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Note: China Labour Bulletin recently published our healthcare workers' report: Unprotected yet Unyielding: The Decade-Long Protest of China’s Healthcare Workers (2013-2023). This is the introduction of the report. To help better understand the issues we discussed, we also included a background of China's healthcare system and hospitals.

Introduction

Healthcare workers in China faced unprecedented challenges to their working conditions and labour rights due to the COVID-19 outbreak in Wuhan, the spread of the epidemic, and the effects of the global pandemic. The death of whistleblower Dr. Li Wenliang on 7 February 2020 in Wuhan exemplifies the types of sacrifices made by healthcare workers, who had continuously faced life-threatening risks over the next few years as China’s pandemic-prevention measures were implemented and then dropped across the country. Not only were healthcare workers required to support government quarantine and sampling facilities, but they also struggled to maintain regular services and prevent infections within hospitals. Medical facilities were severely understaffed as some workers were quarantined at their homes, while equipment like protective gear was in short supply. At the end of 2022, China’s sudden withdrawal of its pandemic-prevention measures further added to the demands of healthcare workers nationwide. As the virus openly swept through the public, healthcare workers now had to work while infected with COVID-19, and with supplies of protective gear reduced now that the pandemic was deemed “over.” In turn, medical schools demanded their residents (规培生) return to work and threatened them with bans from taking their final exams, leading to a wave of protests. Even while healthcare workers were facing excessive workloads and occupational risks, they also faced reduced salaries and even non-payment of wages and social insurance benefits, owing mainly to a drop in regular clinical consultations and the increase in pandemic prevention expenditures.

The legacy of the pandemic continues to affect China’s healthcare workers even today. For example, on 3 November 2023, a group of medical staff from the Ruzhou Maternity and Child Health Hospital in Henan (河南汝州妇幼保健院) held a protest in front of the hospital, saying that their wages have been owed for more than a year. Their social insurance benefits and housing provident funds were also unpaid. A local newspaper, New Yellow River (新黄河), reported the response from local authorities: “Since last year, with a decline in births, the impact of the pandemic and other factors, the centre’s business has declined drastically, leading to a sharp drop in income and a delay in wage payment.”

In mid-December 2023, a post on the People’s Daily “Message Board for Leaders”  (领导留言板) raised concerns about 15 months of unpaid performance-related pay (hereafter “performance pay”) at the Jingchuan County Hospital of Traditional Chinese Medicine (泾川县中医院) in Gansu province. According to the message, temporary staff were paid only around 1,000 yuan per month (U.S. $143). Their social insurance was also unpaid. Temporary staff made up around half of the 386 workers at the hospital. An investigation by the Jingchuan County Commission (泾川县委) confirmed these claims. The impact of the pandemic, declining hospital income, lack of financial support, and new infrastructure projects - including quarantine facilities for pandemic prevention - were cited as reasons for the hospital’s increasing debt and subsequent delay in wage and performance pay, as well as non-payment of social insurance.

However, it would be inaccurate to attribute labour rights issues in China’s healthcare sector primarily to the pandemic. Instead, the public health emergency merely triggered long-standing problems. China Labour Bulletin has been documenting labour rights challenges in China since 2011 in a public database (the Strike Map). The number of cases we collected for hospitals stabilised from 2013 onwards, with a total of 135 cases recorded from 2013 to 2023. These cases involve various issues such as unpaid wages and social insurance, demands for “equal pay for equal work” by informal workers, performance pay and subsidy problems, work safety concerns, and hospital restructuring issues. These cases and data from our Strike Map serve as the foundation of this report. In addition, we also refer to media reports, scholarly articles, and surveys conducted by social organisations to explain the systemic problems in the healthcare sector that contribute to labour rights challenges.

China Labour Bulletin’s database contains collective action cases since 2011 in our Strike Map and individual cases of worker grievances in our Workers’ Calls-for-Help Map since 2020. Our data related to healthcare workers’ collective actions and requests for help are mainly from doctors and nurses in hospitals - rather than primary healthcare institutions, clinics, cosmetic centres or other healthcare institutions - possibly due to biased sampling of online information or the fact that hospital staff account for more than 60 per cent of all healthcare professionals in the country. Due to these limitations in data collection, this healthcare report will concentrate on the working conditions of doctors and nurses in China’s hospitals.

By compiling cases of healthcare workers’ collective actions and their online pleas for help, China Labour Bulletin aims to shed light on the labour rights situation of healthcare workers to the general public, policymakers, and trade union organisers. We argue that the frequent occurrence of labour rights issues in the healthcare sector is related to systemic problems and changes in China’s healthcare system. The lack of a genuine representative for the healthcare workers during these changes has led them to resort to protests or seeking help online. China’s healthcare unions in hospitals and the sectoral unions at ACFTU need to establish an effective and constant mechanism between labour and management in hospitals, which will allow the participation of multiple stakeholders and help resolve labour disputes.

A Brief Note on China’s Healthcare System and Hospitals

To assist in understanding the report, this section will introduce the different components of China’s healthcare system, including the types of hospitals, their grading system and the number of health professionals.

Public and private hospitals

There are three main types of healthcare institutions in China: hospitals, primary healthcare institutions, and specialised public health institutions (e.g., centres for disease prevention and control). China’s hospitals are divided into public and private.  Public hospitals are typically larger general hospitals, whereas private hospitals tend to be smaller and more specialised. According to the Statistical Bulletin on Health Development in China 2022 (2022年我国卫生健康事业发展统计公报), out of 36,976 hospitals in China, 11,746 are public and 25,230 are private. Although private hospitals account for more than 60 per cent of the total, they only account for 20 per cent of the patient visits.  Public hospitals received about 3.2 billion patient visits in 2022 (around 84% of total hospital visits), while private hospitals only received about 600 million visits (around 16% of total hospital visits). The share of private hospital visits from 2010-2019 (before the pandemic) was even lower. According to the China Health Statistical Yearbook (中国卫生健康统计年鉴), the share of private hospital visits increased from 8% in 2010 to 15% in 2019, but the percentage is still much lower than that of public hospital visits.

Hospital services

Hospitals in China provide both inpatient and outpatient services. According to the World Health Organization’s (WHO) report, People’s Republic of China health system review, China’s healthcare system does not yet have a well-established triage system. The country lacks a “gatekeeper system,” in which community-based general practitioners serve as the first point of care, as well as the “two-way referral system” (双向转诊制度),where primary healthcare centres handle minor illnesses and hospitals handle major ones. As a result, hospitals in China still provide basic medical services. Hospitals can be categorised into general hospitals and specialised hospitals, and into Chinese and Western medicine hospitals. Most hospitals in China provide Western medicine, but almost every county and city has a hospital specialising in traditional Chinese medicine. Additionally, some ethnic minority areas have hospitals dedicated to other traditional medicines, such as Tibetan and Mongolian practices.

Grading system of hospitals

The WHO report also introduced the hospital grading system implemented in China in 1989. The system has three levels, each corresponding to the size and function of the hospital (see table below).