China's lagging expansion of medical infrastructure

A woman wearing a protective suit seen at a hospital in Wuhan on April 13, 2020. PHOTO: REUTERS

BEIJING (CAIXIN GLOBAL) - China has been pouring billions of dollars into public health infrastructure since the Covid-19 pandemic broke out, expanding hospitals and infectious disease treatment facilities to upgrade the country's arsenal for fighting the virus.

The collapse of the hospital system in Wuhan during the early days of the pandemic elevated authorities' concerns over the capacity of the health-care system for responding to major infectious diseases.

In response, the National Development and Reform Commission, the National Health Commission and the National Administration of Traditional Chinese Medicine jointly published a plan in May 2020 to increase the capacity of hospitals across the country, improve the urban infectious disease treatment network and build major Covid-19 treatment centers.

Major cities were to build infectious disease hospitals or independent infectious disease departments in general hospitals under the plan. Construction was to be funded by central government investments, local fiscal revenue and local government special-purpose bonds.

In 2020, the Chinese central government set aside 45.66 billion yuan (S$9.68 billion) for investment in the public health system.

But as the pandemic enters its third year with the omicron variant causing a global surge of infections, China still faces enormous challenges of uneven distribution of medical resources across its vast territory.

Construction of intensive care units (ICUs) is lagging behind; infectious disease hospitals are barely meeting standards in smaller cities; and there aren't enough doctors, nurses and other caregiving staff to go around, medical experts say.

While the investment frenzy may ultimately expand health-care infrastructure inrural areas and elsewhere, a key question is how to maintain the facilities' effective operations when the virus retreats.

Long-term planning will be important, said Wang Guangfa, director of the Department of Respiratory and Critical Care Medicine at Peking University First Hospital. Besides investments, there should be supporting plans for personnel, distribution and pricing systems, Wang said.

"It's not just about investing money," he said. "Hospitals have been lagging in infrastructure and talent reserves over the years. "

After the Sars outbreak in 2003, many Chinese cities built or expanded infectious disease hospitals. General hospitals also set up infectious disease departments. But that was far from sufficient.

Cai Weiping, a leading expert of the Infectious Disease Center of the Eighth People's Hospital of Guangzhou, estimated in March 2020 that among the nine biggest Chinese cities, only Shenzhen and Hangzhou could meet the standard of one infectious disease hospital per 10,000 people.

More beds in hospitals

In late January 2020, more than 10,000 workers built a new campus for the Third People's Hospital of Shenzhen for emergency use in 20 days to accept Covid-19 patients. Liu Lei, Communist Party chief of the hospital, said the field hospital has 1,008 negative-pressure rooms and more than 200 intensive care beds. The hospital is responsible for the centralized treatment of Covid-19 patients in five nearby cities.

China's public health system is experiencing its biggest construction boom amid the pandemic, Liu said.

A worker in protective suit disinfects the Wuhan No. 7 Hospital in Wuhan on March 19, 2020. PHOTO: REUTERS

Local governments doubled the share of borrowings from special purpose bonds devoted to public health to 8 per cent of the 3.6 trillion yuan issued in 2020, according to Wu Qiying, a senior macro analyst at GF Securities. From January to May 2021, investment in public health accounted for 6 per cent of the 560 billion yuan of new special-purpose bonds.

The central government issued special-purpose bonds for local governments to improve the health-care system after the Covid-19 outbreak, a person close to the National Health Commission (NHC) told Caixin. Forty percent to fifty percent of the funds were used for the infectious disease control system.

Local governments released plans to expand their hospital systems, most aiming to start construction by the end of 2021. There are now more than 120,000 beds available each quarter for Covid-19 patients across China, according to the person close to the NHC.

A government document issued in Sept 2021 concerning Covid-19 treatment required every major city to designate a hospital for Covid-19 patients. Many cities unveiled plans to build new infectious disease facilities or expand existing ones.

Beijing planned to build a public health center for disease control and increase the number of negative pressure rooms for patients with infectious illnesses to 700 by the end of 2022. Shanghai deployed 8,000 beds for infectious disease and expanded infectious disease hospitals.

In Jiangsu province, the number of beds for Covid-19 patients increased fivefold from 5,014 in February 2020 to 26,375 by the end of March 2021.

"Cities mainly built fever clinics, infectious disease departments, and infectious disease hospitals," the person close to the NHC said. "Almost all provinces and cities arranged funds. In most cities, there are enough wards, beds, materials, and other reserves."

Expanding ICUs

A study of ICU beds in Asian countries published in 2020 showed that China had 3.6 ICU beds per 100,000 people, significantly fewer than in countries such as Singapore, South Korea and Japan. Singapore has 11.4 intensive care beds per 100,000 people.

One critical care expert who participated in the fight in Wuhan against Covid-19 said ICUs in most hospitals in China ran at full capacity or stayed overloaded, making it difficult to respond to public health emergencies.

China tried to allocate more resources to critically ill Covid-19 patients. The September policy document for Covid-19 treatment requires 10 to 15 per cent of the beds in designated Covid-19 hospitals to be ICU beds, and no fewer than 200.

A photo from Feb 14, 2020, shows medical workers inspecting equipment at a blood donation room of the Renmin Hospital of Wuhan University. PHOTO: REUTERS

Infectious disease hospitals barely meet standards. Li Dong, chief physician of the Department of Respiratory and Infectious Diseases of Beijing Youan Hospital, said the role of infectious disease hospitals is more about preventing spread before a pandemic, so they received fewer critical care resources than general hospitals.

"According to the current pricing of medical services, including the cost of human and material resources, the intensive care units cannot make ends meet," Peking University's Wang said. The cost of building intensive care units is huge for hospitals. A shortage of critical care workers is also a concern. Many ICUs in designated Covid-19 hospitals can't meet the 1:3 nurse-to-patient ratio.

Uneven distribution

On the front line of responding to the Covid-19 pandemic, small community hospitals, especially those in rural areas, face higher operating costs but don't get enough medical or human resources. Due to the absence of technology and a lack of specially trained caregivers, those hospitals usually provide only general care rather than intensive care.

Liu Ling, director of the People's Hospital in Nanpi county, Hebei Province, told Caixin that the institution's infrastructure didn't meet the standards for infectious disease hospitals. As the only designated Covid-19 hospital in the county, the center has six doctors, 10 nurses and 22 beds for patients with infectious diseases.

Counties with a population the size of Nanpi's - 350,000 - are required to have 50 beds. "Ultimately, the local government doesn't have enough money," Liu said. She said she asked the county many times to build an infectious disease unit, but that would take 40 million yuan to 50 million yuan.

Pan Pinhua, director of the Department of Respiratory and Critical Care Medicine at Xiangya Hospital, Central South University, said hospitals at all levels built infrastructure during the pandemic, but the number of patients admitted to county-level hospitals has been limited. Those resources are likely to be wasted, Pan said.

The loss of caregivers because of salary issues, staffing quotas and working conditions also hobble many county-level hospitals. Covid-19 made things worse. The director of a hospital in Jiangyou, a county-level city in Sichuan, said the hospital dispatched doctors and nurses from various departments to support the fever clinic during the pandemic. Those working in the fever clinic take a much higher workload with limited compensation, the director said.

The hospital is also experiencing mounting disease control costs since the pandemic, the Jiangyou hospital director said. The hospital spent more than 1 million yuan on human resources for pandemic control, he said.

A source from the medical system of a county in Hunan said few doctors signed up for job interviews since the pandemic started. Some experts worry that the expansion of large hospitals in the cities will lure caregivers away from small hospitals.

This story was originally published by Caixin Global.

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