A patient waits to get medicine in Peking Union Medical College Hospital on September 25, 2012. Photo: CFP

After finally seeing his last patient, Zhang Wei still had no intention of going home, although it was already 6:30 pm. He wanted to recheck the X-rays of a patient due for surgery the next day. But something else had kept this energetic doctor occupied all day, as it had all doctors in the city.

What troubled Zhang was a shocking piece of news exposed by media nationwide in late July. According to an investigation by the local Commission for Discipline Inspection (CDI) of the Communist Party of China (CPC) during the first half of the year, 90 percent of medical staff at all 73 hospitals in the city of Zhangzhou, Fujian Province were found to be involved in medical corruption.

With 57 medical representatives initially arrested, 1,088 medical staff and 133 administrative staff members were eventually implicated with 20.49 million yuan ($3.34 million) in bribes having been returned so far.

A recent scandal involving British drug giant GlaxoSmithKline (GSK) has already shaken China. The Chinese healthcare sector is facing another body blow in the shape of this brewing corruption case.

But this is far from the first time that authorities have cracked down on medical corruption in public hospitals in China. In 2010, all nine pharmacy chiefs at nine major public hospitals in Zhuhai, Guangdong Province were charged with bribery and sentenced to life imprisonment.

The incident rocked the local government and a series of measures was taken across Zhuhai to stop the same thing from happening again. But across the nation, the problem persists.

Although medical corruption is no longer news in China, the scale and level of complicity in Zhangzhou still surprised many. Some questions linger: is this just another case or is the healthcare system in China is rotten to the core?

Doctors' confessions

"To be frank, I was a little surprised but not angry when I first saw this story online," Zhang Wei told the Global Times.

Zhang has been a surgeon at a major hospital in Zhangzhou for more than 20 years. Besides heavy daily outpatient work, he carries out regular surgeries every week as well as teaching medical students.

"When you wear a doctor's coat, you should take on the full responsibility of this job. And I believed most doctors were good and were willing to cure their patients from the bottom of their hearts," Zhang said.

According to Zhang, the hospital he works for was only designed for 1,500 patients but now it handles 3,000 since demand is so high. Doctors often need to work until 1:30 pm without rest when morning working hours are supposed to be over at 11:30. Operation rooms are always full. Even after the scandal was exposed, crowds of patients have kept on flocking to hospitals.

"But in return for all this work, doctors might only be paid some 2,000 yuan per month," Zhang said.

"It's true that there is corruption in hospitals just like the report. Although I don't agree with some doctors who think it is acceptable to take bribes due to the low salary they get for the hours they put in, I think there should be a system to balance the gap. After all, not all doctors adhere to noble medical ethics," Zhang said. 

In Zhang's eyes, writing out prescriptions should be based on safety, efficiency and maintaining prices as low as possible. However, a profit-seeking mentality has twisted the simple ideology which every doctor should follow.

When doctors are always working under high pressure, it is not hard to understand why they will look for some other ways to make ends meet. 

 One main way to earn money for doctors is to use their right to write out prescriptions. Under the current medical system for public hospitals in China, doctors' salaries are linked with the prescriptions they give. The more medicine they give to patients, the more money they earn. Such a business model has been denounced by experts as a way "to cover hospital expenses through medical revenue" and which has become a hotbed of corruption.

Interest chain

According to Cai Xiangdong, director of the CDI at Zhangzhou Health Bureau, the whole corruption scandal this time was initially started from external reports. When the hospital management followed the clues and caught some medical representatives in the act, they confessed that all hospitals in the city were involved in their bribery scheme.

Under the current medical system in China, there are at least four steps that any new drugs must go through before making it into patients' hands. But each of these carries ample opportunity for illicit profit. 

First of all, all medicine allowed to be sold in each province must enter the provincial drug procurement directory before being up for approval at the city or county level. After that, hospitals can then choose drugs from that narrowed list and finally, doctors can hand out prescriptions with the final word on which medicine gets used or not. 

As a result, pharmaceutical companies have to spend a lot of money each step of the way to ensure their products can smoothly access the marketplace, despite fierce competition.

According to confessions from pharmaceutical representatives, more than half the costs for medicine is actually spent on "public relations." Among them, 15 percent goes to government organs in charge of the drug procurement directory, 25 percent to take care of hospitals and doctors and only 10 percent goes into the representatives' own pockets.

For example, an Oxiracetam injection priced at 56.8 yuan could net up to a 20 percent kickback for doctors. This medicine totally sold out in 2011 and 2012 in Zhangzhou, and the doctors who used this medicine made 156,000 yuan in kickbacks from  medical representatives because of this one drug alone. For doctors whose salaries are only a few thousand yuan a month, the temptation of such profits was often too hard to resist.

Although the Zhangzhou CDI refused to reveal the names of the companies involved in the case to the Global Times, many among the public believe that only the tip of medical corruption has been revealed so far. 

Cai told the Global Times that they had taken measures including random checks on the top 10 doctors in each hospital, to look for the usage of drugs, the doses prescribed and the prices charged. This verified if the doctors' prescriptions were reasonable.

But Cai explained the prices for all medicines were set by the provincial level government, and they could do nothing about the price.

According to Professor Li Ling from the National School of Development at Peking University, and a member of State Council Medical Reform Advice Committee, the current price-setting system has to improve.

"The price set by authorities in the drug procurement directory comes from the cost that medicine producer reported plus 15 percent reasonable profit space. But many medicine producers play tricks. On the one hand, they add a lot of hidden 'public relations' fees to the cost, on the other hand, nobody could be knowledgeable enough to know every sort of medical cost," Li said.   

But a senior executive of a major hospital in Zhangzhou who asked not to be named told the Global Times he thought corruption was a deep-seated social problem rather than a medical issue alone.

 "The income of doctors doesn't match their contributions to society and it is therefore hard to eliminate corruption," he said.

According to him, hospitals and doctors are also the victims of the current system which lacks a good top-level design.

Need for reform

Li Ling believes a comprehensive reform focused on changing the unreasonable treatment system of medical staff is urgently needed. 

"Doctors should feel respected in terms of their income and treatment. Judging the performance of a doctor should not depend on how much medicine they have sold and their salary should be absolutely separated from medical fees," Li told the Global Times.

According to Li, China's health authorities have long been aware of the problem plaguing the medical profession, but the latest reforms were back in 2009. However since then, all government efforts have stopped and the situation is worse than before.

 Yu Mingde, director of the Chinese Pharmaceutical Enterprises Association, told CCTV that he thought that building a healthy marketing system might be helpful to eliminate medical corruption at the root level.

"Market-oriented medical services are a trend, instead of everything remaining forever monopolized by the government. After all, the government can't take care of everything no matter how much they invest. Only when hospitals are given enough autonomy to shift their focus to provide the best care at the best price, will we be able to unmake the bed of corruption," Yu said.