charity clinic adopt rational therapeutic methods
The survey discovered that therapeutic methods used by Surmang charity clinic are largely different from those used in public, primary medical institutions, by Tibetan doctors and village-doctors. Table 2 shows the therapeutic comparison between Surmang charity clinic and public, primary medical institutions in Surmang Dutsi-til. Doctors of Surmang charity clinic intend to choose the most economic therapeutic methods which yields the most benefits to the community and individual health.
3.2.1 Medical measures. Doctors in Surmang charity clinic generally resort to the fewest medical measures. Around 40% of the visiting patients are given just health education instead of drugs. The principle for drug use is: minimize the use of multi-drugs, and avoid intravenous injection when possible. In the clinic’s prescribed medications, injections take up less than 10%, of which, intramuscular injection is used for children only when fever persists. The doctors here try to minimize drug-abuse and overtreatment.
In public, primary medical institution, after inquiry about the symptoms, doctors usually prescribe medication as treatment. In using western drugs, over half are injections, of which 90% are intravenous injections. Sometimes, the patients make their own judgments and decide whether to use drugs or not. Doctors sometimes sell drugs without any analysis. Some patients whose diseases were confirmed in hospitals above county-levels come to the public, primary medical institution, with doctor’s advice for injections.
3.2.2 Use of antibiotics and hormones. Doctors in Surmang charity clinic are precautious in avoiding improper use of antibiotics and hormones. In treating the infected patients, except in dire need, generally antibiotics is not used. When it is necessary to use, normally only one type of sensitive antibiotic is used for one disease,for only 3 days. Hormones is only used in critical condition, and is not used as a routine prescription. Patients feedback their at-home post-treatment conditions to the doctors who think that restriction in antibiotics use reduces the infection among local residents and make them more sensitive to antibiotics. Table 1: Common Diseases Found in Medical Institutions of All Levels and the Rural Areas of Qinghai
Township-level Medical Outpatient Services of
* means the ranking is in line with the medical records of Surmang charity clinic over the latest five years;** means the
ranking is in accordance with interviews and the recent medial records.
While in public, primary medical institutions, antibiotics are used frequently, and there is no restriction on hormones. Surveys show that more than half of the drugs used by doctors of the primary medical institutions are antibiotics and that approximately 80 percent of the drugs used in injections are also antibiotics, and they are usually used for three to six days. Meanwhile, hormones are often used in intravenous injections.
3.2.3 Health education and psychological counseling. Doctors in Surmang charity clinic advocate health knowledge to all of their patients, and around 40 percent of the patients are only offered suggestions on diet and behaviors with no drugs. As for those who are psychologically dependent on drugs, particularly antibiotics, doctors, in general, only provide them with psychological counseling. After the persuasion, patients usually think that they have got the best answers and then return home with satisfaction. For instance, if it is determined by doctors that they have viral diseases, doctors would tell patients to drink boiled water, have more rests and pay attention to hygiene (in particular keep hands clean), so as to prevent themselves from infections. 3.2.4 Pay attention to the long-term benefits of health. Doctors in Surmang charity clinic are committed to improving the health level of local people, not pursuing any profit or short-term benefit. Since a long-term cooperative relationship has been established and stabilized between doctors and patients, doctors not only pay much attention to the treatment practices of low cost and wide coverage, but also make great efforts to improve local disease spectrums and protect people’s long-term benefits of health. 3.3 Doctors of Surmang charity clinic use drugs rationally
Surmang charity clinic provides 139 kinds of common drugs, of which there are 16 kinds of commonly used oral antibiotics and 7 kinds of common antibiotic injections. According to the list of common diseases, doctors of the clinic commonly use 78 drugs. A check with the National Essential Drugs List (for Primary Healthcare Facilities) (2009) finds that 35 drugs are included in the list, and other 43 drugs also belong to inexpensive and affordable essential drugs (see Table 3). Surveys show that doctors of Surmang charity clinic use these essential drugs reasonably in the diagnosis and treatment process and effectively cure various common diseases.
When we conducted the survey in Surmang charity clinic, we met two trauma patients. Doctors cleaned up their wounds, sewed them up, and then changed the dressings and took out the stitches, and they applied no antibiotics to either of them. We followed the whole process of their diagnoses and found that they recovered fast and are both in good conditions.
Table 2: Comparison of Different Medical Institutions in terms of the Sponsors, Charges and Treatment
Surmang Public, Primary Medical Institutions
There are charges for drugs and some kinds of treatment and
no charges for registration, physical examination or injection.
Table 3: Drugs Used for Common Diseases in Surmang Charity Clinic
Metoclopramide, Yeast tablets*, Cimetidine*, Famotidine, Cabernet Franc
Sidel, Domperidone, Stomach Bristol*, Belladonna, Dimethicone Tablets*,
Ibuprofen, Indomethacin, Piroxicam tablets*, Red Flower Oil*, Musk
analgesic cream*, Joint pain relief cream*, Cephalexin, Paracetamol,
Metoprolol tablets*, Hydrochlorothiazide, Captopril Tablets, Apocynum
tablets*, Compound antihypertensive capsule*, Enteric-coated aspirin*,
Liquorice tablets, Ciprofloxacin, Compound Diclofenac Sodium
Chlorphenamine Maleate*, Watermelon frost lozenge*, Paracetamol, New
Suxiao Capsule*, Spirulina*, APC*, Metronidazole, Oxytetracycline*(used
Choleretic alcohol*, Xiaoyan Lidan Pian, Dantong*, Limonene capsules*
Amoxicillin granules, Erythromycin particles, Erythromycin Ethylsuccinate
Tablets*, Cephalosporin, Liquorice tablets, Antipyretic suppository*,
Compound Sulfadimidine Powder (for children)*, Bupleurum, Dry yeast*,
Multivitamin, Vitamin A and D Drops*, Prednisone (only used in special
Ibuprofen, Red Flower Oil*, Band-Aid*, Burn Ointment*, Ciprofloxacin,
Cephalexin (only used when the wound is festering)
Metronidazole, Tetracycline*, Norfloxacin Capsules, Furazolidone*
Zhenzhu Mingmu Diyanye*, Qianbai Biyan Tablets*, Erythromycin eye
Toothache drops*, Clofenamic Acid*, Vitamin B2, Penicillin V Potassium*,
Skinheal Cream*, Fluocinolone*, Urea ointment, Tetracycline ointment*
Mebendazole Tablets*, Albendazole Tablets
Rifampicin, Ethambutol, Isoniazid, Glucurolactone*, Vitamin B6
*: drugs not included in the National Essential Drugs List (for Primary Healthcare Facilities) (2009).
It is the behaviors of providers that decide the influence of medical activities on people’s health. Doctors are major providers of medical activities; therefore it is a significant subject to study physician behaviors. In accordance with this research, the reason why physician behaviors of Surmang charity clinic are obviously different from those of public, primary medical institutions may lie in the following aspects:
4.1 Lifting of the profit-driven mechanism
Compared with public, primary medical institutions, doctors of Surmang charity clinic have no pressure of operation and survival. They freely provide medical services and drugs, and no doctors sell drugs or provide excessive medical services for profits. This complies with the concept of building two independent lines of revenue and expenditure that is implemented in China’s medical reform.
4.2 The influence of income on physician behaviors
In 2009, the monthly salary of the doctors in Surmang charity clinic was RMB 4,000. The salary of its doctors, slightly higher than that of county-level public servants, was equivalent to the upper income level of local villagers. Doctors of Surmang charity clinic are paid salaries, and the administrative cost of this kind of payment might be the lowest. When the market value of doctors can be well reflected by proper income, bad physician behaviors pursuing profits are directly reduced.
4.3 The professional training and physician behaviors
In the surveyed area, public, primary medical institutions have more full-time staff than the clinic, but the professional quality of their staff is relatively low. While in Surmang charity clinic, local doctors can receive sustained trainings to effectively improve their professional expertise and become qualified for providing medical services. Good trainings also increase people’s demand for health care services. In contrast, local primary medical institutions lack professionals, and the medical behaviors of their staff are not standardized. Rural doctors can not receive enough professional training, and the capability of these institutions in providing primary health care services needs to be improved. Surveys show that although local county-level hospitals send medical staff to assist the health care services in rural areas and provide helps for designated public, primary medical institutions, the services these institutions can provide are vey limited. Therefore, it shall be put on the government’s agenda to take the development and training of doctors and the improvement of their professional capabilities as the key to develop the rural health care cause, so as to enhance the quality of rural health care services.
4.4 The reputation of doctors and physician behaviors
In medical services, doctors are both the agents of patients and the ones to maximize their own interests. The interests of patients may conflict with those interests of doctors. If the providers are profitable, there will certainly be conflicts between the two groups. Based on this, non-profit medical institutions can reduce this kind of conflicts, but the lack of profit motives may lead to low efficiency. The reason for doctors in Surmang charity clinic to achieve high efficiency and good effects in this non-profit clinic lies in the stimulation to win good reputation. Doctors’ reputation may influence their identification and sense of responsibilities towards the society and their working attitude, which will further have an impact on their behaviors. Doctors of the clinic accumulate a wealth of experience by serving local patients and win good reputation. Moreover, they don’t need to consider how to compete in the market for patients. All of these factors encourage the doctors to choose the best treatment programs according to the specific conditions of patients, so as to maximally
avoid irrational and nonstandard behaviors.
This research is funded by Surmang Foundation and supported by China Rural Health Alliance and Gates Foundation. Our special thanks go to President of Surmang Foundation Mr. Lee M. Weingrad and doctor Phuntsok.
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169-172.  Economic Analysis of the Distribution of Health Care Workforce, by Huang Chengli,
[J].Chinese Health Economics, 2010, 29(7): 39-41.  Health Needs and the Building of Medical Security System: A Study of China’s Rural Areas,
by Feng Jin, [M]. Shanghai People’s Publishing House, Shanghai, 2009.
[Received on: Sep. 18, 2011] (Executive Editor: Yang Yongmeng)
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