Challenges to healthcare reform in China: profit-oriented medical practices, patients' choice of care and guanxi culture in Zhejiang province.

Doctors' profit-oriented practices in public institutions were widespread in China. Two major targets of the healthcare reform launched in 2009 were to curb the profit-making practices in public institutions and to encourage the citizens to use primary care. After 6 years, the status of profit-orientation of public institutions remains unknown. Compared with hospitals, there is no trend of increasing use of primary care. Our study aimed to explore the status of profit-orientation of public institutions and patients' utilization preference. The impacts of guanxi (personal relationship) on patients' utilization of healthcare and doctors' practices were also explored. From September 2014 to September 2015, we conducted focus group and individual interviews, followed by a survey with doctors (n = 1111) in Hangzhou, Zhejiang province. Thematic analysis, independent t-test and Fisher's exact test were conducted to analyse the data. This study found that 36.8% of survey respondents needed to consider making profits for their institutions, especially the hospital specialists. A total of 38.5% and 40.7% thought that their practices led to patients' worries of unnecessary drugs and tests, respectively. Doctors attributed their profit-oriented practices to institutions' agenda setting, poor salary and an organizational bonus system. Their awareness of breaching medical ethics created a guilt feeling and frustration. Nearly 65.0% reported patients' preference for hospital-based care even for minor conditions and 76.2% if the patient was a child. Ineffective gate-keeping mechanism, weak primary care and mistrust in community-based care were major reasons. More specialists than primary care practitioners (41.0 vs 21.5%, P < 0.001) said that patients would use guanxi to gain better services and 64.5% of doctors reported better dedication when patients were somehow connected. In conclusion, profit-orientated practice widely exists in public institutions. Patients generally prefer hospital-based services. Guanxi, which affects both patients' and doctors' practices, is more often used to access hospital-based services.