Inner Mongolia Sustainable Cross-Border Development Investment Program (RRP PRC 51192)

Supplementary Document Assessment on the Medical Equipment Upgrading for the Erenhot International Traditional Chinese and Mongolian Medicine Hospital

People’s Republic of China: Inner Mongolia Sustainable Cross-Border Development Investment Program

Prepared by Xiaoli Guan (Health Facility Specialist) for the subproject in Erenhot – Medical Equipment Upgrading for the Erenhot International Traditional Chinese and Mongolia Medicine Hospital

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A. Summary

1. The Erenhot International Traditional Chinese and Mongolian Medicine Hospital (EITCMMH - formerly Erenhot City Hospital) is the only modern comprehensive secondary level hospital in Erenhot City, with a 188-bed capacity but only 131 functioning available bed. EITCMMH has a setup of 38 departments (16 clinical departments, 7 medical departments, 8 medical auxiliary departments and 7 administrative departments and engages a total of 262 employees (86 doctors, 103 nursing staff, 10 medical technicians, 12 pharmacists, and 51 other medical staff), which meets up with the government hospital staffing standard. Compared with similar hospitals at the same level, the total income of EITCMMH is low. General average hospital revenue per bed in the People’s Republic of China (PRC) is usually around 600,000– 1,200,000 CNY/year, while the EITCMMH’s averages 275,000 CNY/year. The medical equipment at the hospital are outdated (i.e. over 10 years old) and levels for utilization of beds are low (45.7%), indicating a potential for income growth. In 2018, 600 patients had to be referred to other hospitals due to lack of diagnostic or treatment capacity at EITCMMH.

2. The project will support the establishment and upgrading of emergency and stroke centers, as well as the upgrading of operating rooms which will increase the capacity for cost recovery. Overall, the upgrading of hospital facilities is expected to address many of the concerns highlighted by city inhabitants and will likely increase the profitability of the hospital.

3. Since Zamyn-Uud City is 550 kilometers (km) away from Ulaanbaatar, the capital of Mongolia, but only 9 km from Erenhot, its proximity will lead citizens to seek medical support in EITCMMH. Because of this reason, EITCMMH and Zamyn-Uud City Hospital in Mongolia have been working collaboratively since 2014. EITCMMH has carried out a series of activities, for example, medical outreach services in outlying areas, in particular the cataract operations for Mongolia patients. In addition, the EITCMMH has provided the Mongolian patients with medical costs that are 20% lower than those for the local residents. Therefore, the project will very likely strengthen this linkage between the two hospitals for the benefit of border communities. Activities facilitating the care of Mongolians, such as medical fees and discounts and translation services will help increase the use of services by Mongolians.

B. Methodology

4. The following methodologies have been applied for preparing this assessment report:

➢ Field study of the EITCMMH; ➢ Interview with the Dean and hospital management group of EITCMMH, such as Financial, Human Resources and Administration staff; ➢ Interview with the Director of Erenhot Municipal Health Committee; ➢ Interview with the Representatives from Erenhot Municipal Insurance Board; ➢ Review on the EITCMMH’s financial report and all the necessary documents; and ➢ Survey from the Internet and related medical websites.

C. An overview of Erenhot Hygiene and Health Care

5. Erenhot City is located in the Inner Mongolia autonomous region, west of the Xilin Gol league area, with Mongolia’s bonder on the door. The distance between the two cities is 9 km. The area under its jurisdiction is 4,015 square kilometers, and the urban built-up area is 27 square kilometers. It has a mid-temperate continental monsoon climate and arid desert grassland climate. The total population of Erenhot is about 100,000, and the household registries population is 31,000, of which males make up 49.78% and females 50.22%. The age structure is as follow: 17.26% are of ages 0-14 years old, 79.8% are of ages 15-64 years old and 2.93% are over 65 years old. The top three diseases with the highest mortality rates in Erenhot City are the same as the other city in the country. They are cardiovascular and cerebrovascular diseases, cancer and respiratory diseases.

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6. In the city, there were in total 44 medical facilities which includes 11 public facilities and 33 private clinics. The Erenhot City Hospital (currently the Erenhot International Traditional Chinese and Mongolian Medicine Hospital) is the only modern comprehensive secondary level hospital in the city. Among them, there are 326 health technicians which include 127 medical doctors, 126 nurses, 38 technicians, 25 pharmacists, and 29 other health technicians. The ratio between medical doctors and the inhabitants is 3.26/1,000 people now. This ratio has to increase to 3.5/1,000 people by 2020 according to Erenhot City Council’s request.

7. According to the Erenhot’s Municipal Statistical Bureau’s report (2019-04), the per capita expenditure of Erenhot on basic public health services was increased to CNY 55, and 68,384 people have made electronic health records registration. The level of disease prevention and control has been improved in recent years. In the field of prevention and control of infectious diseases, 241 cases of class B and C infectious diseases has occurred with a decrease of 18.06% compared to the same time of year in 2017. In addition, both rate of infectious disease network reporting and rate of timely audit are 100%.

8. In 2018, 31 medical specialists from superior hospitals were invited to attend a total of 71 short-term visits and 7 long-term hospital involvements. There are 543 fields under supervision (417 public places, 49 medical institutions, 15 schools and kindergartens, 4 radiation hygiene, 53 infectious diseases prevention and 5 drinking water supplying institutions).

9. In 2018, The primary health care institutions have provided service to the 75,484 inhabitants, building up 67,738 electronic health files and a registration rate of 89.13%. They have provided health management for 5,844 children with a health management rate of 95.74%. Furthermore, 308 patients with severe mental disorders and 128 schizophrenia patients have been registered. They have provided health management for 14 tuberculosis patients with a management rate of 100%. 8,501 school-age children have received vaccination cards and certificates. The vaccination rate was over 98.82%. In 2018, free distribution of contraceptives was also included in the basic public health services. A total of 243 cases of class of B and C infectious disease occurred, with a total incidence of 32,193 cases among 100,000 inhabitants. Compared with the year of 2017, the incidence was increased by 7.05%.

10. In general, the health insurance of Erenhot City is balanced with a surplus of CNY 1.1 billion of employee medical insurance and CNY 19.87 million in 2018. As the EITCMMH is the only comprehensive hospital in Erenhot City, the municipal health policy and development plan are highly consistent with the hospital strategy.

D. Introduction of the Erenhot International Traditional Chinese and Mongolian Medicine Hospital

11. The EITCMMH was founded in 1956. The hospital was moved to its present location in 2007, covering an area of 120,000 square meters (m2) with a building area of 25,000 m2. It is the only modern comprehensive level A hospital that integrates medical treatment, first aid, and prevention under the investment of the Erenhot Municipal Government. Erenhot is located in the northern part of the autonomous region and faces the Mongolian port city of Zamyn-Uud across the border which is the largest inland port open to Mongolia in PRC. Therefore, early in 2002, Erenhot City Hospital was designated as an international medical assistance hospital and fulfilled its international assistance obligations.

12. From 2008 to 2017, EITCMMH was fully hosted by the affiliated hospital of the Inner Mongolia Medical University. During these ten years, EITCMMH hospital relied on the hosting influence from the affiliated hospitals, and the number of patients gradually had been increased. New technology and new business continued to expand. Hospital revenue continued to climb year after year. In 2015, it was successfully promoted to the ‘level of Secondary A’ hospital 3 with excellent results and completed the hosting, meaning that the key goal of the hosting was accomplished. In 2017, the agreement resigned from full hosting to technical assistance.

13. There are 38 departments including 16 clinical departments, 7 medical technical department, 8 medical auxiliary departments, and 7 administrative departments. EITCMMH’s number of beds are 188, but only 131 have been functionally available up to now. There are 262 employees, including 86 medical doctors, 103 nurses and 22 medical technicians. Among the employees, there are 3 with master degrees, 54 with undergraduate degrees, 199 health professionals, 27 with deputy senior professional titles and 49 with intermediated professional titles.

Figure 1: View of the EITCMMH (July 2019)

E. EITCMMH Operation Related Data Collection and Analysis

14. Outpatient Clinic. In 2018, the number of received patients at the outpatient clinics in EITCMMH was 87,432, with a 9.28% increase rate in comparison with the year of 2017. The average fee of outpatient is 202.5 CNY per patient and the average number of daily visits is 57.28. The income from the outpatient clinic contributes 51% of EITCMMH’s total medical related income. The main income composition is 28% from inspection, 20% from laboratory and 19% from the drug.

15. Hospitalization Component. EITCMMH is the only comprehensive secondary level hospital in Erenhot with a 188-bed capacity, but only 131 functioning available beds right now. In 2018, the number of discharged patients were 2,987, with an increasing rate of 5.4% over the previous year. The utilization of beds was 45.7% out of 131 hospital functional beds and the utilization rate was decreased by 1.56% compared to 2017. The duration time of each inpatient is 6.3 days with an average expense of CNY 5,186.6. In comparison with the previous year, the income from the inpatient part was 1.56 million, with an increase of 14.24 million. The main income composition includes 38% of the drug, 12% of medical material and 12% of medical treatments (as shown in Table 1 and Table 2).

Table 1: Summary of EITCMMH operation in 2018 Item 2018 Increase Rate Remarks Outpatient Clinic 87,432 9.28% 57.28 st/day Emergency Patients 20,907 Discharged Patients 2,987 5.40% Referred Patients 600 Rate Utilization of Beds 45.70% -1.56% Health Check up 11,700 171 CNY/st Gave 20% discount for

women in labour and Mongolia Patients 2,150 health check-up Cataract Operation for the

Mongolia patients 22

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Item 2018 Increase Rate Remarks Total Income CNY 36 million 14.24% 51 : 49 Outpatient/Inpatient’s Income

Inspections 28% Outpatient clinic income’s Laboratories 20% components Drugs 19% Source: survey, July 2019.

Table 2: Data on EITCMMH cost and others (unit: CNY) Items 2016 2017 2018 Total Incomes 28,910,000 30,900,000 36,000,000 Subsidies from the Government 14.76 million 20.14 million +36% Medial related Cost 31.11 million 34.02 million +9% Administration Fee 13.98 million 17.59 million +26% Annual Balance -1,200,000 -450,000 Source: survey, July 2019.

16. 687 cases of operation have been completed with an increasing rate of 15.08% compared with the previous year. In 2018, EITCMMH had 623 newborn babies, with an increase of 4.0% over the previous year. More than 600 patients were referred to other hospitals due to lack of diagnostic or treatment capacity at EITCMMH (Table 3).

Table 3: Analysis of the Referred Patients Sort of Disease Number Percentage Fracture 47 7.9% Coronary Heart Disease 31 5.2% Gallbladder stones 20 3.36% Diabetes, Hypertension 30 5.04% Infarction 11 1.85% Uterine fibroids 18 3.03% Liver disease 24 4.03% Stroke, Brain trauma, Heart disease 69 11.6% Lung and trachea 44 7.39% Abdominal and kidney disease 54 9.08% Cancer and the other undiagnosed 178 29.92% Leukemia, neonatal asphyxia, etc 68 11.60% Source: survey, July 2019.

F. Human Resources and Capacity of EITCMMH

17. There are 262 employees at EITCMMH including 86 medical doctors, 103 nurses and 22 medical technicians; 3 of which have master’s degrees and 54 have undergraduate degrees. Among the 199 health professionals, 27 have deputy senior professional titles and 49 have intermediate professional titles (Table 4). The Director of EITCMMH, Wen Du Su, is from Mongolia and has worked at EITCMMH for more than 15 years. He is a medical doctor and works in the clinic as well. He knows EITCMMH very well and has a good, positive vision regarding the EITCMMH’s development in the future. EITCMMH’s human resources level (1.61 medical staffs /bed) meets the standards of the Government hospital staffing requirement which is 1.4 staff/ bed. However, this level is still insufficient compared to EITCMMH’s number of 188 beds.

18. EITCMMH has established medical community units with the autonomous region’s Medical University Affiliated Hospital (MUAH) of Inner Mongolian. MUAH sends medical experts to EITCMMH regularly such as surgery, consultation, medical round, and in many other aspects. They have a ‘Green Channel’ priority for diagnosis and treatment and even for transferring patients. EITCMMH has also established cooperation with Beijing’s Space General Hospital, Tongren General Hospital, Beijing University Sixth Hospital and Xilingol Confederate Hospital to have medical experts for support and consultation, and even for clinical surgery 5 demonstrations, etc. EITCMMH also has cooperated with a third party of the Medical Lab center – Di’an Medical Lab Center, with a specimen delivery agreement in order to supplement EITCMMH’s existing lab capabilities.

19. EITCMMH obtained the Erenhot municipal governments support of CNY 60 million in the year of 2018. They have carried out indoor and outdoor environment renovation, the operating room’s reconstruction, and build up the Emergency center and sterile supply center. Also insulation of the exterior walls, hardening of the courtyard, and replacement of the pipe network, etc. was carried out. In 2019, EITCMMH is planning to renovate the infectious disease area. Also, the Erenhot City hall will provide funding of more than CNY 1 million every year to support medical experts consultant and academic exchanging.

Table 4: Details of Departments and Personnel information Items Doctor Nurse Technician Others Medical I 8 8 Medical II 6 7 Surgical 9 9 Gynecology 12 13 Pediatrics 7 9 ophthalmology 2 2 Facial feature 4 3 Dermatology 2 1 Dental 4 1 Emergency 5 14 Operation room 6 7 Pathology 2 1 Lab 1 10 Functional 6 1 EKG 2 Digestive endoscope 1 2 Dialytic 1 4 Radiology 6 2 1 Pharmacy 10 Supply room 3 1 Outpatient office 1 2 Direct office 4 2 1 office 6 Medical record 2 statistic 1 2 Human resource 1 1 Administration 1 Finance 18 Chief nurse 2 Disinfection control 3 Medical service 2 1 Insurance I 1 Insurance II 1 IT 4 Equipment 3 Administration 8 Ambulance driver 8 Source: survey, July 2019.

G. Medical Service for Mongolians

20. Due to its unique geographical location, EITCMMH has Sunite Zuoqi on the east side, Sunit Youqi on the south, Ulanqab City on the southwest and East Gobi province on the north side. For example, Zamyn-Uud City is 550 kilometers away from Ulaanbaatar, capital of Mongolia and 9 kilometers from Erenhot City. Eventhrough there are several tertiary level

6 hospitals in Ulaanbaatar of Mongolia, most are private and hence not accessible to the majority. The public teritiary hospitals often lack capacity. The medical-related cost is very high due to lack of medical facilities, and also because almost all medicine and medical supplies need to be imported. Furthermore, the distance between the cities of Mongolia is around 150- 200 km, very far apart from each other. The medical resources and conditions in these cities are very limited, often with only one assistant doctor or junior doctor plus 10-20 beds. Therefore, EITCMMH undertakes the functions of the regional medical center and mainly covers the first aid for trauma and blood using guarantee during the first aid, as well as pediatrics, obstetrics and other special inspections.

21. EITCMMH has many exchanges and cooperation with Mongolia in medical-related fields. They have sent medical teams to the hinterland of Mongolia’s East Gobi province in order to provide compulsory medical service for three consecutive years. Since 2014, EITCMMH and Zamyn-Uud City Hospital in Mongolia have conducted collaborative activities such as provide cataract operations, etc. Just in 2018, they provided cataract operations free of charge for 22 patients of Mongolia. In order to attract Mongolian patients to seek medical treatment, EITCMMH even implemented the policy of 20% relief of medical treatment for Mongolian patients. The hospital has set up a foreign patient service department on the first floor and is equipped with two medical personnel with Mongolia language proficiency. They are responsible for the reception and translation for the Mongolia patients. Only in the year of 2018, EITCMMH provided medical service for in total 2050 outpatients from Mongolia.

22. EITCMMH has also carried out many urgent medical treatment tasks during the past years. Such as under the assistance and guidance of Chinese consular officials, to pick up severely injured patients with the ambulance at the "zero kilometers" area with the close coordination and cooperation of all parties, such as border inspection authorities, customs and inspection and quarantine authorities of China and Mongolia.

H. Medical Facilities Survey and Procurement Analysis of EITCMMH

23. Most of the medical-related facilities and medical equipment were purchased in October 2007, while EITCMMH was moved to its current location. This medical equipment has been used for more than 12 years and is outdated even some of the equipment no longer functions. Therefore, the upgrading and purchase of medical facilities are in urgent need and necessity.

24. According to the introduction from Med. Dr. Du Su Wen, Chief Director of EITCMMH, The main future directions for the development of EITCMMH are as follows:

a) Enhance EITCMMH’s First Aids, Emergency clinic capacity in order to improve the acute, trauma and severe disease’ diagnose and treatment capacity. More specific initiatives are to establish three Emergency Centers: Stroke Center, Pulmonary Heart Disease Diagnosis and Treatment Center, and Pediatric Emergency Center. At the moment, EITCMMH’s current medical facilities, such as radiology equipment, lab facilities and auxiliary equipment cannot meet the need for medical development and an update for first aids facilities is in urgent needed. For example, EITCMMH has 4 ambulances which have used for more than 10 years. Current Ambulances fails to meet the needs for quick, safety and long-distance transportation of emergency patients. The ambulances need to be replaced as soon as possible; b) Increase the surgery scope and provide high-level operations, such as cardiovascular surgery, stent replacement, angiography, joint/hip replacement, etc. EITCMMH performed operation renovation by upgrading the operation rooms as well as increase the number from two to four. However, the corresponding medical equipment for operation, such as C-arm, operation bed, operation room’s lamp, and many surgical instruments are not enough for usage, with some even being lacked out; c) Improve the diagnostic and treatment capacity through the enrichment and upgrading 7

of diagnostic equipment, such as radiology, lab facilities, etc.; and d) Ophthalmology and Otolaryngology department’s examination and treatment level need to be improved in order to provide high quality medical treatment, especially for the cataract operation for Mongolia patients.

I. Category and Summary of Facilities Procurement List

25. The Medical facilities procurement list of EITCMMH can be summarized into 50 sets and 86 pieces, which belong to the 11 different departments. The roughly cost is about CNY 51.31 million. If we categorize the amount of money for procurement, there are radiology equipment (43.27%, CNY 22.20 million, 5 pieces, 5 items), function section equipment (27.48%, CNY 14.10 million, 7 pieces)，laboratory equipment (7.13%, CNY 3.66 million, 5 pieces, 5 items) , surgery facilities (5.22%, CNY 2.68 million, 4 pieces, 3items), plastic surgeryy equipment (4.48%, CNY 2.30 million, 4 pieces, 4 items), ophthalmology equipment (3.61%, CNY 1.85 million, 6 pieces, 6 items), otolaryngology equipment (3.33%, CNY 1.71 million, 3 pieces and 3 items), internal medicine (2.59%, CNY 2.59 million, 30 pieces, 4 items), pediatrics devices (1.24%, CNY 0.63 million, 19 pieces and 7 items), first aid center (0.97%, CNY 0.5 million, 2 pieces, 1 item- Ambulance), disinfecting supply room’s facilities (0.58%, CNY 0.3 million,1 pieces, 1 items).(Table 5).

J. Necessity Analysis of Facilities Procurement List

26. Among the 50 sets and 86 pieces from the facilities procurement list, there are 14 pieces which together has an estimated cost of CNY 21.4 million, corresponding to 47.5% of the total amount belong to the replacement or upgrading due to outdated or out of function (i.e. over 10 years old). The majority of these 14 pieces are from the radiology and Laboratory department. The other 72 pieces were procured under three main purposes. First of all, it is the department’s requirement after the hospital reconstruction, such as 3 new Emergency Center establishment, the operation room expansion and disinfection supplying room renovation. The secondary is replacement or upgrading. The third is business development need such as Otolaryngology facilities due to more patients with allergic rhinitis and nasal polyps in the Inner Mongolian area. With EITCMMH’s cooperation with affiliated hospitals, the number of examination and operations has increased. Therefore, it is very necessary to have such medical facilities. The same reason applies for ophthalmology equipment due to the increase of cataract patients, even of Mongolia patients.

K. Conclusion of the Medical Facilities Survey and Procurement Analysis of EITCMMH

27. Overall, the procurement of EITCMMH facilities meets the requirements of hospital development. It is very necessary, urgent and appropriated. Upgradation of hospital facilities would greatly improve the hospital’s operating capacity and will likely increase the profitability of EITCMMH.

Table 5: Classification and Proportion of Medical Facilities Procurement Medical Facilities Procurement List Amount Division Items Number Percentage (CNY 10,000) Radiology 5 5 2220 43.27% Function Section 6 7 1410 27.48% Laboratory 5 5 366 7.13% Surgery/ Anesthesiology 3 4 268 5.22% Plastic Surger 4 4 230 4.48% Ophthalmology 6 6 185 3.61% Otolaryngology 3 3 171 3.33% Internal Medicine 9 30 133 2.59%

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Pediatrics 7 19 63.5 1.24% First Aid Center 1 2 50 0.97% Disinfecting supply room 1 1 30 0.58% Total 50 86 5131.5 100.00% Source: domestic FSR, July 2019.

L. Key Findings and Suggestions

L.1. Operating Capacity of EITCMMH

28. EITCMMH’s operation capacity is low. The reasons are:

a) The revenue per hospital bed (The total income of hospital divided the number patient of hospital discharging) is one of the core financial indicators to measure the operating capacity of medical institutions. The revenue per hospital bed of an average general hospital in the PRC is around 600,000-1,200,000 CNY/year, while the EITCMMH’s average is only 275,000 CNY/year in 2018;

b) The average income of EITCMMH, both in outpatient visit and hospitalization is lower than the average of Inner Mongolia’s hospitals. For example, the outpatient fee in EITCMMH is CNY 202.4 compared with CNY 234.3 of Inner Mongolia; the cost of hospitalization is CNY 5,186.6 compared with CNY 8,324.3 of the Inner Mongolia in the year of 2017;

c) Levels for utilization of beds is only 45.7% out of 131 functioning available bed, which is lower than the average of 78.3% of Inner Mongolia. However, EITCMMH has 188 beds to be operated. Indicating potentials for EITCMMH’s medical-related income to growth.

29. Therefore, it is suggested that EITCMMH’s operating capacity need to be improved and strengthened through the upgrading of medical facilities and the recruitment of core clinical staff. The hospital should make full use of the government’s policy of encouraging medical experts or doctors to work in multiple locations in EITCMMH. At mean time, it’s highly suggested to have a couple of external medical experts to provide some capacity-building services for EITCMMH during the implementation period.

30. From the perspective of market and enterprise behavior, it is necessary to strengthen hospital operation management in order to achieve quality improvement and efficiency through staff training and education. In addition, the market promotion and network promotion for EITCMMH need to be carried out and strengthened, too.

L.2. About Referred Patient

31. The number of patients referred to the other hospitals and other cities were 600 in 2018. After EITCMMH improves the capacity such as emergency, diagnostic and therapeutic standard through upgrading of medical facilities, enhancement of the communication as well as training, the referred number of patients will certainly be decreased rapidly. At the same time, the Siphon Effect of EITCMMH will be prominent, the ability to attract peripheral and Mongolian patients will be strengthened. This estimation is based on three mean reasons:

a) First of all, the uniqueness derived from the fact that EITCMMH is the only modern comprehensive secondary level hospital in Erenhot city; b) Secondly, the existence of a huge gap within the overall medical condition in Mongolia; and c) Thirdly, EITCMMH has a special geographical location, which has been described in detail previously. 9

L.3. About Mongolian Patients

32. EITCMMH, as an international hospital, in 2018, treated 2,150 patients from Mongolia, corresponding to 2.45% of total outpatients of the hospital. The number of patients from Mongolia should increase with the EITCMMH’s facilities upgrading, especially in the Emergency part and ophthalmic surgery (i.e., cataract operation). It could be reasonably assumed that this percentage should be larger than 2.45%, even though, we do not have the conclusive data to fully support this assumption with a detailed percentage increase.

33. It is suggested to establish an effective and long-term mechanism between China and Mongolia, in order to facilitate the emergency work and strive for the best treatment time of Mongolia patients. Consider regular formal or informal dialogue with Zamyn-Uud city health officials for better coordination.

34. Meanwhile, EITCMMH should strengthen foreign patient service capacities such as to reserve more medical staffs with Mongolian language proficiency to meet the increasing demand. Increase capacity for translation facilities into Mongolian, including having signs in Mongolian, more Mongolian speaking staff, forms and information leaflets in Mongolians for better documentation.

35. It is suggested to strengthen the marketing work, to carry out a large amount of training, and to provide free health consultation. Meanwhile, EITCMMH should increase the breadth and depth of the “Bright Walk Project” (which provides cataract operation free of charge for Mongolia inhabitants) in the future. Consider further discount for Mongolians, particularly those who work in the Special Economic Zone through an ID card system. 36. It is suggested EITCMMH should improve the occupational health service, particularly for preventing and treating work-related stress and injury.