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HONG KONG (Reuters) - As a young Chinese doctor earning 4,000 yuan ($600) a month, Zhang Fei was faced with having to cough up 2,000 yuan for a bill that a patient left unpaid after Zhang removed a tumor from her womb.
Zhang managed to track down the patient after alerting her neighbors and only avoided having to settle the bill when the patient returned to the hospital to sign a promise to pay.
"I'm only a doctor, why do I have to pay for it? I was very, very depressed. I spent many, many days ringing her, trying to track her down and I had to get other villagers to knock on her door," Zhang told Reuters in an interview.
China is overhauling the biggest healthcare system in human history and has made significant changes since 2003: implementing a basic universal medical insurance system and heavily subsidizing a growing list of essential drugs.
In March, it pledged more money to bring more people under the insurance scheme, raise reimbursements and improve services to meet the needs of its 1.34 billion people who are increasingly troubled by costly, chronic, non-communicable illnesses such as heart disease, stroke, diabetes and cancer.
The government also slashed the maximum retail price for more than 1,200 types of antibiotics and circulatory system drugs to cap profits of foreign and domestic drug makers and ward off grumbling over high healthcare costs.
But missing are plans to deal with other entrenched problems in the healthcare system, such as the absence of good hospital management which can often result in health workers being pitted against patients, like the situation Zhang faced.
Zhang and her colleagues often need to confront patients to get payment, or risk forking out for unpaid bills out of their pockets.
"There should be a department that deals with this and post-operation services that have nothing to do with therapy. But in China, doctors do a lot of work that has nothing to do with doctoring," Zhang said.
"Every year at my hospital, bad debts are over 100,000 yuan for each department. Whether we are patients or doctors, we are helpless, yet we are constantly fighting each other and our relationship is very tense."
At the hospital where Zhang works in the southern Chinese city of Guangzhou, salaries are tied to how much the hospital makes. The higher the debts, the lower the salaries; and wages rise when costs are kept low.
The problem began when China made hospitals self-funding in the 1990s to ease a heavy burden on state coffers. Costs were passed on to patients and in many hospitals, doctors are tasked with ensuring patients do not skip payment.
"Patients have to pay doctors' wages, pensions for retirees like me, pay for doctors to train overseas, pay for this huge building, all the equipment, utility bills," said Liu Jinpeng, a former senior administrator at a large general hospital in the southern city of Guangzhou.
Hospitals and doctors are notorious for prescribing expensive or unnecessary tests and drugs to boost revenues, an accusation which Health Minister Chen Zhu recently admitted to, according to media reports.
Zhang, however, says there are other reasons why doctors order exhaustive tests.
"Elsewhere, doctors can buy insurance to protect themselves in case they make mistakes. In China, there is no such thing, so I'm entirely exposed," Zhang said.
"In China, the blunder is blamed on the doctor alone ... it is easier to blame one person than admit the system is wrong."
"Why do we put patients through comprehensive tests? I need to make sure my diagnosis is correct. Before an operation, I will find out everything I need to find out and I leave nothing to chance because if there's a blunder, it will be my fault."
The stress of such exposure exacts a price and turnover of doctors is very high. Zhang had to inject tranquilizers to go to sleep at one point in her career.
"A batch of 20 doctors joined my hospital 10 years ago. Three years ago, only 5 remained. The rest became administrators in government departments, some went overseas and others joined pharmaceutical companies," she said, adding that some of her colleagues left because of low wages.
The government appears to know it must provide subsidies if medical bills are to be affordable. It now takes care of about 15 percent of hospital budgets -- but both doctors and hospital administrators say that is too low to make much difference.
Without enough funding, facilities at the county and village level are unable to provide more than just basic services and can not treat some chronic diseases such as cancer.
Shi Liuchang, a retired power station worker in Henan province suffering from late-stage liver cancer, cannot find treatment at the county hospital where he is covered by government-backed healthcare insurance.
"It can't handle cancer, its facilities are limited. If I go to other hospitals, this insurance won't cover the bills," Shi said. "Once I went to a city hospital, it couldn't help too, it was a general hospital with only basic equipment."
Shi, whose cancer is linked to hepatitis B virus infection, was laid off a few years ago. Two operations in Beijing wiped out the entire 112,000-yuan compensation he was given.
"Together with my wife's pension, we have 3,000 yuan a month, which we rely on for healthcare," said Shi, 61.
Shi said he was not taking medication for his hepatitis B.
"I cannot afford it. All my four siblings are infected by hepatitis B and one of them has died. No one can afford the drug except my younger sister."
Retired civil servant Fang Ding's anti-hypertension drugs are covered by monthly insurance payouts of 150 yuan, but she is hardly satisfied.
"I have been having a stomach pain for weeks and they made me go through two tests, which cost 1,200 yuan. I just learnt that I will only get a reimbursement of 40 yuan," Fang said.
"I tell you, we can die, but we can't get sick." ($1=6.5 yuan) (Editing by Robert Birsel)