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Illegal Private Clinics: Ideal Health Services Choices among Rural–Urban Migrants in China? a
Yan Li a
School of Arts and Humanities, Nottingham Trent University, Nottingham, United Kingdom Published online: 28 Jul 2014.
To cite this article: Yan Li (2014) Illegal Private Clinics: Ideal Health Services Choices among Rural–Urban Migrants in China?, Social Work in Public Health, 29:5, 473-480, DOI: 10.1080/19371918.2013.873996 To link to this article: http://dx.doi.org/10.1080/19371918.2013.873996
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Social Work in Public Health, 29:473–480, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1937-1918 print/1937-190X online DOI: 10.1080/19371918.2013.873996
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Illegal Private Clinics: Ideal Health Services Choices among Rural–Urban Migrants in China? Yan Li School of Arts and Humanities, Nottingham Trent University, Nottingham, United Kingdom
The main purpose of this article is to explore the important issues and the role of illegal private clinics in health services access among rural–urban migrants in China. The function that illegal private clinics substantially play on the health among rural–urban migrants in China is rarely discussed in studies. A study on a migrant community in Beijing shows the disadvantaged status of health services choices and the constraints for access to health services among migrants. It argues that the existence of illegal private clinics provides a channel to migrants for medical services in the city and reflects the difficulties and high cost of providing medical services to migrants in urban public hospitals. Occasionally the illegal private clinics can cause danger to the health of migrants. Keywords: Rural–urban migrants, illegal private clinics, health services access, China
INTRODUCTION National policy in China has long been established on locality-based schemes that depend on household registration (hukou), which is not easily transferable from rural to urban areas (Hu, Cook, & Salazar, 2008). Currently this system still affects current rural–urban migration as rural residential identification is permanent, even though rural residents may have left their rural origins for an urban life. The hukou system hinders migrants from enjoying the benefits of urban public services equally with local residents, including health care services. In the last two decades, rural–urban migration has increased yearly, as migrants are attracted by better job opportunities and higher incomes in city areas, despite unfavorable working and living conditions (Li & Wu, 2010; Xiang, 2005). By the end of 2011, 158 million people had migrated (National Bureau of Statistics of China, 2012). These migrants are not permanently registered in their current places of residence, and the majority of them are rural residents moving from rural villages to cities in coastal regions. Given the massive scale of internal migration in China, health issues matter not only to rural– urban migrants but also have important implications for a wider range of communities. Most migrants have almost completely assumed responsibility to undertake the dirtiest, heaviest, and most physically dangerous work in the cities. This group requires the most medical protection. Address correspondence to Yan Li, School of Arts and Humanities, Nottingham Trent University, Clifton Lane, Nottingham, UK, NG11 8NS. E-mail: [email protected] or [email protected]
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However, in reality migrants encounter many difficulties and constraints in accessing proper medical treatment. They are marginalized in city areas and unable to integrate into city life (Wong, Li, & Song, 2007). When they fall ill, many do not receive proper treatment in time, and thus their illnesses may be prolonged. The model of consumers’ buying can be divided into five stages: for example, confirmation of the problem, the information search, the project evaluation, the purchasing decision and postbuying behavior (Engel, Blackwell, & Miniard, 1993). This model means that when consumers purchase products, they usually experience these five stages. In other words, the purchasing process is already underway before buying, and it will take some time to conclude after purchasing. People do not wish to buy most medical services in terms of being a patient. For them, the purpose of medical service are recovering or maintaining health. Andersen (1968) and Andersen and Aday (1974) introduced a medical model that provides a complete framework and contains three elements of usage of medical service. The first is tendency: demographic characteristics, social structure characteristics, and attitudes toward healthy living. The second is capability: individual, family, and social resources. And the third is need: a person’s own appraisal of his or her health and the medical officer’s objective appraisal. According to empirical studies, researchers found that the choice of medical services is governed mainly by the following factors: the treatment skills, the medical ethics, the medical service instrumentation and equipment, the service attitude of the doctors, and the distance to obtaining the medical service. In previous studies, Gautham, Binnendijk, Koren, and Dror (2011) discussed that rural people in India seek outpatient primary care from private providers for many conditions, including newborn/child illnesses (Kaushal et al., 2005; Deshmukh, Dongre, Sinha, & Garg, 2009), malaria/febrile illnesses (Chaturvedi, Mahanta, & Pandey, 2009), tuberculosis (Fochsen et al., 2006), and women’s health (Rani & Bonu, 2003). People’s choice of provider may reflect provider proximity, cost, reputation, perceived “recovery,” lack of faith in the public sector, and lay notions of etiology (Ager & Pepper, 2005; Dongre, Deshmukh, & Garg, 2008; Kamat, 1995). The private health sector in rural India includes a heterogeneous mix of providers; some are professionally trained, but the majority are unqualified. Phenomenon of do-nothing or visit to small private pharmacy was also observed in many developing countries. Sahn, Younger, and Genicot (2003) explored that consumers in Tanzania are highly responsive to the price of health care, and that this responsiveness is greater for individuals at the lower end of the income distribution. When prices of services are increased, there will be a precipitous decline in use of those public clinics and dispensaries. Consequently, price increases or user fees will result in poor people opting for self-treatment or do nothing for the health problems. This comes as no surprise, in light of previous research on health demand, and the evidence from countries, such as Ghana (Waddington & Enyimayew, 1990), Kenya (Mwabu, Ainsworth, & Nyamete, 1993), India (Gautham et al., 2011), and Zambia (Kahenya & Lake, 1994), which have reported declines in the use of public clinics subsequent to the imposition of user fees. What is the difference in China? Some scholars (e.g., Xiang, 2005) have pointed out that the rapid commercialization of medical services in China compounds the situation. Over the last decades, costs of medical treatment in China have risen dramatically, and the utility ratio used by migrants when choosing a hospital service is lower than that of the local resident (Xiang, 2005). Currently in urban China, illegal private clinics (known as “black clinics”) have become a popular health service choice mainly for migrants. These clinics are set up to serve the poor people in urban China, almost all of them are rural–urban migrant who have come to urban areas to find a job. Most illegal private clinics are in the migrant community on the outskirts of the city, or near large construction sites that can employ hundreds of migrant workers. They offer a cheaper alternative to the city’s government-backed clinics and hospitals. But there are problems—they are often dirty, staffed by people with no formal medical qualifications, and it is not clear where they buy their medicine and equipment (Bristow, 2009).
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This article aims to investigate the important issues within health services access among rural– urban migrants and the role of illegal private clinics in China. The substantial influence of illegal private clinics upon the health of rural–urban migrants in China has rarely been discussed in studies.
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METHOD Beijing is a center of national and international exchanges, including tourism and businesses, and is a city with a high density of migrants. In Beijing, Dengcun Village in Fengtai District was used as the case study site. Fengtai District, one of Beijing’s suburban districts, has been a concentrated migrant community for low-skilled manual workers and their families for nearly two decades. It experienced changes in national policies concerning migration and the changes in patterns of migrant settlement, yet it remains one of the least developed districts in Beijing. Dengcun Village is not an officially defined village in administrative terms. It is a migrant community transcending geographical, social, administrative, and ideological boundaries essential to the established system. It displays spontaneous migration challenges within the system because migrant issues cross boundaries and migrants may establish their own “rooted” and “territorialized” space in the new destination areas. Two facts-money and information on the one hand, and the creation of tangible communities on the other-are inter-related to these trans-regional flows of people. This article is based on a case study of qualitative interviews in the Dengcun village within Dahongmen area—a migrant community in Beijing, China. Participants were owners of illegal private clinics, and rural–urban migrants who had direct experience of illness, or had experience of illness of an immediate family member. Many small private clinics within migrant communities in urban China are classed as illegal because they do not possess formal licenses. The majority of migrants interviewed originated from the rural areas of South China, many having travelled from the rural Zhejiang province and who spoke the Zhejiang dialect. None was a new migrant; they had all resided in Dengcun Village for more than 3 years. RESULTS According to this study, the lack of access to financial help and proper treatment forces migrants to adopt a variety of unhealthy reactions to falling ill. Upon initially becoming ill, migrants will typically do nothing but wait, hoping the illness will go away by itself. If the situation worsens, they will buy cheap medicines at small pharmacies according to their own medical knowledge. Only when the illness becomes unendurable will they attend hospitals, but the high cost of treatment causes many of them to visit illegal private clinics, by which time the disease may have already become serious. For example, the gastric ulcer is a common disease among the migrants interviewed, and migrants often buy painkillers when experiencing stomachaches that subsequently exacerbate the ulcer due to the delay in treatment. This is worsened by the youthfulness of migrants, which, in some cases, allows them to endure the illness, only for it to possibly develop into a more serious illness when they age (Li & Wu, 2010). Illegal private clinics have taken root in the migrant communities and play a significant role. The illegal private clinic is one of the main choices of health services for migrants. The existence of illegal private clinics not only provides a channel to migrants for medical treatment services in the city, but also reflects the difficulties and high cost of providing medical services to migrants at public hospitals. It is too expensive for migrants to visit either the pharmacist or a doctor at a public hospital, which in turn leads to them declining hospital treatment.
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The findings indicate that, as to the types of illegal private clinics, these usually include clinics specializing in dentistry general illness, diverse illnesses (such as gynecological diseases, skin diseases, sexually transmitted diseases, Chinese medicine, etc.), gynecology (providing services such as abortion and the sale of contraceptives), and private pediatric clinics. The definition of private clinic is based on its private ownership (Xiang, 2005). A doctor who runs an individually owned private clinic solely is described as a “private doctor,” and a “private doctor” is realistically described as a self-employed “doctor” without a proper license. In accordance with the Regulations Governing the Administration of Medical Institutions in China, those opening a private clinic must satisfy the following criteria: the utilization area of the clinic should be no less than 40 square meters, and they at least should contain a consulting room and a therapeutic room; clinics of traditional Chinese and Western medicine should have a Chinese pharmacy; moreover, practitioners should hold a Certificate of Medical Practitioner and be experienced in working in a specialized clinical medicine for no fewer than 5 years (Li & Wu, 2010). Many illegal private clinics are located at the roadside, and in general, clinics have only one small private rented room of approximately 15 to 20 square meters. The equipment in these clinics is poor, and they offer a small range of medicines. The clinics are usually operated by one or two (husband-and-wife) staff. There are no nurses as the owner acts as doctor and nurse. Some owners claimed that they were professional in specialist fields and could treat many diseases, such as gynecological diseases, pediatrics, Chinese medicine, and sexually transmitted diseases (Q. Lin, He, Cao, & Zhang, 2006). The emergence of these clinics has several explanations. For instance, some “doctors” claimed that their skills were inherited from earlier generations and ancestors. Some “doctors” opened illegal private clinics in migrant communities because there were many migrants from the same province, which was good for business. The authorities are currently tightening their attitudes to illegal private clinics, but this crackdown on illegal medical practices is too little and inefficient because several departments are jointly responsible for law enforcement, such as Health Inspection, Public Security, and the Industrial and Commercial Administrative Department. Illegal private clinics are currently punished by means of fines and confiscation. Despite these enforcements, the illegal private clinics reopen shortly afterwards. Authorities are concerned with the realistic role of the illegal private clinics from two sides: on the one hand, they provide an alternative option to public hospitals and a substantial complement to the imperfect health system in China. Because migrants are not either covered or covered equally to the urban residents by the social allowance system, it is too heavy a financial burden for them to afford treatment in public hospitals. On the other hand, the unqualified conditions of illegal private clinics leads to poor quality of services, which is another constraint to the health of migrants, and potentially dangerous to their lives. There are mainly five reasons for migrants choosing health services provided by illegal private clinics. The first is cost: migrants are attracted by the cheap price charged by the illegal private clinics. The high cost of public hospital services makes them prohibitive. A visit to a public hospital can cost 10 times more than to an illegal clinic. I got the illness of lumbar intervertebral disc protrusion. I firstly went to a public hospital in Beijing and have spent two hundreds RMB for type-B ultrasonic, and then the doctor asked me to take the examination of nuclear magnetic resonance, which would cost me further two thousands RMB. That was very expensive and I was not willing to spend too much money. I am not a Beijing resident with urban hukou, so I am not qualify for cheaper health care at government hospitals, and my hometown is too far away to take advantage of medical subsidies there. So I turned to a private clinic and bought some analgesic drugs and took naprapathy there with very cheap prices. (Participant)
The second is that private clinics provide a prompt service with a positive attitude toward clients, whereas in public hospitals, many migrants feel discrimination by doctors.
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The doctors are nice to me in private clinics, I don’t want to go to big public hospitals because I get no respect there. I felt the impatient attitude from the doctor when she knew from my accent that I was not a Beijing Native, although I just saw she had a nice manner to another patient with a Beijing accent. I do not like the feeling there so I will choose the private clinic for the treatment if my son gets ill again, because the attitude in the private clinic is much better. (Participant)
The third is that private clinics offer longer and flexible business hours, and convenient locations to the migrants’ living quarters. The fourth is provision of uncomplicated procedures: private clinics are more convenient to migrants, and they do not have to wait long periods between registration and treatment, unlike public hospitals. Intravenous infusion can be undertaken immediately if necessary, and medication can be prescribed instantly. And finally, the flexible approach in paying for treatment also attracts migrants to the medical services provided in illegal private clinics. They can postpone paying for the treatment and do not have to pay on account in the private clinic; this is impossible in public hospitals. However, the problems within illegal private clinics deserve more attention. One such problem was the lack of qualified doctors, which caused a low quality of medical care. Moreover, the equipment in these clinics is poor, as is the hygiene and limited range of medicines. The private clinics actually can not treat major diseases as the medical equipment there is very poor. and also, the size of many private clinics is small so they cannot provide a thorough examination. Some private clinics only have one single room with a stethoscope and a bare light bulb. (Participant)
The second issue is the medicine sold by private clinics. The participants of private clinics in this study just stated that their medicines are cheaper and they have their own channels of stocking medicine, but when they were asked about the details, they reused to answer. Although no serious hurt or death caused by the treatment in private clinics was found in this study, it was widely reported that fake medicine was sold at illegal private clinics. The drugs are obtained through illegal channels and may potentially cause harm to migrants’ health. These caused problems in that the diseases of some migrant patients were exacerbated following use of medicine from private clinics. The third concern is the threat and danger to migrant health caused by illegal private clinics, although these clinics are a popular choice when seeking health care. Two migrant participants in this study stated that they suffered serious infection, when they received dental extraction in illegal private clinics. Some scholars, such as Zhang (2007) also stated that the diseases of some migrant patients were exacerbated after using health services from illegal private clinics. For example, in pregnant migrants in Beijing, Wuhan, and Shenzhen reported at least one prenatal examination rate of 50% to 70%, and a hospital delivery rate of 50%; their preferred option is delivery by private clinic “doctors” or “midwives.” Illegal midwifery has a severe negative impact on the health and well-being of these pregnant women. Illegal midwifery is the number one killer of migrant pregnant women. In Guangdong province, from January to November 2005, more than 50 migrant pregnant women died because of massive hemorrhage when giving birth at illegal private clinics (Zhang, 2007). In China, as a country with a seriously flawed health system, the coverage of health care and insurance is usually directly tied to hukou status (household registration identity). Previous government and state-owned enterprise insurance programs have been subsumed by the Urban Basic Medical Insurance program, which is funded by employer and employee contributions (6%–10% and 2% wages) split between individual medical savings accounts and socially pooled accounts. Recent reforms have aimed to increase health insurance coverage of the population. In urban areas, coverage has been extended to the nonemployed natives (e.g., students, children, elderly, those unemployed or out of the labor force) by a new voluntary Urban Resident Basic Medical Insurance Scheme that was introduced in September 2007 in 79 cities. It enrolled 43 million people by year-end 2007 and planned to expand to 229 cities in 2008 (W. Lin, Liu,
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& Chen, 2009; World Bank, 2009). However, migrants are not included in the current medical insurance system and are forced to step into a black clinic. One limitation regarding illegal private clinics in this study is that because of the sensitivity of their illegal practices, the access to interviews was difficult although I got participants successfully, and moreover, the participants tended to be suspicious of interviewer, and some of them refused to answer few questions.
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DISCUSSION Migration is a result due to difference in economic opportunity between the place of residence and work, In the last two decades, attracted by better job opportunities and higher incomes in city areas, rural–urban migration has been increasing each year, despite the unfavorable working and living conditions (Li & Wu, 2010). Rural–urban migration has made an enormous contribution to the formation of the labor market in recent decades in urban China, however, they are forced into a seedy and unregulated world of back alley “illegal private clinics (black clinics)” if they fall ill. Financial constraint is one hardship why migrants chose the illegal private clinics for provision of medical services. On the one hand, the financial resource is often the most lacking resource for most migrants because many of them are engaged in manual jobs with very low payment, or worse if they experience wage arrears. Yet on the other hand, financial resource is of the first and foremost importance because it can be used directly or can be used to acquire other services, including medical service (Li & Wu, 2010). The main obstacles to accessing health services are not only the shortage of financial resources among rural–urban migrants, but also the institutional blind spot regarding health care provision, rural–urban dualism and a unique household registration system in China (Li & Wu, 2010). The hukou system, which dates to 1958, has split China’s 1.3 billion people along urban-rural lines, preventing many of the roughly 800 million Chinese who are registered as rural residents from settling in cities, and enjoying basic urban welfare and services. As far as the medical services system is concerned in China, there is an urgent need to increase access to basic medical treatment services for the poor. New mechanisms need to be introduced so that targeted subsidies can be provided for migrants who are unable to pay for the high medical costs. China’s new government has vowed to change this divisive system with reforms aimed at sharing more equally the bounty of China’s economic growth and consumption-led growth, however, no details have yet been announced, so black clinics will remain the affordable last resort for migrant workers. The surveillance and supervision of illegal private clinics requires strengthening. One problem of these private clinics is the lack of formal licenses. Health authorities in Beijing often turn down applications from private clinics for licenses on the ground that they fail to meet the basic standards in facilities and fail to provide acceptable qualifications of doctors. Medical services for migrants could potentially be used as an effective means to consolidate migration management, and local government should adopt flexible measures to channel the emergence and development of private clinics, rather than simple prohibition. Despite various problems shown within illegal private clinics, their positive function and services to migrants cannot be ignored. Local government, on the one hand, can help to integrate migrants into the urban communities through providing medical services of good quality at affordable prices. On the other hand, medical services can also be used by the local government to collect basic information of floating migration. Based on the actuality of increasing costs in medical treatment and the widening gap between the rich and poor in urban China, the government should consider encouraging the reasonable development of private clinics based on the migrant communities. In the meantime, firm enforcement must be adopted by the governmental authorities to tighten restrictions on private clinics staffed by unqualified doctors and the quality of medicines provided.
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In the migrant community where migrants aggregate, administrative points and medical service stations can be established. First, a health care information network for the migrants is expected to establish. Second, health education among migrants is required, and the education background and the capability of learning and understanding need to be taken into account so that the health knowledge can be best absorbed by the migrants. The education is expected to include the introduction to the knowledge on imaginable health problems among migrant groups and relevant training on coping with those problems. It is also important to have the perceptions of some migrants on health and sanitation transferred and improved, by means of relevant education and training. Last but not least, it is a good channel for the local government to encourage the migrants to go to the existing public health center within their own communities for medical treatment, especially the treatments for common diseases. As most of the common diseases can be treated in community health center, and the cost there is generally cheaper than that in public hospitals, it will be more efficient to secure the quality of medical services provided to the migrants and reduce the negative side effect or, even potential danger, from the illegal private clinics. By doing so, it can gradually bring about the migrants’ access to basic medical services and build up the correct perception on basic health knowledge among them.
CONCLUSION In China, health care insurance and other social insurances are closely linked to hukou. Illegal private clinics are the dark corner of China’s medical system, rural–urban migrants are their main patrons largely due to flaws in the health insurance system. China’s health care insurance system is a fragmented one, mostly coordinated within counties. But migrant workers usually have to seek medical treatment outside their home counties. Portable social insurances are key to encourage labor migration, but it will take some time for a country as big as China. China has beefed up spending on health care reform with last year’s overall expenditure at 719.9 billion RMB, a 12% increase from the previous year. Yet last year’s figures from the Ministry of Human Resources and Social Security showed that only about 20% of migrant workers have health insurance (Reuters, 2013). For those who are insured, reimbursement only comes after payment and often is complicated by bureaucratic red tape, putting families at risk of bankruptcy when major health problems strike. Health insurance works locally, but when people go work in other places, only some provide health insurance, which still requires a lot of procedures. And each could take months and still wouldn’t come through. Although building a countrywide health care reimbursement system is the goal of health system reform in China, there is still quite a long way to go.
ACKNOWLEDGEMENT I thank those who participated in the interviews for this research.
FUNDING This research was supported by the Ministry of Education in China, Humanities and Social Sciences Youth Fund Project (project number 13YJCZH092) and by the Independent Innovation Foundation of Shandong University (project number 2012TB007).
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Social Work in Public Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/whsp20
Illegal Private Clinics: Ideal Health Services Choices among Rural–Urban Migrants in China? a
Yan Li a
School of Arts and Humanities, Nottingham Trent University, Nottingham, United Kingdom Published online: 28 Jul 2014.
To cite this article: Yan Li (2014) Illegal Private Clinics: Ideal Health Services Choices among Rural–Urban Migrants in China?, Social Work in Public Health, 29:5, 473-480, DOI: 10.1080/19371918.2013.873996 To link to this article: http://dx.doi.org/10.1080/19371918.2013.873996
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Social Work in Public Health, 29:473–480, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1937-1918 print/1937-190X online DOI: 10.1080/19371918.2013.873996
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Illegal Private Clinics: Ideal Health Services Choices among Rural–Urban Migrants in China? Yan Li School of Arts and Humanities, Nottingham Trent University, Nottingham, United Kingdom
The main purpose of this article is to explore the important issues and the role of illegal private clinics in health services access among rural–urban migrants in China. The function that illegal private clinics substantially play on the health among rural–urban migrants in China is rarely discussed in studies. A study on a migrant community in Beijing shows the disadvantaged status of health services choices and the constraints for access to health services among migrants. It argues that the existence of illegal private clinics provides a channel to migrants for medical services in the city and reflects the difficulties and high cost of providing medical services to migrants in urban public hospitals. Occasionally the illegal private clinics can cause danger to the health of migrants. Keywords: Rural–urban migrants, illegal private clinics, health services access, China
INTRODUCTION National policy in China has long been established on locality-based schemes that depend on household registration (hukou), which is not easily transferable from rural to urban areas (Hu, Cook, & Salazar, 2008). Currently this system still affects current rural–urban migration as rural residential identification is permanent, even though rural residents may have left their rural origins for an urban life. The hukou system hinders migrants from enjoying the benefits of urban public services equally with local residents, including health care services. In the last two decades, rural–urban migration has increased yearly, as migrants are attracted by better job opportunities and higher incomes in city areas, despite unfavorable working and living conditions (Li & Wu, 2010; Xiang, 2005). By the end of 2011, 158 million people had migrated (National Bureau of Statistics of China, 2012). These migrants are not permanently registered in their current places of residence, and the majority of them are rural residents moving from rural villages to cities in coastal regions. Given the massive scale of internal migration in China, health issues matter not only to rural– urban migrants but also have important implications for a wider range of communities. Most migrants have almost completely assumed responsibility to undertake the dirtiest, heaviest, and most physically dangerous work in the cities. This group requires the most medical protection. Address correspondence to Yan Li, School of Arts and Humanities, Nottingham Trent University, Clifton Lane, Nottingham, UK, NG11 8NS. E-mail: [email protected] or [email protected]
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However, in reality migrants encounter many difficulties and constraints in accessing proper medical treatment. They are marginalized in city areas and unable to integrate into city life (Wong, Li, & Song, 2007). When they fall ill, many do not receive proper treatment in time, and thus their illnesses may be prolonged. The model of consumers’ buying can be divided into five stages: for example, confirmation of the problem, the information search, the project evaluation, the purchasing decision and postbuying behavior (Engel, Blackwell, & Miniard, 1993). This model means that when consumers purchase products, they usually experience these five stages. In other words, the purchasing process is already underway before buying, and it will take some time to conclude after purchasing. People do not wish to buy most medical services in terms of being a patient. For them, the purpose of medical service are recovering or maintaining health. Andersen (1968) and Andersen and Aday (1974) introduced a medical model that provides a complete framework and contains three elements of usage of medical service. The first is tendency: demographic characteristics, social structure characteristics, and attitudes toward healthy living. The second is capability: individual, family, and social resources. And the third is need: a person’s own appraisal of his or her health and the medical officer’s objective appraisal. According to empirical studies, researchers found that the choice of medical services is governed mainly by the following factors: the treatment skills, the medical ethics, the medical service instrumentation and equipment, the service attitude of the doctors, and the distance to obtaining the medical service. In previous studies, Gautham, Binnendijk, Koren, and Dror (2011) discussed that rural people in India seek outpatient primary care from private providers for many conditions, including newborn/child illnesses (Kaushal et al., 2005; Deshmukh, Dongre, Sinha, & Garg, 2009), malaria/febrile illnesses (Chaturvedi, Mahanta, & Pandey, 2009), tuberculosis (Fochsen et al., 2006), and women’s health (Rani & Bonu, 2003). People’s choice of provider may reflect provider proximity, cost, reputation, perceived “recovery,” lack of faith in the public sector, and lay notions of etiology (Ager & Pepper, 2005; Dongre, Deshmukh, & Garg, 2008; Kamat, 1995). The private health sector in rural India includes a heterogeneous mix of providers; some are professionally trained, but the majority are unqualified. Phenomenon of do-nothing or visit to small private pharmacy was also observed in many developing countries. Sahn, Younger, and Genicot (2003) explored that consumers in Tanzania are highly responsive to the price of health care, and that this responsiveness is greater for individuals at the lower end of the income distribution. When prices of services are increased, there will be a precipitous decline in use of those public clinics and dispensaries. Consequently, price increases or user fees will result in poor people opting for self-treatment or do nothing for the health problems. This comes as no surprise, in light of previous research on health demand, and the evidence from countries, such as Ghana (Waddington & Enyimayew, 1990), Kenya (Mwabu, Ainsworth, & Nyamete, 1993), India (Gautham et al., 2011), and Zambia (Kahenya & Lake, 1994), which have reported declines in the use of public clinics subsequent to the imposition of user fees. What is the difference in China? Some scholars (e.g., Xiang, 2005) have pointed out that the rapid commercialization of medical services in China compounds the situation. Over the last decades, costs of medical treatment in China have risen dramatically, and the utility ratio used by migrants when choosing a hospital service is lower than that of the local resident (Xiang, 2005). Currently in urban China, illegal private clinics (known as “black clinics”) have become a popular health service choice mainly for migrants. These clinics are set up to serve the poor people in urban China, almost all of them are rural–urban migrant who have come to urban areas to find a job. Most illegal private clinics are in the migrant community on the outskirts of the city, or near large construction sites that can employ hundreds of migrant workers. They offer a cheaper alternative to the city’s government-backed clinics and hospitals. But there are problems—they are often dirty, staffed by people with no formal medical qualifications, and it is not clear where they buy their medicine and equipment (Bristow, 2009).
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This article aims to investigate the important issues within health services access among rural– urban migrants and the role of illegal private clinics in China. The substantial influence of illegal private clinics upon the health of rural–urban migrants in China has rarely been discussed in studies.
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METHOD Beijing is a center of national and international exchanges, including tourism and businesses, and is a city with a high density of migrants. In Beijing, Dengcun Village in Fengtai District was used as the case study site. Fengtai District, one of Beijing’s suburban districts, has been a concentrated migrant community for low-skilled manual workers and their families for nearly two decades. It experienced changes in national policies concerning migration and the changes in patterns of migrant settlement, yet it remains one of the least developed districts in Beijing. Dengcun Village is not an officially defined village in administrative terms. It is a migrant community transcending geographical, social, administrative, and ideological boundaries essential to the established system. It displays spontaneous migration challenges within the system because migrant issues cross boundaries and migrants may establish their own “rooted” and “territorialized” space in the new destination areas. Two facts-money and information on the one hand, and the creation of tangible communities on the other-are inter-related to these trans-regional flows of people. This article is based on a case study of qualitative interviews in the Dengcun village within Dahongmen area—a migrant community in Beijing, China. Participants were owners of illegal private clinics, and rural–urban migrants who had direct experience of illness, or had experience of illness of an immediate family member. Many small private clinics within migrant communities in urban China are classed as illegal because they do not possess formal licenses. The majority of migrants interviewed originated from the rural areas of South China, many having travelled from the rural Zhejiang province and who spoke the Zhejiang dialect. None was a new migrant; they had all resided in Dengcun Village for more than 3 years. RESULTS According to this study, the lack of access to financial help and proper treatment forces migrants to adopt a variety of unhealthy reactions to falling ill. Upon initially becoming ill, migrants will typically do nothing but wait, hoping the illness will go away by itself. If the situation worsens, they will buy cheap medicines at small pharmacies according to their own medical knowledge. Only when the illness becomes unendurable will they attend hospitals, but the high cost of treatment causes many of them to visit illegal private clinics, by which time the disease may have already become serious. For example, the gastric ulcer is a common disease among the migrants interviewed, and migrants often buy painkillers when experiencing stomachaches that subsequently exacerbate the ulcer due to the delay in treatment. This is worsened by the youthfulness of migrants, which, in some cases, allows them to endure the illness, only for it to possibly develop into a more serious illness when they age (Li & Wu, 2010). Illegal private clinics have taken root in the migrant communities and play a significant role. The illegal private clinic is one of the main choices of health services for migrants. The existence of illegal private clinics not only provides a channel to migrants for medical treatment services in the city, but also reflects the difficulties and high cost of providing medical services to migrants at public hospitals. It is too expensive for migrants to visit either the pharmacist or a doctor at a public hospital, which in turn leads to them declining hospital treatment.
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The findings indicate that, as to the types of illegal private clinics, these usually include clinics specializing in dentistry general illness, diverse illnesses (such as gynecological diseases, skin diseases, sexually transmitted diseases, Chinese medicine, etc.), gynecology (providing services such as abortion and the sale of contraceptives), and private pediatric clinics. The definition of private clinic is based on its private ownership (Xiang, 2005). A doctor who runs an individually owned private clinic solely is described as a “private doctor,” and a “private doctor” is realistically described as a self-employed “doctor” without a proper license. In accordance with the Regulations Governing the Administration of Medical Institutions in China, those opening a private clinic must satisfy the following criteria: the utilization area of the clinic should be no less than 40 square meters, and they at least should contain a consulting room and a therapeutic room; clinics of traditional Chinese and Western medicine should have a Chinese pharmacy; moreover, practitioners should hold a Certificate of Medical Practitioner and be experienced in working in a specialized clinical medicine for no fewer than 5 years (Li & Wu, 2010). Many illegal private clinics are located at the roadside, and in general, clinics have only one small private rented room of approximately 15 to 20 square meters. The equipment in these clinics is poor, and they offer a small range of medicines. The clinics are usually operated by one or two (husband-and-wife) staff. There are no nurses as the owner acts as doctor and nurse. Some owners claimed that they were professional in specialist fields and could treat many diseases, such as gynecological diseases, pediatrics, Chinese medicine, and sexually transmitted diseases (Q. Lin, He, Cao, & Zhang, 2006). The emergence of these clinics has several explanations. For instance, some “doctors” claimed that their skills were inherited from earlier generations and ancestors. Some “doctors” opened illegal private clinics in migrant communities because there were many migrants from the same province, which was good for business. The authorities are currently tightening their attitudes to illegal private clinics, but this crackdown on illegal medical practices is too little and inefficient because several departments are jointly responsible for law enforcement, such as Health Inspection, Public Security, and the Industrial and Commercial Administrative Department. Illegal private clinics are currently punished by means of fines and confiscation. Despite these enforcements, the illegal private clinics reopen shortly afterwards. Authorities are concerned with the realistic role of the illegal private clinics from two sides: on the one hand, they provide an alternative option to public hospitals and a substantial complement to the imperfect health system in China. Because migrants are not either covered or covered equally to the urban residents by the social allowance system, it is too heavy a financial burden for them to afford treatment in public hospitals. On the other hand, the unqualified conditions of illegal private clinics leads to poor quality of services, which is another constraint to the health of migrants, and potentially dangerous to their lives. There are mainly five reasons for migrants choosing health services provided by illegal private clinics. The first is cost: migrants are attracted by the cheap price charged by the illegal private clinics. The high cost of public hospital services makes them prohibitive. A visit to a public hospital can cost 10 times more than to an illegal clinic. I got the illness of lumbar intervertebral disc protrusion. I firstly went to a public hospital in Beijing and have spent two hundreds RMB for type-B ultrasonic, and then the doctor asked me to take the examination of nuclear magnetic resonance, which would cost me further two thousands RMB. That was very expensive and I was not willing to spend too much money. I am not a Beijing resident with urban hukou, so I am not qualify for cheaper health care at government hospitals, and my hometown is too far away to take advantage of medical subsidies there. So I turned to a private clinic and bought some analgesic drugs and took naprapathy there with very cheap prices. (Participant)
The second is that private clinics provide a prompt service with a positive attitude toward clients, whereas in public hospitals, many migrants feel discrimination by doctors.
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The doctors are nice to me in private clinics, I don’t want to go to big public hospitals because I get no respect there. I felt the impatient attitude from the doctor when she knew from my accent that I was not a Beijing Native, although I just saw she had a nice manner to another patient with a Beijing accent. I do not like the feeling there so I will choose the private clinic for the treatment if my son gets ill again, because the attitude in the private clinic is much better. (Participant)
The third is that private clinics offer longer and flexible business hours, and convenient locations to the migrants’ living quarters. The fourth is provision of uncomplicated procedures: private clinics are more convenient to migrants, and they do not have to wait long periods between registration and treatment, unlike public hospitals. Intravenous infusion can be undertaken immediately if necessary, and medication can be prescribed instantly. And finally, the flexible approach in paying for treatment also attracts migrants to the medical services provided in illegal private clinics. They can postpone paying for the treatment and do not have to pay on account in the private clinic; this is impossible in public hospitals. However, the problems within illegal private clinics deserve more attention. One such problem was the lack of qualified doctors, which caused a low quality of medical care. Moreover, the equipment in these clinics is poor, as is the hygiene and limited range of medicines. The private clinics actually can not treat major diseases as the medical equipment there is very poor. and also, the size of many private clinics is small so they cannot provide a thorough examination. Some private clinics only have one single room with a stethoscope and a bare light bulb. (Participant)
The second issue is the medicine sold by private clinics. The participants of private clinics in this study just stated that their medicines are cheaper and they have their own channels of stocking medicine, but when they were asked about the details, they reused to answer. Although no serious hurt or death caused by the treatment in private clinics was found in this study, it was widely reported that fake medicine was sold at illegal private clinics. The drugs are obtained through illegal channels and may potentially cause harm to migrants’ health. These caused problems in that the diseases of some migrant patients were exacerbated following use of medicine from private clinics. The third concern is the threat and danger to migrant health caused by illegal private clinics, although these clinics are a popular choice when seeking health care. Two migrant participants in this study stated that they suffered serious infection, when they received dental extraction in illegal private clinics. Some scholars, such as Zhang (2007) also stated that the diseases of some migrant patients were exacerbated after using health services from illegal private clinics. For example, in pregnant migrants in Beijing, Wuhan, and Shenzhen reported at least one prenatal examination rate of 50% to 70%, and a hospital delivery rate of 50%; their preferred option is delivery by private clinic “doctors” or “midwives.” Illegal midwifery has a severe negative impact on the health and well-being of these pregnant women. Illegal midwifery is the number one killer of migrant pregnant women. In Guangdong province, from January to November 2005, more than 50 migrant pregnant women died because of massive hemorrhage when giving birth at illegal private clinics (Zhang, 2007). In China, as a country with a seriously flawed health system, the coverage of health care and insurance is usually directly tied to hukou status (household registration identity). Previous government and state-owned enterprise insurance programs have been subsumed by the Urban Basic Medical Insurance program, which is funded by employer and employee contributions (6%–10% and 2% wages) split between individual medical savings accounts and socially pooled accounts. Recent reforms have aimed to increase health insurance coverage of the population. In urban areas, coverage has been extended to the nonemployed natives (e.g., students, children, elderly, those unemployed or out of the labor force) by a new voluntary Urban Resident Basic Medical Insurance Scheme that was introduced in September 2007 in 79 cities. It enrolled 43 million people by year-end 2007 and planned to expand to 229 cities in 2008 (W. Lin, Liu,
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& Chen, 2009; World Bank, 2009). However, migrants are not included in the current medical insurance system and are forced to step into a black clinic. One limitation regarding illegal private clinics in this study is that because of the sensitivity of their illegal practices, the access to interviews was difficult although I got participants successfully, and moreover, the participants tended to be suspicious of interviewer, and some of them refused to answer few questions.
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DISCUSSION Migration is a result due to difference in economic opportunity between the place of residence and work, In the last two decades, attracted by better job opportunities and higher incomes in city areas, rural–urban migration has been increasing each year, despite the unfavorable working and living conditions (Li & Wu, 2010). Rural–urban migration has made an enormous contribution to the formation of the labor market in recent decades in urban China, however, they are forced into a seedy and unregulated world of back alley “illegal private clinics (black clinics)” if they fall ill. Financial constraint is one hardship why migrants chose the illegal private clinics for provision of medical services. On the one hand, the financial resource is often the most lacking resource for most migrants because many of them are engaged in manual jobs with very low payment, or worse if they experience wage arrears. Yet on the other hand, financial resource is of the first and foremost importance because it can be used directly or can be used to acquire other services, including medical service (Li & Wu, 2010). The main obstacles to accessing health services are not only the shortage of financial resources among rural–urban migrants, but also the institutional blind spot regarding health care provision, rural–urban dualism and a unique household registration system in China (Li & Wu, 2010). The hukou system, which dates to 1958, has split China’s 1.3 billion people along urban-rural lines, preventing many of the roughly 800 million Chinese who are registered as rural residents from settling in cities, and enjoying basic urban welfare and services. As far as the medical services system is concerned in China, there is an urgent need to increase access to basic medical treatment services for the poor. New mechanisms need to be introduced so that targeted subsidies can be provided for migrants who are unable to pay for the high medical costs. China’s new government has vowed to change this divisive system with reforms aimed at sharing more equally the bounty of China’s economic growth and consumption-led growth, however, no details have yet been announced, so black clinics will remain the affordable last resort for migrant workers. The surveillance and supervision of illegal private clinics requires strengthening. One problem of these private clinics is the lack of formal licenses. Health authorities in Beijing often turn down applications from private clinics for licenses on the ground that they fail to meet the basic standards in facilities and fail to provide acceptable qualifications of doctors. Medical services for migrants could potentially be used as an effective means to consolidate migration management, and local government should adopt flexible measures to channel the emergence and development of private clinics, rather than simple prohibition. Despite various problems shown within illegal private clinics, their positive function and services to migrants cannot be ignored. Local government, on the one hand, can help to integrate migrants into the urban communities through providing medical services of good quality at affordable prices. On the other hand, medical services can also be used by the local government to collect basic information of floating migration. Based on the actuality of increasing costs in medical treatment and the widening gap between the rich and poor in urban China, the government should consider encouraging the reasonable development of private clinics based on the migrant communities. In the meantime, firm enforcement must be adopted by the governmental authorities to tighten restrictions on private clinics staffed by unqualified doctors and the quality of medicines provided.
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In the migrant community where migrants aggregate, administrative points and medical service stations can be established. First, a health care information network for the migrants is expected to establish. Second, health education among migrants is required, and the education background and the capability of learning and understanding need to be taken into account so that the health knowledge can be best absorbed by the migrants. The education is expected to include the introduction to the knowledge on imaginable health problems among migrant groups and relevant training on coping with those problems. It is also important to have the perceptions of some migrants on health and sanitation transferred and improved, by means of relevant education and training. Last but not least, it is a good channel for the local government to encourage the migrants to go to the existing public health center within their own communities for medical treatment, especially the treatments for common diseases. As most of the common diseases can be treated in community health center, and the cost there is generally cheaper than that in public hospitals, it will be more efficient to secure the quality of medical services provided to the migrants and reduce the negative side effect or, even potential danger, from the illegal private clinics. By doing so, it can gradually bring about the migrants’ access to basic medical services and build up the correct perception on basic health knowledge among them.
CONCLUSION In China, health care insurance and other social insurances are closely linked to hukou. Illegal private clinics are the dark corner of China’s medical system, rural–urban migrants are their main patrons largely due to flaws in the health insurance system. China’s health care insurance system is a fragmented one, mostly coordinated within counties. But migrant workers usually have to seek medical treatment outside their home counties. Portable social insurances are key to encourage labor migration, but it will take some time for a country as big as China. China has beefed up spending on health care reform with last year’s overall expenditure at 719.9 billion RMB, a 12% increase from the previous year. Yet last year’s figures from the Ministry of Human Resources and Social Security showed that only about 20% of migrant workers have health insurance (Reuters, 2013). For those who are insured, reimbursement only comes after payment and often is complicated by bureaucratic red tape, putting families at risk of bankruptcy when major health problems strike. Health insurance works locally, but when people go work in other places, only some provide health insurance, which still requires a lot of procedures. And each could take months and still wouldn’t come through. Although building a countrywide health care reimbursement system is the goal of health system reform in China, there is still quite a long way to go.
ACKNOWLEDGEMENT I thank those who participated in the interviews for this research.
FUNDING This research was supported by the Ministry of Education in China, Humanities and Social Sciences Youth Fund Project (project number 13YJCZH092) and by the Independent Innovation Foundation of Shandong University (project number 2012TB007).
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