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【经济学人】中国基层医疗现状:严重短缺,支离破碎



中国的基础医疗体系落后,其中有历史原因。国人预期寿命的延长以及人口老龄化程度的加剧,对中国医疗体系提出了巨大挑战。尽管近年来中国政府在医疗改革上取得一定成果,但是在基础医疗建设上仍存在较大问题。原因有二:一是财政配套政策的不足;二是民众对于全科医生的不信任。解决中国医疗问题任重道远。


中国基层医疗现状:严重短缺,支离破碎


译者:赵萌萌&徐嘉茵

校对:李苏苑

策划:邹世昌


China is trying to rebuild its shattered primary health-care system. Patients and doctors are putting up resistance.

中国正尝试重建其破碎的基础医疗体系。患者和医生拒绝接受。


本文选自 The Economist | 取经号原创翻译

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QUEUES at Chinese hospitals are legendary. The acutely sick jostle with the elderly and frail even before gates open, desperate for a coveted appointment to see a doctor. Scalpers hawk waiting tickets to those rich or desperate enough to jump the line. The ordeal that patients often endure is partly the result of a shortage of staff and medical facilities. But it is also due to a bigger problem. Many people who seek medical help in China bypass general practitioners and go straight to hospital-based specialists. In a country once famed for its readily accessible “barefoot doctors”, primary care is in tatters.

在中国排队很有传奇色彩。医院还没开门,重病患者就已开始与失能老人互相推搡,不顾一切只为抢到那人人觊觎的就诊机会。黄牛向富人或是极度渴望尽早看到医生的人兜售挂号牌。患者之所以经常忍受这些折磨,部分原因在于医院职工及医疗设施的紧缺。在中国,许多人绕过全科医师,直奔医院专家以寻求医疗帮助,这也是问题所在。在一个曾以“赤脚医生”闻名,看病方便的国家,基础医疗体系却支离破碎

jostle [‘dʒɒs(ə)l]   v. 推挤,撞;争夺

coveted [‘kʌvitid]  adj. 垂涎的;梦寐以求的

赤脚医生(barefoot doctors):赤脚医生,是上世纪60~70年代“文化大革命”中期开始出现的名词,指一般未经正式医疗训练、仍持农业户口、一些情况下“半农半医”的农村医疗人员。当时来源主要有三部分:一是医学世家;二是高中毕业且略懂医术病理;三是一些是上山下乡的知识青年。赤脚医生为解救中国一些农村地区缺医少药的燃眉之急做出了积极的贡献。


Even in its heyday under Mao Zedong, such care was rudimentary—the barefoot variety were not doctors at all, just farmers with a modicum of training. Economic reforms launched in the late 1970s caused the system to collapse. Money dried up for rural services. In the cities, many state-owned enterprises were closed, and with them the medical services on which urban residents often relied for basic treatment. It was not until 2009, amid rising public anger over the soaring cost of seeing a doctor and the difficulty of arranging consultations, that the government began sweeping reforms. Goals included making health care cheaper for patients, and reviving local clinics as their first port of call.

即便是在毛泽东领导下的全盛时期,医疗体系也未得到完善发展——赤脚医生并不是医生,他们只是接受过些许训练的农民。在二十世纪七十年代后期所开展的经济改革使得该体系完全瓦解。农村医疗服务缺乏资金。在城里,大量国企倒闭,而城市居民通常依赖于通过这些企业所提供的医疗服务而获得基础治疗。公众对就医的高昂费用及预约难的愤怒日益膨胀,直到2009年,政府才开始进行全面改革。改革目标包括:降低医疗费用以及重新发展地方诊所,使其作为患者就医的首选之地。

rudimentary [ruːdɪ’ment(ə)rɪ]  adj. 基本的;初步的;退化的;残遗的;未发展的


The reforms succeeded in boosting the amount that patients could claim on their medical-insurance policies (some 95% of Chinese are enrolled in government-subsidised schemes). They have also resulted in greater funding for community health centres. In 2015 there were around 189,000 general practitioners (GPs). The government aims to have 300,000 by 2020. But there would still be only 0.2 family doctors for every 1,000 people (compared with 0.14 today—see chart). That is far fewer than in many Western countries.

改革成功地提高了患者通过医保政策所能报销的费用额度(95%的中国人都参与了这一政府资助的计划)。同时,社区医疗中心也获得了更多资金支持。在2015年,全国共有将近18.9万名全科医师,政府的目标是到2020年这一数目达到30万名。但家庭医生的比例仍然仅有0.02%(现该比例为0.014%)。这比许多西方国家要小得多。


It is not just long waiting-times at hospitals that necessitate more clinics. People are living far longer now than they did when the Communists took over in 1949: life expectancy at birth is 76 today, compared with 36 then. People from Shanghai live as long as the average person in Japan and Switzerland. Since 1991, maternal mortality has fallen by over 70%. A growing share of medical cases involve chronic conditions rather than acute illnesses or injuries. GPs are often better able to provide basic and regular treatment for chronic ailments. The country is also ageing rapidly. By 2030 nearly a quarter of the population will be aged 60 or over, compared with less than one-seventh today. More family doctors will be needed to manage their routine needs and visit the housebound.

并不仅是因为在医院排队需要花费太多时间才突显设立更多诊所的必要性。自共产党1949年成立新中国以来,人的寿命愈来愈长:如今,新生代的预期寿命为76岁,而在当年仅为36岁。上海人跟日本及瑞士人的平均寿命一样长。自1991年以来,产妇死亡率已下跌超过70%。慢性疾病病例占医学病例的比例正在不断上升,急性疾病或急性伤害病例的比例正在下降。全科医师通常能够更好地为慢性疾病患者提供基础常规治疗。中国也处于极速老龄化状态。到2030年,将近四分之一人口将会超过60岁(含),现在这一比例还不到七分之一。中国将会需要更多家庭医生以满足日常需要和上门治疗。


But setting up a GP system is proving a huge challenge, for two main reasons. The first is the way the health-care system works financially. Hospitals and clinics rely heavily on revenue they generate from patients through markups on medicine and other treatments. The government has curbed a once-common practice of overcharging patients for medicines. But doctors still commission needless scans and other tests in order to make more money. Community health centres are unable to offer the range of cash-generating treatments that are available at hospitals. So they struggle to make enough money to attract and retain good staff. Most medical students prefer jobs in hospitals, where a doctor earns about 80,000 yuan ($11,600) a year on average—a paltry sum for someone so qualified, but better than the 50,000 yuan earned by the average GP. Hospital doctors have far more opportunities to earn substantial kickbacks—try seeing a good specialist in China without offering a fat “red envelope”.

但建立全科医师体系也面临着巨大的挑战,主要原因有两个。首先是医疗体系在财政方面该如何运作。医院和诊所的盈利很大部分依赖于药品涨价和其他治疗。政府已经限制医生向病人收取过高医药费的行为,这在过去很普遍。但医生仍旧安排病人进行不必要的检查以牟取更多利益。社区医疗中心无法像医院一样,提供具有盈利性的治疗。因此,他们很难赚足够的钱来吸引和留住优秀员工。大部分医学学生更喜欢在医院工作,医生平均年薪可达8万元(折合约1.16万美元)——对于有能力的人而言,这明显不够,但总比全科医师5万元的平均年薪要好。在医院工作的医生有更多机会赚取回扣——你可以试试看,不拿一封大红包,找不找得到好的专家看病。

kickback  [‘kɪkbæk]  n. 回扣,佣金;强烈反应;退回赃物


As a result, many of those who train as GPs never work as one. Most medical degrees do not even bother teaching general practice. That leaves 650m Chinese without access to a GP, reckon Dan Wu and Tai Pong Lam of the University of Hong Kong. The shortage is particularly acute in poor and rural areas. The number of family doctors per 1,000 people is nearly twice as high on the wealthy coast as it is in western and central China.

这样的结果就是,很多接受全科医师培训的医生,学成后却不干这行。大多数医学学位甚至都不教授全科课程。对此,香港大学的Tai Pong Lam和Dan Wu预计,6.5亿的中国人将没有机会去全科医师处看病。全科医师的短缺状况在农村与贫困地区尤为严重。在中国东部沿海地区,每1000人拥有的家庭医生总数是中西部地区的近两倍之多。


The second main difficulty is that many ordinary Chinese are disdainful of primary-care facilities, even those with fully qualified GPs. This is partly because GPs are not authorised to prescribe as wide a range of drugs as hospitals can, so patients prefer to go straight to what they regard as the best source. There is also a deep mistrust of local clinics. The facilities often lack fully qualified physicians, reminding many people of barefoot-doctor days. Chinese prefer to see university-educated experts in facilities with all the mod cons.

第二个主要的困难是,很多普通中国人对基础医疗设施不屑一顾,即使是那些配备了具有完全资格的全科医师的医疗设施。部分原因是因为全科医师不像医院那样,有权限开很多种药品,所以病人更愿意直奔他们认为的最佳资源。除此之外,原因还有病人对当地诊所深深的不信任。诊所医疗设施中通常不具备完全资格的医生,让很多人想起了赤脚医生的日子。中国人更愿意在现代化设施一应俱全的医疗设施中,去接受过大学教育的专家那里看病。

Disdainful [dis’dain·ful] adj. contemptuous, scornful 轻蔑的; 骄傲的


Patients have few financial incentives to consult GPs. Even those who have insurance still have to meet 30-40% of their outpatient costs with their own money. Many prefer to pay for a single appointment with a specialist rather than see a GP and risk being referred to a second person, doubling their expenditure. Since the cost of hospital appointments and procedures is similar to charges levied at community centres, seeing a GP offers little price advantage.

从经济方面讲,人们几乎没理由去看全科医师。即使是有医疗保险的病人还是得花自己的钱来支付30-40%的门诊费用。很多人宁愿把钱一次付清,只看专科医师,也不愿看全科医师,因为那样可能会被转给其他医生,花销还要翻倍。因为在医院,预约和各种程序的花费和社区中心收的差不多,因此去看社区的全科医师没有什么价格上的优势。


The government’s efforts to improve the system have been piecemeal and half-hearted. Primary-care workers are now guaranteed a higher basic income, but are given less freedom to make extra money by charging patients for services and prescriptions. This has helped clinicians in poor areas, but in richer ones, where prescribing treatments had been more lucrative, it has left many staff worse off—particularly when they have to see more patients for no extra pay.

政府为改善医疗体制做出的努力是碎片化的,也不是很用心。基础医疗工作者能保证稍高一些的基本收入,但没有那么自由,不能通过向病人收取服务及处方费用来赚取外快。这对贫困地区的临床医生是有帮助的,但在开具处方的治疗更有利可图的富裕地区,这让医生们的处境更加糟糕——尤其是他们必须接诊更多病人却没补贴的时候。


It would help if the government were to further reduce the pay gap between GPs and specialists. It is encouraging GPs to earn more money by seeing more patients and thus increase revenue from consultation fees. In big cities such as Beijing and Shanghai patients are being urged to sign contracts with their clinics in which they pledge to use them for referrals to specialists. In April the capital’s government raised consultation fees at hospitals, hoping to encourage people to go to community centres instead. Fearing a backlash, it has also pledged to reduce the cost to patients of drugs and tests.

如果政府能够缩小全科医生与专科医生之间的收入差距,将会有很大帮助。这样可以鼓励全科医生通过接诊更多病人来赚更多钱,进而从诊金中增加收入。北京和上海这样的大城市,要求病人与诊所签订协议,保证通过诊所来看专科医生。四月时,中央政府提高了医院的诊金,希望鼓励人们去社区中心。但政府也害怕有负面影响,于是也保证减少病人买药和检查的费用。

Referral [rɪ’fɜːrəl]n. direction to another person or source of information; one who is directed to another person or source of information 提及; 推荐; 参考; 介绍


Despite the government’s reforms, underuse of primary care has actually worsened. In 2013, the latest year for which data are available, GPs saw a third more patients than in 2009. But use of health-care facilities increased so much during that time that the share of visits to primary-care doctors fell from 63% of cases to 59% (the World Health Organisation says it should be higher than 80%, ideally). For poor rural households, health care has become even less affordable. And public anger has shown no sign of abating. Every year thousands of doctors are attacked in China—despite the police stations that have been opened in 85% of large-scale hospitals. It is not a healthy system.

尽管政府做出了改革,但其实基础医疗没有得到充分利用的情况更严重了。2013年的最新数据显示,相比于2009年,全科医生接诊的病人数量增加了三分之一。然而,大幅增加医疗设施使用的同时,看全科医生的比重却从63%下降到了59%(世界卫生组织表示,理想状态下比重应高于80%)。对农村贫困地区的人家来说,医疗卫生服务更难负担。公众对此的愤怒不满没有丝毫减少的迹象。尽管85%的大医院都设立有警卫处,每年还是有成千上万的中国医生被袭击。中国的医疗制度并不健康。


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<原文链接:http://www.economist.com/news/china/21721948-memories-barefoot-ones-put-some-people-seeing-them-china-needs-many-more-primary-care>

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