双语阅读｜“赤脚医生”不再光脚，但仍不好受
China is trying to rebuild its shattered primary health-care system. Patients and doctors are putting up resistance
中国政府正竭力重建支离破碎的基础卫生保健体系，不料遭到医患双方的反抗。
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.
中国医院门前的排队情况堪称一景。医院开门前，重病患者和虚弱的老年人就已在医院门口排队等候，都希望能约到给自己看病的医生。黄牛党向那些有钱人或者病情紧急的人兜售位置让他们插队。病人经常遭受这种折磨，一部分原因在于医疗卫生人员匮乏和医疗设施不足。不过，最根本的原因是，很多中国人直接去医院找专家就诊而非向普通医生寻求帮助。过去，中国的“赤脚医生”很是出名，哪儿都有他们的身影，而如今基础卫生保健体系却支离破碎。
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.
毛泽东当年大力推崇基础卫生保健体系，但收效甚微，赤脚医生并非专业人士，他们大都是农民，从未受过专业的医疗训练。20世纪70年代末期，实行经济改革，基础卫生保健体系不复存在。乡村医疗资金枯竭，城里的国有医疗机构纷纷倒闭，此前很多城市居民都是向这些机构寻求基础治疗服务。随着看病贵、挂号难等看病难题让群众怨声载道、愤声迭起，政府从2009年开始大力进行改革，旨在减少患者看病的花费，让地方诊所重新成为他们看病的首选之地。
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 every1,000 people (compared with 0.14 today). That is far fewer than in many Western countries.
上述改革成功使得患者享受医保政策带来的好处，增加他们报销的比例（近95％的中国人能够享受到政府在这方面的资助），也使得社区医疗中心得到更多的资金投入。2015年，全国约有18.9万名普通医生（GPs），政府力争2020年将这一数量提升至30万。尽管如此，每1000人中家庭医生的比例也仅为0.2（现在的比例是0.14），和西方国家相比，更是相差甚远。
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.
在医院排队时间过长只是亟需增加诊所数量的原因之一。还有一个原因是现在人们的寿命和1949年中共执政时大大延长，当时人们的平均寿命为36岁，现在已上升至76岁。上海市民的平均寿命和日本、瑞士国民的寿命一样长。1991年以来，产妇死亡率下降了70％以上。慢性疾病在所有病例中的比例也开始变得比严重疾病和受伤高。普通医生通常更能为慢性疾病提供基本的常规治疗。中国现在老龄化情况日益严重，截止到2030年，全国将有近1/4的人口年龄在60或60岁以上，现在这一比例还不到1/7。因此，需要更多的家庭医生来负责他们的日常所需，到那些无法出门的老人家里为其看病。
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.
但是，建立一套完善的基础普通医生体系是项巨大的挑战，原因有二。首先，医疗保健体系要靠资金维持。医院和诊所在很大程度上依赖从患者身上赚取的药物和其他治疗方式的加成来盈利。虽然政府已下令有关单位要一改常态，不得再对患者所购的药物多收费，但是医生仍旧为了多赚钱而给患者安排扫描等不必要的检查项目。
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”.
社区医疗中心不能像医院那样给患者安排烧钱的治疗方式，因此它们需要多赚钱来吸引并留住好的员工。很多医学专业的学生都想在医院工作，因为在那儿工作的医生年均工资在8万元左右（合计1.16万美元）。虽然和其专业能力相比这些工资少的可怜，但在诊所工作的普通医生年均工资却仅为5万元。在医院工作的医生还有大把的机会赚取巨额回扣，在中国要想看专家门诊就得塞个厚厚的红包。
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 per1,000 people is nearly twice as high on the wealthy coast as it is in western and central China.
这种情况的结果就是，很多接受普通医生培训的人没当普通医生。很多医学专业甚至都不开普通医生上的课程。来自香港大学的吴丹教授和林大邦教授估计，中国有6.5亿人身边没有普通医生。在贫困的乡村地区，普通医生人员尤为匮乏。和中国的中部、西部地区相比，在中国富庶的沿海地区，每1000人的人家庭医生数量约为其两倍。
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.
其次，很多中国百姓看不起基础医疗中心，即使配备的普通医生非常专业，他们也不愿去。一方面是由于普通医生未被充分授权，不能像医院一样给病人开各种类型的药物，病人更愿直接去医院，他们觉得医院拥有最好的资源。人们还对地方诊所存有很大的偏见。他们觉得地方诊所还像赤脚医生那个年代一样，大都没有专业的医生。中国人更愿去找那些科班出身的专家，在他们工作的地方，现代化的设备应有尽有。
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.
患者去咨询普通医生，对他们来说并没有什么金钱上的诱惑。就算他们有医保，也要自己掏腰包支付30％至40％的门诊费用。很多人更愿去专家门诊付一次钱，也不愿冒险去找普通医生，避免多人经手，导致花费翻倍。这是因为，医院挂号就诊等花费和社区中心征收的费用相差无几，去找普通医生在价格上并未太大优势。
The government’s efforts to improve the system have been piecemeal and halfhearted. 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.
政府为改善基础卫生保健体系做出的努力可谓零零散散、三心二意。基础保健体系的员工现在收入有所增加，但是他们向患者收取服务费和处方药费以赚取外快的空间减小。对于在贫困地区的诊所工作的员工来说，这是好事；但在较为富裕的地区，处方药利润十分丰厚，上述举动会让很多员工境况变得糟糕：他们接待的患者人数增多，却无任何外快可赚。
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.
如果政府能够进一步缩小普通医生和医院专家的待遇差距，情况可能会有所改善。政府鼓励普通医生多劳多得，从挂号费入手，增加收入。在北京、上海等大城市里，患者须与社区诊所签订合同，只要社区诊所能够为其办理专家转诊，患者就承诺在该诊所就诊。四月，北京市政府提高了医院的挂号费，希望借此鼓励人们去社区中心就医。担心这样做会引起不满，北京市政府同时承诺会降低患者买药、检查等的花费。
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.
虽然中国政府出台了一系列改革政策，基础医疗设施少人问津的现状并未出现好转，反而是持续恶化。目前最新的数据显示，2013年，普通医生接待的患者人数和2009年相比增加了1/3。但在此期间，就医的患者人数也大大增加，基础卫生保健中心的医生接待患者的比例反而从2009年的63％下降到了2013年的59％。（世界卫生组织表示，理想估计，这一比例应为80％以上）对于贫困乡村地区的家庭而言，看病变得更加难以承担。老百姓的怒火并未得到缓解。虽然85％的大型医院都设有派出所，中国每年仍有上千名医生被患者攻击。这样的基础卫生保健体系并不完善。
编译：陈思
审校：刘婷婷
编辑：翻吧君
英文来源：经济学人