‘They Want the Horse to Run but Without Providing Feed’
Labour Exploitation of Healthcare Workers in China
On 13 December 2022, the hashtag ‘Sudden Death of a First-Year Graduate Student on Duty at the West China Hospital of the Sichuan University’ (#华西研一学生在岗猝死#) on Sina Weibo triggered heated discussions about the welfare of healthcare workers in China. Chat logs and medical records circulating online indicated that 23-year-old student Chen Jiahui had tested positive for Covid-19 and had a fever for three days, but his mentor told him to keep working all the while, resulting in his death from cardiac arrest. The hospital denied the claims and announced that, contrary to rumours, Chen was alive and in intensive care. Even so, insiders observed that Chen’s diastolic pressure was as low as 13 and his life was being sustained only by machines. At the time, his death was compared with that of Dr Li Wenliang (Xiao et al. 2022a), suggesting the treatment was a meaningless and humiliating ploy to delay the inevitable for political purposes. Many considered this effort a strategy adopted by hospital administrators to gesture towards their efforts to save lives, to avoid accountability, or to buy time to respond to a public relations crisis—or all three. In the middle of this crisis, the Graduate School of Clinical Medicine of Sichuan University published an article on its WeChat account to pay respect to its medical students, who ‘fight on the frontline of Covid-19 containment’ (the official account was closed and the article deleted after the event attracted public attention). Meanwhile, many netizens blamed Chen’s death on his overwhelming workload resulting from the uncontrollable spread of Omicron variants after the government lifted its Dynamic Zero-Covid Policy on 7 December.
At that time, many healthcare workers attempted to go beyond the contingent circumstances and draw public attention to the deep-rooted exploitation of medical students and residents. As one healthcare worker stated on Weibo: ‘Please focus on the systemic violent exploitation of the residency system on medical students. This Weibo post was to speak up for our medical students’ (emphasis added). Indeed, Chen’s death was not a unique case and there are records of suicides of healthcare professionals going back years, long before the Covid-19 pandemic. For instance, in 2017, Hua Dong, a 27-year-old resident at Qilu Hospital, killed himself by intravenous injection of propofol partly due to stress from continuous night shifts and low compensation (Yuan and Zhang 2017). Without doubt, the Covid-19 outbreak made a situation that was already untenable even worse. Social media discussions indicated that since 2020, medical students and residents had been forced to participate in Covid-19 containment under threat of losing their graduation, medical certification, and postgraduation employment opportunities. While being on the frontline, they were treated the worst in terms of personal protective gear, working conditions, and compensation. Many were shamed as ‘deserters’ (逃兵) for refusing to join the effort. After China lifted its Zero-Covid Policy, medical students and residents organised protests in many hospitals and universities, demanding to be ‘allowed to return home, equal pay for equal work’ (应返尽返, 同工同酬), and stating that ‘[You] do not properly compensate us residents, so we refuse your threats’ (不补规培, 拒绝威胁).
On Weibo under the abovementioned hashtag, a medical student wrote:
Unfair and unjust treatment is rampant throughout our entire student period. Some might ask: ‘Aren’t you in school? Why are you still working?’ … We pay tuition fees, which is a normal part of pursuing an education. But are we paying to be at the bottom of the hospital hierarchy? To be manipulated by our mentors? To be treated as a punching bag by officially employed healthcare workers … Some people may say that medicine requires rigour, and that someone must strictly regulate you before you become a doctor. Is this true … Perhaps all doctors would say that the passion they had when they were medical students was consumed along the way to becoming a doctor. If the passion is gone, what can sustain you? Consuming passion is also an important lesson for graduate students pursuing a degree in medicine. I become more and more indifferent, but I wasn’t like that before. They talk about passion and dedication, but can anyone survive without eating and living? Nowadays, who doesn’t ensure their livelihood before discussing their passion? But is our livelihood really guaranteed?
This essay attempts to address some of the questions raised by this student. From 2009, China implemented nationwide healthcare reforms, which by 2011 had achieved national coverage of more than 95 per cent of the population from less than 80 per cent during the 2000s, contributing to increased demand for healthcare provision. Despite a consistent effort to establish a tiered public health system that triages patients at community-based health institutions, large public hospitals in counties and cities remain overcrowded, resulting in high demand for healthcare workers in these areas. Underfunded and constrained by policy, public hospitals are incentivised to pursue profit in part by exploiting their employees. This essay highlights some of the structural problems in China’s healthcare system and discusses multiple ways in which healthcare workers are treated unfairly. Based on my analysis of the working conditions and welfare of medical students and residents in large, certified resident training hospitals and healthcare workers in county-level public hospitals, I argue that China’s exploitative public health system has created a deteriorating working environment for medical professionals, eroding their passion, morale, and ethics, resulting in a chronic shortage of medical personnel. These effects have created a vicious cycle that is detrimental to China’s healthcare provision capacity.
Medical Students and Residents as Cheap Labour
Low compensation and unstandardised training are two deep-rooted problems in the certified training institutes for medical professionals (State Council 2019). Despite the critical role of the residency program in preparing students for medical practice, many healthcare workers said it had not provided proper clinical training. Instead, they were required to perform only low-skill tasks such as writing up medical records and measuring blood sugar levels and blood pressure, which are considered nurses’ responsibilities. According to Gong Xiaoming, Deputy Director of the Obstetrics and Gynaecology Department at Peking Union Medical College Hospital, in some hospitals, training was a formality and was not properly evaluated: ‘[Residents] merely work but do not receive training’ (Yuan and Zhang 2017). Apparently, this situation has not changed. Many residents believed the training during their residency was a waste of time and they had to retrain themselves after finding a job.
In 2013, seven national government departments led by the National Health and Family Planning Commission announced the Guiding Opinions on Establishing a Standardised Training System for Residents Physicians (NHFPC et al. 2013). This residency program often takes three years to complete and is targeted at three categories of people: those who have completed undergraduate education but are not officially employed (ungraduated residents), those who are pursuing a master’s or doctoral degree (graduate residents), and those who are sent by their employers to the certified (and often superior) medical institutes for training (employed residents). Since the program was enforced nationwide in 2015, the residency certificate has become institutionalised as essential for a medical career. By 2022, more than 460,000 medical students had been trained by the program in more than 100 certified institutes, most of which were top-ranking public hospitals in large cities.
This residency program was conceived as early as the 1990s but did not become a reality until 2013, coinciding with a rapid increase in public demand for healthcare provision. Many healthcare workers believed that, despite good intentions, the residency program was used by the certified hospitals more to compensate for labour shortages than to cultivate qualified medical practitioners. As one netizen observed:
If a tertiary hospital with training qualifications wants to hire doctors, there are too many people vying for the positions. It’s not that there’s a lack of resources, but that the directors don’t want to hire full-time employees because they would have to share the profit. However, they can exploit students without having to pay them and students are obedient, so they can easily be exploited.
Statements like these can be corroborated by the fact that many hospitals would not be able to sustain their operations without using residents’ labour. As one insider commented: ‘Many hospitals would be paralysed without students pursuing a specialty master’s in medicine. The number of full-time employees is insufficient to support the turnaround of admitted patients. Specialty masters are the cheapest labour.’ Another netizen said:
Many clinical departments can’t survive without labour from residents, postgraduates, and master’s students. Of course, they also obtain many opportunities for practising and learning. But for hospitals, their healthcare provision capacity and patient admission would be significantly reduced without them.
These accounts capture how the pressure to sustain hospital operations, and thus China’s health system more broadly, has largely shifted to medical students and residents through the interconnected hierarchies of education, certification, administration, and bureaucracy.
These days, four certificates—an academic degree, a diploma, a residency, and a medical licence—have become a basic requirement for medical master’s students. Although students have the option to obtain a residency after graduation, many feel compelled to complete their residency training before graduating to be competitive in the job market. An anaesthesiologist in Qilu Hospital in Shandong Province noted in 2017 that there were many residents working in its Anaesthesiology Department, which provided anaesthesia for 200 to 300 surgeries every day, with doctors working an average of more than 10 hours a day. He explained: ‘Anaesthesiologists work more than 12 hours for two-thirds of the week. They start working at 7:30 am and rarely leave before 7:00 pm. This is the nature of our work, and residents are more exhausted than we are’ (Yuan and Zhang 2017). A resident and graduate student at Qilu Hospital said he arrived for work every day before 7.30 am, did morning rounds, changed dressings, and wrote up medical records. In the afternoon, he participated in surgeries and, once the doctors had left, he had to stay to prepare for the next day’s work. When he was not on duty, he needed to conduct research for his mentor (Yuan and Zhang 2017). Chen’s death showed that the situation for residents had not improved by 2022. The West China Hospital in Chengdu City requires graduate students to complete 33 months of residency and complete their thesis in three months. Even though graduate school does not begin until September, students are required to ‘voluntarily’ sign up for residency beginning in July. This means they have few breaks during the three years of graduate school (Zhang et al. 2022).
Compared with their workload, the compensation for residents is disproportionately low, albeit differentiated depending on the categories into which they fall and the hospital where they work. Salaries for undergraduate and employed residents comprise a basic income and performance bonus, which is often higher than that for graduate residents but lower than for official employees. Graduate residents’ compensation comes from public funding, which allocates a minimum of RMB30,000 (US$4,350) to each student per annum, part of which is allotted to training infrastructure. Despite large differences in living and housing expenses in Chinese cities, this public funding does not consider the residents’ location. According to a survey conducted in 2020 by Dingxiang Yuan (2022), China’s renowned healthcare platform, 27.5 per cent of residents’ monthly compensation was less than RMB1,000 (US$145 or US$1,740 a year) and, within this group, 8 per cent had no income. Only 32.3 per cent of residents had a monthly subsidy of more than RMB3,000 (US$435), and only 4.4 per cent of these were graduate residents.
West China Hospital’s resident recruitment introduction indicates that the salary of undergraduate residents is RMB48,000 to RMB60,000 per annum (US$7,000–8,700). One of Chen’s classmates said the hospital gave its graduate residents a monthly subsidy of RMB800 (US$116) in their first year, which increased to RMB1,000 in the second year if they obtained their medical licence (Zhang et al. 2022). Low compensation and stressful workloads are pervasive, leaving few options for students who want to find a less exploitative environment. As one medical student wrote on Sina Weibo:
Under every college’s Super Topic, the common sentiment is to run away and not come to study there. Each medical school and their affiliated hospital are in collusion, where can medical students run to? They are just being used as fuel, jumping from one pit to another. Everything stems from the second when we filled out our college application form.
A National Institutes of Health study indicates a high dropout intention among medical postgraduates due to dissatisfaction with the healthcare environment, career choice regret, and high perceived stress (Peng et al. 2022).
The exploitation and burnout medical students and residents experience have eroded their passion and life aspirations. As one netizen commented:
Medical students are among the most obedient [听话] groups. From the first day of school, we are disciplined and reprimanded, to ‘have medical ethics’, to ‘be dedicated’, to ‘be selfless’, and to ‘be fearless’. If one is not oppressed to the extreme, will one ever come to question those that are always taken for granted? How many people have carried with them a passion for medicine and a reverence for life … Yet, now they cannot even protect their own lives. So, tell me, what did I study for so many years? My kindness, enthusiasm, and dedication have been completely consumed, and yet a group of people, who drink my blood and eat my flesh, stand on the moral high ground and accuse me. How ridiculous!
Director Zhang, a former gynaecologist, is now Director of the Human Resources Department and member of the Community Party Committee at the Ling County People’s Hospital (hereinafter LPH) in Shanhe City, Guangdong Province. She said that a major reason for the chronic shortage of medical professionals over the past 10 years was that many medical students, on graduation, chose non-clinical roles such as salesperson for a pharmaceutical company or medical administrator. Students who decide to stay in practice often work in county-level public hospitals like LPH where exploitation and unfair treatment take different forms (Interview data).
Worker Exploitation in County-Level Public Hospitals
I conducted ethnographic research in LPH between September 2021 and June 2022, during which I mainly worked in the departments of neurology and neurosurgery. As the largest public hospital in the county, LPH is representative of the many public hospitals in China’s more than 2,800 counties and county-level districts. They are squeezed between top-ranking city-level and provincial public hospitals on the one hand, and community-based primary healthcare institutions at the township level and below on the other. They are often overcrowded with patients with diverse needs, ranging from simple everyday illnesses such as the common cold to life-threatening emergencies like heart disease and stroke. China has 2.4 licensed doctors per 1,000 inhabitants—half the rate of top-ranking Organisation for Economic Co-operation and Development (OECD) countries, and similar to countries such as Mexico (2.4), South Korea (2.5), and Japan (2.6). This low doctor-to-patient ratio has profound everyday effects for doctors, such as heavier workloads, longer hours, impacts on physical and mental wellbeing, and burnout—all of which were exacerbated by the Covid-19 pandemic (Dong et al. 2022; Xiao et al. 2022b). These effects are complicated by factors such as China’s large ageing population and the uneven spatial distribution of healthcare resources.
At LPH, the departments of neurology and neurosurgery and the affiliated Interventional Radiology Centre serve the county’s 119,000 high-risk residents aged 60 and above, who represent 11.67 per cent of the county’s population. LPH faces significant challenges in attracting and retaining young healthcare professionals. Director Zhang explained that they faced more severe staff shortages than hospitals in larger, more affluent cities like Guangzhou and Shenzhen. The latter have better financial and political resources, provide higher salaries and better career prospects for their employees, and thus tend to compete with neighbouring places such as Ling County for staff (Interview data).
When I arrived at LPH in 2021, its Neurology Department had two directors, two deputy directors, and eight physicians equally divided between two districts; a ninth physician worked in the Cardiology Department to mitigate its staff shortage. By June 2022, two young doctors had resigned, a senior doctor was hired but left after several months, and two junior physicians intended to resign but eventually stayed. It was not until the spring of 2023 that three new hires arrived to fill some staffing gaps. Healthcare workers in county-level public hospitals feel that their time and expertise are not used effectively. Zhou Huiying, Deputy Director of District 1 and my fieldwork supervisor, said she was doing the same tasks she had done back in 2011 when she was a hospital intern and graduate student in Guangzhou. In city-level and provincial public hospitals, directors and deputy directors are not required to admit patients or take nightshifts. Although LPH helps train general practitioners for community-based health institutions, doctors saw these people more as a burden than as compensatory labour because they had little time to provide help before rotating to the next department. Two years after being appointed deputy director, Zhou was finally taken off nightshifts.
Many senior healthcare workers said LPH was like a ‘self-financing factory’ (自负盈亏的工厂)—an allusion to the factories built during the 1980s and 1990s when China reformed and opened up. Like most public hospitals in China, LPH is underfunded and therefore highly profit-driven. The hospital’s leaders encourage each department to admit as many patients as possible, despite a severe staff shortage. Although Ling’s Health Bureau claimed to have 2.78 certified (assistant) physicians per 1,000 residents, many senior physicians serve as directors, administrators, or both, and engage in minimal clinical tasks, shifting most of their clinical workload on to junior physicians. For most of 2021 and 2022, District 1 had 48 to 52 beds with one for intensive care and, counting Deputy Director Zhou, each doctor was assigned 10 beds for patient admission. In 2021, the district admitted 15,245 patients, averaging 3,049 patient beds per doctor, which means a neurologist managed eight to nine patients at a time.
Doctors were on a five-day roster and had few holidays or weekends off (Table 1). In theory, this accumulated to 186 hours per month per doctor; however, few doctors ever left work on time. Those on night shifts often worked extra hours until midday to complete routine tasks (highlighted in yellow in the table). During regular shifts, they generally worked overtime, and some returned after lunch to work extra hours. Director Li Qin, a former neurologist with 10 years’ clinical experience and now director of an important administrative department at LPH, told me: ‘If you have an emergency in the morning, you’ll need to complete your planned work in the afternoon’, which, unfortunately, was not uncommon for clinical departments with life-threatening emergencies. Long Yue, Director of the Department of Neurosurgery and Interventional Radiology Centre, said that due to their proximity, county-level hospitals treated many more emergencies than city-level and provincial hospitals. As a result, their doctors also face much higher risks when communicating with patients and their caregivers regarding diagnoses, treatments, and health expenditures under time constraints.
The doctors believed in the significance of sharpening their expertise, but were constantly distracted by administrative tasks that compromised their clinical capacity and healthcare provision. To avoid getting sued due to China’s worsened patient–doctor relations (Du et al. 2020), healthcare workers are required to file more and more paperwork that goes beyond reasonable clinical purposes. What’s worse, LPH faces financial constraints and delayed its plan to fully digitise its medical records system. Thus, healthcare workers must file both handwritten and digital medical records, significantly increasing their per patient workload. A survey indicates that administrative tasks have substantially contributed to burnout among doctors (Dingxiang Yuan 2022). These tasks compete for time with diagnosis, treatment, and patient communication, eroding patient trust and respect in doctors and intensifying the patient–doctor tensions they were put in place to address. Professor Zhu Jie, an expert in cerebrovascular diseases from a hospital in Guangzhou and who served as a deputy dean at LPH during 2021, commented on the roles of county-level public hospitals in China’s tiered healthcare system, stating that doctors in county-level hospitals were tougher but more docile and thus could handle as many patients as necessary if pushed hard enough. They serve as the most important medical workforce, dealing with the large patient population at the county level, helping to cushion the pressures on higher-ranking hospitals in large cities.
Doctors’ wages are unreasonably low given their training and expertise, workload, and stress. In 2017, the Ministry of Human Resources and Social Security spearheaded reform of the salary system in public hospitals, which was enforced nationwide in 2021 (MHRSS 2017, 2021). These reforms gave public hospitals more flexibility to develop their own wage plans to increase incomes for healthcare professionals while discouraging malpractice and corruption. Despite these efforts, disproportionately low wages continue to be a feature of China’s public health system. A survey of 25,120 medical professionals from June 2019 to January 2020 in six Chinese provinces revealed that 35.5 per cent of those surveyed had a monthly income of less than RMB5,000 (US$723) and 56.5 per cent earned between RMB5,000 and RMB10,000 (US$1,444) (Xiao et al. 2022b). Most of the participants (83.7 per cent) held a bachelor’s or master’s degree; 51.3 per cent were aged between 26 and 35, with 25.4 per cent aged between 36 and forty-five. These figures suggest that many of the participants were senior practitioners with substantial experience.
Wages, especially bonus plans, vary significantly according to location, hospital, and department. At the LPH Neurology Department, salaries are predetermined based on seniority and qualifications for all public employees and adjusted every two years by the MHRSS; social welfare such as housing compensation is determined by the local government; and departmental bonuses are usually a percentage of the total profit a department has made for the hospital. Table 2 exemplifies the first two components in a random month of 2021 in District 1, which are disbursed around the tenth day of every month. Although Dr Peng has less experience than Dr Zhao, her qualifications, including a master’s degree, her bianzhi (编制) status, and a resident’s certificate allow her to earn even more. People with a bianzhi status are considered public employees and thus enjoy better salary, social welfare, and social and political status.
Bonuses are the most crucial part of the doctors’ monthly income, although they vary between doctors and from month to month and are disbursed irregularly. The lack of transparency and inconsistency of bonus plans have become a major source of workplace suspicion and discontent. Bonuses in the LPH Neurology Department are determined according to three components: 1) workload, such as the number of nightshifts, patients, and procedures, where patient admission and minimally invasive image-guided procedures are major sources of the departmental bonuses; 2) departmental contributions such as joint consultations (RMB5 each), outpatient services (less than RMB10 per patient), mentorship, and teaching; and 3) managerial contributions based on the quality of medical recordkeeping. For example, Chu Wanxing, Director of both the Neurology Department and District 2, said that for each procedure, Director Lu as the main surgeon received 80 per cent of the amount allocated by the hospital, while the rest of the doctors and nurses shared the remaining 20 per cent. The head nurse of District 1, however, complained that despite much procedure-related work, nurses received less than half of the remaining 20 per cent for their post-procedure workload, while nurses in some departments received a RMB50 bonus for preparing a patient for surgery. Zhou Guoli said he split an RMB1,000 bonus per procedure with Director Lu. His bonuses ranged from RMB7,000 to RMB10,000, making his monthly income about RMB11,400–14,400 after taxes and deductions (US$1,644–2,077). In the entire department, only Director Lu had mastered minimally invasive image-guided procedures, and doctors Zhao Duojie and Zhou Guoli were his aids; all three were students (and aids) of Director Long Yue. Nurses hoped to share more of the profits from these procedures, the introduction of which has increased their workload significantly.
Doctors’ attitudes towards their incomes shifted according to with whom they compared themselves. They had given up comparing their salaries with their peers in the United States and instead compared themselves with their LPH colleagues. Doctors and nurses often complained that their wages were disproportionate to their levels of stress, risk, and workload. Despite this, they were content when comparing their salaries with the average income in the county. Among them, neurologists saw themselves as having a moderate workload, stress level, and income compared with their peers. Deputy Director Zhou expressed her satisfaction given the high unemployment rates caused by the economic downturn exacerbated by Covid-19 lockdowns and said that at least doctors would always find a job. Doctors resented the hospital administrators’ lack of fairness when comparing their salaries with those in other departments in LPH, such as the laboratory and the Urology Department. It was suggested that the hospital deans used their power to benefit these latter departments, as they were once their directors and still shared their bonuses. Regular urologists had monthly bonuses of about RMB20,000 (US$2,900), and senior urologists had total monthly incomes ranging from RMB30,000 to RMB50,000 (US$4,300–7,200)—both of which were much higher than the neurologists’ incomes.
Doctors felt that hospital administrators wanted them to work hard but did not provide enough support, and repeated the phrase: ‘They want the horse to run but without providing feed’ (想要马儿跑又不给马儿吃草). They believed LPH’s large administrative structure consumed a significant portion of the profits made by the clinical section. By January 2023, the hospital employed 1,631 people, with more than 250 employees working in nine administrative departments and offices; 54 employees worked in the Finance Department—the largest among the nine. Many doctors believed that hospital administrators and county health officials took a share of the bonuses that were supposed to go to them. Doctor Zhou said he did not care how these individuals split the money and whether they engaged in corruption, but they should at least be fair to the doctors. Zhou was one of hardest working doctors; he was married, took out a mortgage, and had his first child in the spring of 2022. He said: ‘I hope my kids have more options.’
True or not, these suspicions and perceptions have eroded doctors’ morale and passion. Sometimes on receiving their paycheque they complained that their salaries were the same no matter how many patients they admitted and how many procedures they assisted with, and they felt less motivated to work hard. Starting in November 2021, the hospital administrators began to conceal how hospital profits were distributed among different departments and started to withhold 20 per cent of departmental profits for hospital-level performance evaluation of medical recordkeeping, without clear guidelines. Fearing the power the finance administrators possessed, neurologists were reluctant to talk with the Finance Department about their confusion and complaints. Instead, they discussed the bonus plans and their own salaries in the office, and Deputy Director Zhou acted as a broker to communicate their concerns with directors Chu Wanxing and Lu Jianguo and hospital administrators.
An increasingly opaque hospital redistribution plan has made it difficult for the directors to provide satisfactory explanations to the doctors for their incomes. Healthcare workers have recognised the advantages of holding senior clinical and administrative positions in the hospital. As Deputy Director Zhou told me:
When you become a director or above, either in clinical or administrative departments, you have more power and freedom. You have more say over your time, medical practice, and salaries. That’s why almost all doctors want to get these positions. However, there are often a maximum of two directorships [one director and one deputy director] in each department, so the hospital creates many administrative positions to keep senior doctors happy.
As one of the two women directors among approximately 100 male directors in LPH’s clinical sector, Deputy Director Zhou aspired to have more normal working hours including, if possible, being able to have breakfast with her two children before rushing to weekday meetings at 8 am. She hoped to take them out for fun for several weekends a year without having to worry about her patients and mentees.
Navigating Contradiction and Ambiguity
Before I started my fieldwork at LPH, a retired county bureau chief told me that the deputy chief of the county health bureau had pocketed tens of millions of yuan and would retire at the end of 2021. He said, ‘LPH might have a hard time’, reminding me to look out for myself. Li Zhenlu, deputy director of a street office in Haiwan District—one of the most affluent in Shanhe City—called the national healthcare insurance plans a ‘Ponzi scheme’, implying rampant corruption and fraud. His wife, Doctor Hu Xiaoyun, a paediatrician who had been practising at Haiwan District Hospital since 2012 with bianzhi status, was penalised by the hospital for refusing to prescribe medicines that would not have helped her patients. Her bonus was cut to 10 per cent of what was promised in her contract. In 2020 and 2021, Doctor Hu Xiaoyun was assigned to work in the Haiwan Covid-19 Fever Clinic, cutting short her maternal leave and keeping her from her newborn son and three-year-old daughter. Both Doctor Hu Xiaoyun and Director Li Zhenlu worked on the frontline of Covid-19 containment and had to stay in rental accommodation for months, leaving their home to their children and their own parents. Doctor Hu resigned in 2021 and was shamed as a deserter before the hospital administrators let her go. She later found a job at a physical examination centre in Shenzhen with a four-hour round-trip bus commute every day. ‘At least I can get off work regularly for my children now,’ she said. Among my informants, she was the only bianzhi employee who gave up her status.
Since its establishment in 2018, the National Healthcare Security Administration (NHSA) has enforced a joint action plan to crack down on corruption and fraud in the national healthcare insurance fund (中国医疗保障基金 or 医保基金)—a pool of premiums mainly from two public health insurance schemes: one paid by working citizens and their employees, the other for non-working citizens paid out of pocket. In 2022, Guangdong HSA audited 44,924 healthcare establishments, penalised 415 of them, and recovered RMB1.56 billion (GHSA 2023a). Despite the pervasive involvement of governments and health officials, state media focused on reporting the roles played by hospitals, healthcare workers, and insurees. Reported violations include unreasonable prescriptions, duplicated charges, overcharging, and health expenditure beyond the security caps for hospitals (China News 2021; GHSA 2023b). Shanhe City’s HSA and Health Commission conducted two audits on LPH in July and September 2021 under the NHSA joint action plan. In response to audits like these, LPH has organised multiple intrahospital teams to perform quality control weekly, biweekly, monthly, and irregularly depending on the priorities of the moment. Given the impact of the auditing results on departmental bonuses, each clinical department was compelled to implement its own quality-control procedures. In District 1, Deputy Director Zhou and Doctor Xiao were appointed to flag incomplete and problematic medical records and patients with over-the-cap expenditures, daily.
These seemingly definitive violations reflect the ambiguity, contradictions, and inconsistency of the regulations and objectives within the public health system, which have exacerbated the challenges of medical autonomy (Yao 2017), burnout (Xiao et al. 2022b), and workplace violence (Du et al. 2020). Clinical directors and healthcare workers embody these ambiguities, contradictions, and inconsistencies in different ways. Doctors referred to themselves as medical practitioners, risk managers, quality controllers, and bookkeepers. They must monitor numerous indicators daily, such as health expenditure, out-of-pocket expenditure, length of hospital stays, and the breakdown of fees for various medical items per patient. Directors called themselves doctors, managers, businesspeople, and accountants—exemplified by the messages they passed down to their subordinates through workplace rituals such as weekday meetings. Directors Chu and Lu frequently reminded the doctors of various violations and their penalties, including suspension of hospital operations and medical licences.
They vaguely warned that the authorities were ‘catching typical cases’ (抓典型) and urged doctors to ‘observe the bottom line and not cross the red line’ (守底线, 不要踩红线). They reminded them to avoid overprescribing and prioritise medications on the centralised drug procurement lists, while insisting on ‘prescribing medications in accordance with diagnosis’ (对症下药). While some directors were focused on improving their department’s clinical capacities, others strived to make profits. Director Chu warned that LPH had exceeded its 2021 healthcare fund cap by RMB7 million. He required doctors to admit as many patients as possible, provide ‘personalised service’, and prescribe rehabilitation services to ‘increase effective incomes’. He also stressed that ‘practising in accordance with laws and regulations’ and increasing effective incomes were ‘political tasks’ (政治任务). The seemingly endless list of political tasks often took precedence over the clinical and ethical aspects of medical practice, especially when the objectives for the former and the latter did not align.
The political, administrative, and managerial mandates that physicians must navigate during their everyday practice are even more extensive and vaguer. Directors understood the risks involved in practising medicine under these requirements in addition to clinical discretion. Therefore, they repeatedly urged doctors to write detailed medical records and obtain informed consent from patients and caregivers for everything they do, emphasising the need for self-protection. Doctor Peng, as the most junior doctor in District 1, experienced episodes of confusion, anxiety, and burnout after receiving new messages. She would go through her medical records, engage in intense self-reflection, and seek peer recognition repeatedly, adding an extra burden to her regular work. Deputy Director Zhou said whether and to what extent doctors can meet these requirements depended on the priorities of the time and day-to-day situations.
The ambiguities, contradictions, and inconsistencies shown above arise as state policies are passed down through the country’s political, administrative, and managerial hierarchies, each with its own set of priorities and objectives, creating challenges and misaligned incentives for practitioners. For instance, drug prescriptions were affected by policies aiming to encourage centralised drug procurement, eliminate mark-ups for medicines sold in public hospitals, and lower medication expenditure. The policies also aim to discourage doctors from over-prescription, leading hospitals to focus on other profit-generating avenues like rehabilitation services. Additionally, doctors were required to meet performance metrics tied to bonuses, such as prescription quotas for each listed drug for each hospital, department, and/or doctor. The LPH pharmacy had the power to withhold supplies of medications and force doctors to use alternatives or stop prescribing medications. Imported ‘gold standard drugs’, which are often more expensive and effective, generally run out quickly, leaving doctors with few options. Doctor Zhou said the centralised drug procurement lists reflected a ‘planned economy’ for medication, and he envied peers in the United States who have more autonomy in a free market.
Doctors feel powerless when facing political, administrative, and managerial interference and, as a result, take risks (and the associated stress) to seek solutions. Their diagnoses and treatments were mediated by factors related to patient management, such as the types of insurance coverage patients have, which determine reimbursement rates and affordability, and patients’ social status, such as whether they have connections with the hospital’s leadership (关系户). Often, patients were advised to purchase medicines outside the hospital. Patients were unhappy with this solution because these medicines would then not be covered by their insurance. They also needed to spend time comparing prices and procuring the medicines, increasing the burden on their already exhausted caregivers. Cutting medication made inpatients anxious about the efficacy of their treatments. Many patients with cerebrovascular diseases evaluated their recovery progress and the degree of importance their doctors attached to them based on the number and frequency of medications they received. The longer patients were hospitalised, the more medicines they needed to pacify their anxiety. Covid-19 restrictions exacerbated this situation as inpatients were prohibited from leaving the wards during their stay, giving them more time to worry about their health. Additionally, doctors tended to admit patients with mild symptoms and extend their stay as strategies to increase hospital revenue, further complicating the situation. These strategies often created distrust and conflict between doctors and patients.
To mitigate the risks arising from a worsening working environment, doctors often employ interpersonal tactics to seek institutional recognition. Some recognised the advantages of having more power and thus wanted to hold administrative or clinical positions or move to a larger public hospital, further exacerbating the chronic staff shortages. Doctors and nurses also saw bianzhi status as crucial, not just for job security and higher incomes, but also for institutional protection in cases of patient threats and lawsuits. Among LPH’s 1,631 employees, only 812 had bianzhi status and one-third were dailisheng (代理生); most of the latter, including Doctor Zhao, were working in clinical departments. In the face of the limited number of people with bianzhi status and the poor social stigma attached to temporary/contract workers, hospitals created the dailisheng status to retain health professionals. As a new category of employee in public hospitals, dailisheng can enjoy incomes and social welfare that fall between that of bianzhi employees and that of temporary workers (临时工). Doctor Zhao’s strong desire for bianzhi status motivated him to prioritise aiding Covid-19 affected cities, even at the cost of missing his licensure exam and the birth of his second child. Interpersonal connections (关系) with hospital administrators are seen as essential for upward mobility and risk management. Despite experiencing negative reactions like severe rashes, doctors continued to consume alcohol at social events with hospital administrators as a performance of loyalty and to build interpersonal connections. Doctor Zhao also experienced episodes of temporary blindness and severe nausea after heavy alcohol consumption. Doctors hoped that having these connections would be useful if they make a mistake in the future. Through these processes, they have developed their own strategies to increase their life satisfaction while addressing the risks of practising in a workplace filled with inconsistencies, ambiguities, and contradictions.
The Impact of the Pandemic (and Beyond)
Li Qin took on the directorship of an administrative office in August 2020. She received confirmation of her appointment one day in June and cried until 4 am the next morning. ‘I studied [Chinese] medicine for eight years and practised neurology for 10 years, but I couldn’t endure this job anymore.’ She had thought about it thoroughly before submitting a second application to transfer to an administrative position. Although she was the most competitive candidate for the deputy directorship that Deputy Director Zhou eventually held, Director Li did not think she was qualified. She felt that she could not handle the workload, responsibilities, and stress of being either a senior physician or a deputy director. She was expecting her second daughter, which exacerbated her stress and anxiety. She said: ‘I was exhausted. Even though the job was rewarding, and the income was high, I was truly burnt out.’ She believed that other neurologists would be a better fit because of their ability to withstand high levels of stress, having a master’s degree in neurology, mastery of minimally invasive image-guided procedures, and excellent communication skills.
She blamed herself for lacking these crucial qualifications, even though she was one of the most empathetic, responsible, ethical, and respected physicians from the perspective of her patients and colleagues. She felt ashamed and that it was inappropriate to ask for a full-time position in the outpatient clinics. Outpatient doctors have a much lower workload and less stress than inpatient physicians while still enjoying prestige as a doctor and receiving high incomes, which she thought was unfair to her inpatient colleagues. ‘I will feel like a traitor to them. I couldn’t overcome this mental barrier.’ Instead, she prepared a backup plan to resign and teach at a nursing school. After lengthy negotiations, the hospital leadership valued her expertise and offered her the current position. They also provided her with some outpatient sessions to compensate for her drop in wages. Although her current income was only about half of what she had earned before, she was content with it. She could finally have a solid sleep every night and did not need to worry about the phone ringing or hearing an ambulance. Li thought of herself as the luckiest doctor, because very few healthcare workers could enjoy such luxury.
This essay sheds light on the ways in which healthcare professionals have been exploited. Facing increased demands, most public hospitals are underfunded, experiencing staff shortages, and are subject to multiple regulations and objectives. They are thus incentivised to prioritise profits over patient care and cut costs through the exploitation of their employees. While large reputable public hospitals use their affiliation with medical schools to issue resident certificates to exploit medical students, county-level public hospitals often overburden their employees with non-clinical tasks to mitigate risks from litigation brought forward by disgruntled patients. Junior and non-bianzhi employees are particularly vulnerable to exploitation due to their low levels of expertise and employment status. Furthermore, spatial inequalities in public resources and staffing have exacerbated labour exploitation, hindering medical practitioners from realising their career aspirations. Thus, healthcare workers face heavy workloads and high levels of stress and risk, while receiving disproportionately low and unfair incomes and welfare provisions. Consequently, many suffer from physical and mental problems, which erode their passion and morale and affect their life satisfaction.
Seeing through the lens of healthcare workers is critical to understanding the intersections of labour economics, political priorities, and health governance in contemporary China. This essay draws attention to some of the structural issues plaguing China’s public health system, such as rampant corruption and fraud and vested, conflicted interests. Political, bureaucratic, and managerial objectives constantly impinge on medical autonomy. Healthcare workers feel powerless and have limited options but follow a constantly evolving and increasingly challenging set of regulations, which can sometimes compromise their medical integrity. This essay captures the tensions that have arisen between an educational and regulatory apparatus that trains a competent and ethical public workforce to improve population health and a disciplinary apparatus that cultivates obedient citizens and state agents for social control and party legitimacy. It is critical to study the profound implications of a chronic labour shortage on population health. While state discourse depicts healthcare workers as dedicated professionals with high ethics, the Chinese Government has created working environments that constantly put them in ethical dilemmas. More studies are needed to address how deteriorating working conditions have eroded patient trust in doctors and affected patient–doctor relations, and to understand the roles of public hospitals and healthcare workers in China’s transition from a post-socialist country to an authoritarian regime.
Worker exploitation and structural issues within the public health system were significantly exacerbated by the Chinese Government’s political prioritisation of zero-Covid for almost three years. Against the backdrop of a seemingly unstoppable economic downturn, the war against the pandemic (战役)—including restrictive measures such as frequent lockdowns, mass testing, and surveillance (Chen 2023; Chen and Oakes 2023)—has become a major source of party legitimacy. These public health responses were largely political and ideological rather than scientific and rational, with profound consequences. These containment measures not only competed for labour and funding with the regular operation of the health system, but also swallowed public funding and exacerbated the economic decline. After the containment strategy was lifted, excessive deaths were not properly documented, and trauma and grievances were left unaddressed (Stevenson and Mueller 2022). My interviewees’ experiences and Chen Jiahui’s death exemplify the struggles of Chinese workers in an increasingly exploitative, bureaucratic, and ideology-driven health sector that mirrors other Chinese industries and public sectors. While public hospitals were wrestling with both the pandemic’s repercussions and the intensifying anticorruption campaign (Xu et al. 2023), many private hospitals went bankrupt (Qian 2022). More and more health professionals attempted to leave clinical positions, or the health sector altogether, in search of a better working environment (Zhang 2023), creating a dire health-provision landscape. Without forward-looking leadership to amend deep-rooted issues for public welfare, more profound social, political, economic, and health effects of the pandemic will take years to surface.
I would like to thank the Department of Geography, Graduate School, the Center to Advance Research and Teaching in the Social Sciences, Center for Humanities & the Arts, and the Graduate and Professional Student Government, at the University of Colorado Boulder, as well as the Society of Woman Geographers, for their generous financial support. I also thank the two editors, Ivan Franceschini and Nicholas Loubere, for their comments and editing.
Featured Image: Protest organised by medical master’s students at the Anhui Medical University on 13 December 2022. PC: @whyyoutouzhele Twitter account.