Marketisation in China’s Health System: A Thematic Exploration of Impacts on Doctor-Patient Relationships

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Marketisation has not only reshaped healthcare delivery but has also fundamentally shifted the responsibilities of doctors and patients within the system. This paper reveals the increasing responsibilities borne by individual doctors and patients because of this trending. Methods This qualitative study involved thematic analysis of semi-structured interviews with 28 doctors and patients from various provinces in China. Participants were selected to represent diverse experiences within the health system. Thematic analysis was conducted to identify and interpret key patterns within the data. Results Three main dimensions of privatisation emerged from the analysis: accessing healthcare, care coordination, and healthcare financing. Findings indicate that marketisation has significantly increased the responsibilities placed on individual doctors and patients, effectively transferring systemic burdens to these individuals. Doctors face intensified pressures to manage care within fragmented health services, while patients confront greater personal responsibility in navigating access to care, coordinating their treatments, and handling healthcare expenses. These shifts exacerbate existing inequalities and complicate doctor-patient interactions. Conclusions The marketisation of healthcare responsibilities places significant burdens on both doctors and patients, transferring systemic responsibilities to individuals in access to healthcare. The concept of ‘privatised responsibilities’ offers a useful theoretical framework for further investigation of healthcare marketisation and its broader social implications. Based on these insights, we make policy recommendations aimed at defining more clearly the government’s role in ensuring equitable and accessible healthcare. Healthcare Marketisation Privatisation Doctor-patient responsibilities China 1. Introduction Since its establishment in the 1950s, the Chinese healthcare system has undergone significant transformations, shifting from a government-dominated model to market-driven one, so that now it represents a hybrid model combining the state and the market: the government provides political leadership and control, while the market governs the operation of the system [ 1 – 3 ]. While government leadership theoretically mitigates excessive commodification and maintains ethical oversight, in practice the dominance of market-oriented incentives frequently leads doctors to prioritise revenue generation, potentially reducing consultation time and fostering transactional interactions. For patients, despite the government’s commitment to accessibility and equity, healthcare is often experienced as a consumer-driven commodity, heightening expectations and financial pressures [ 4 ]. Moreover, contrary to the expectation that the reforms would improve healthcare quality, access to medical resources has significantly deteriorated, highlighting a critical gap between policy intentions and outcomes [ 3 ]. The proportion of personal health expenditure rose from 361.9 yuan (approximately £40.2) in 2000 to 6425.3 yuan (approximately £713.9) in 2024, reflecting an average annual growth rate of 12.73%. Meanwhile, out-of-pocket spending accounted for 27.7%, exceeding the 15–20% range recommended by the World Health Organization [ 5 , 6 ]. Doctors—as frontline medical providers—have gradually faced criticism for being profit-driven. Medical disputes have continued to escalate. Hospitals in some regions reported that 89.84% of emergency department doctors have experienced verbal abuse, insults, threats, or even physical violence [ 7 ], which highlights the increasing tensions in doctor-patient relationships. Dominant perspectives within health policy, epidemiological and biomedical frameworks, while valuable for clinical outcomes, offer little assistance in understanding the complexities and inequalities concerning accessibility within healthcare systems [ 8 ]. Therefore, this paper explores the impact of the systemic healthcare organization on doctor-patient relationships. First, it reviews the changes in China’s healthcare system and its marketisation. Then it outlines the qualitative interview approach involving 28 frontline doctors and their patients, who were directly experiencing the current healthcare system under the influence of marketisation. This research reveals that marketisation has led to the privatisation of responsibilities for both doctors and patients, significantly increasing the pressures on them. It reveals that, within the marketised healthcare system, the responsibilities undertaken by doctors and patients, including healthcare assessment, care coordination, and financial obligations, are treated as their own responsibility. The findings are examined considering their broader implications, offering guidance for optimising medical policies on doctor-patient responsibilities and ensuring the accessibility of medical resources across diverse social and cultural contexts. Institutional Frameworks and Doctor-patient Relationships Healthcare systems function as a central institution in society, structured to maintain public health, support economic stability, and uphold social order [ 8 , 9 ]. The development of national healthcare systems directly influences the doctor-patient relationships and how responsibilities are distributed between doctors and patients [ 9 , 10 ]. In Western contexts, the influence of institutional frameworks on doctor-patient relationships has often been studied through the lens of market. Numerous politicians and policy-makers argued that marketisation, primarily characterised by neoliberal ideologies, emphasises competition, consumer choice, and cost-efficiency, have introduced transactional dynamics into healthcare interactions, reshaping patient identities from passive recipients of care to active consumers who make informed choices and bear responsibility for their healthcare outcomes [ 11 ]. Some concerns raised that marketization may lead to a decline of professional autonomy, potentially leading to a decline in altruistic or service-oriented attitudes toward patients [ 12 ]. By contrast, models featuring strong government control, such as the UK’s National Health Service (NHS), reflect different institutional pressures. The NHS system historically prioritises equity and accessibility, embedding doctor-patient relationships in a framework of public trust and collective responsibility [ 13 ]. However, it introduces specific constraints, including bureaucratic rigidity, long waiting times, and restricted patient choice, which may adversely affect patient satisfaction and trust [ 14 ]. Research in Northern England implied a clear reduction in doctors’ autonomy and offer little resistance to it [ 15 ]. The hybrid institutional model, combining elements of state control with market-driven operation, is particularly evident in China’s contemporary healthcare system. Ideally, this model is intended to provide a balanced approach to healthcare governance through government leadership, while promoting operational flexibility and innovation through market-based incentives [ 16 ]. While some research [ 1 – 3 ] revealed that, in this framework, doctors assume dual responsibilities, they are expected to achieve public welfare objectives set by the government while simultaneously meeting institutional revenue targets shaped by market principles. Patients, in turn, face increased financial burdens and are required to assume greater responsibility in healthcare decision-making, thereby adopting more consumer-oriented behaviours. It is worth noting that China’s healthcare system has experienced all three of the aforementioned models, thereby offering a valuable case for examining how institutional context influence doctor-patient relationships. National Healthcare Construction and Changing Doctor-patient Responsibilities in China China’s healthcare system has undergone three major reforms, each of which has brought corresponding changes to doctor-patient relationships and the distribution of responsibilities. After the 1950s socialist revolution, China established a unique intimate relationship between its people and the state through the direct allocation of resources. At that time, most hospitals and community health centres in China were publicly owned and operated under the jurisdiction of district, municipal, and regional governments, the collective ‘work unit’ (or ‘danwei’ system) provided primary care as its foundation, offering free healthcare and facilitating bidirectional referrals among its three-tier institutions: city hospitals, district (county) hospitals, and work unit healthcare groups [ 3 , 17 ]. Doctors served as salaried national public service providers and did not have any direct economic relationships with patients (although undeclared payments by patients were said to be common). Their main responsibility was patient care. Medical resources were mainly allocated through public channels, and patients passively accepted unified arrangements and were charged only minimal healthcare fees [ 3 , 17 ]. Doctor-patient relationships during this era coupled with the ideology of collectivism, fostered a sense of organizational solidarity that far surpassed any divisions caused by disparities between doctors and patients in modern healthcare [ 3 ]. However, the state-funded healthcare system placed significant financial strain on the national budget [ 18 , 19 ]. Beginning in the late 1970s and accelerating through the 1980s and 1990s, China implemented a series of economic reforms that introduced market mechanisms into public services, including healthcare [ 20 ]. By the turn of the century, the welfare-based work unit system had been largely abandoned [ 20 ]. Marketisation, driven by neoliberal ideology, begins with the purposeful intention of the state to retreat in terms of both funding and provision [ 21 ]. Starting in 1980 the Chinese government deliberately decreased its contribution to healthcare spending, which declined from 36.2–15.21% in 2002 [ 22 ]. From 1998 to 2014, the state provided only 6–8% of financial support for the budget deficits of hospitals, with the remaining approximately 90% of the shortfall being made up from revenues from medical services, and the sales of pharmaceuticals and medical devices [ 23 ]. As a result, the welfare orientation of healthcare has been reduced, public hospitals were encouraged to generate their own income through service fees, drug sales, and operate with financial self-sufficiency and compete for patients and revenue [ 24 ]. Doctors have shifted from being ‘national public service providers’ to practitioners in a healthcare market [ 2 , 10 ]. This marked the beginning of healthcare marketisation, with patients increasingly seen as consumers and medical services as products. It is at this stage that the doctor-patient relationship in China has changed. As hospital revenues were directly linked to doctor’s salaries, physicians were compelled to align their practices with the hospitals’ profit-driven objectives and earned benefits from patients. Financial pressure transferred to patients, in nationwide, the annual per-capita cost of outpatient and inpatient care experienced a significant increase of approximately 14%, from 1993 to 2002, per capita outpatient costs rose from CN¥21.5(UK£2.39) to CN¥99.6(UK£11.07), and inpatient costs from CN¥933.4(UK£103.71) to CN¥3597.7(UK£399.74) ‘Hard to see the doctor, expensive to see the doctor’ have become a common view in the public [ 25 ]. Widespread scepticism about the ethical standards of healthcare professionals prevails [ 3 ]. The deterioration of doctor-patient relations and increasingly fierce conflicts have triggered the latest round of healthcare reforms [ 4 , 26 ]. Since 2000s, the Chinese healthcare system represents a hybrid model, combining state-led political control with market-based operational mechanisms[ 1 , 16 ]. Although the current system declares a leading governmental role, competitive market forces continue to exert substantial influence [ 27 ]. This hybrid model triggered three key characteristics. First, the unequal distribution of healthcare resources has become more apparent. Marketisation introduced competition among hospitals, weakening their collaborative efforts and undermining the intended three-tiered medical treatment structure, in which most diseases were intended to be treated in primary or secondary hospitals, with only severe or complex cases referred to tertiary hospitals [ 27 ]. Hospitals increasingly rely on revenue generation for operations, concentrating resources in economically developed regions and larger institutions [ 27 , 28 ]. In 2023, the number of medical and health technicians per 1,000 residents in urban areas stood at 10.20, compared to 6.55 in rural areas, a ratio of 1.56 to 1. Moreover, the majority of healthcare resources are located in the eastern, more developed provinces [ 5 ]. Second, the referral system remains weak. Data from the Sixth Health Service Survey indicate that over half of two-way referrals fail to materialise [ 29 ]. Tertiary hospitals, equipped with superior resources and advanced medical equipment, enjoy a competitive edge in the healthcare market. As a result, they receive a disproportionate share of patients, accounting for more than 50% of total medical services [ 30 , 31 ]. Finally, medical insurance reimbursement remains incomplete: patients are only reimbursed for a proportion of costs, patients continue to shoulder rising out-of-pocket expenses. In recent years, annual medical costs have increased by around 8%. Between 2011 and 2021, the national average hospitalisation cost per visit rose from 6,632 yuan (£736.89) to 11,003 yuan (£1,222.50), an increase of approximately 66%. The average outpatient cost grew from 180 yuan (£20.00) to 329 yuan (£36.56), marking an increase of about 83% [ 5 ]. In this context, we sought firsthand knowledge about how doctors’ and patients’ responsibilities are shaped and allocated within China’s contemporary healthcare system. 2. Methods This study adopted interpretive description as its methodological approach, which seeks to transcend traditional qualitative methodologies such as grounded theory, phenomenology, and ethnography, offering a flexible framework for applied health research [ 32 , 33 ]. Previous studies verified that interpretive description is an effective qualitative methodology for applied research, as it builds upon, rather than disregards, existing experiential knowledge related to the subject of interest [ 32 , 33 ]. This also aligns with our study, allowing for exploration and rich description of emerging doctor-patient relationships, particularly within complex healthcare system. Qualitative interviews enabled flexibility, allowing for in-depth exploration of the participants’ perspectives [ 32 , 33 ]. As the research aimed to explore how doctors and patients experience the impact of marketisation on their relationship within the healthcare system. The fieldwork employed semi-structured interviews with frontline doctors from 13 public hospitals and patients across five provinces in China. The selection of participants was purposive, ensuring a diverse range of insights into the healthcare reforms. All participating doctors held valid Chinese practicing physician certificates, with their experience ranging from 2 to over 20 years. This variation allowed for a blend of in-depth, seasoned perspectives from more experienced doctors and fresh viewpoints from younger doctors who are recent entrants to the field. For the patient participants, the criteria focused on individuals with personal medical treatment experiences who were willing to share their healthcare journeys. Special attention was given to patients under long-term treatment, as they have been managing their illnesses for decades and were most directly affected by the healthcare reforms. These participants provided the most direct insights into the effects of the healthcare system. A total of 28 semi-structured interviews were conducted, involving 13 doctors and 15 patients, providing key insights for the research. The study received ethical approval and followed standard ethical procedures, including informed consent, confidentiality, and voluntary participation. The semi-structured interviews were primarily composed of open-ended questions, conducted in the participants’ native Chinese language. The interviews were structured into three main parts: introductory questions to build rapport, participants’ perceptions of doctor-patient relationships, and questions specific to working experience for doctors and questions of healthcare experience for patients. Particular attention was given to exploring how systemic changes shaped two sides of the healthcare experience. Most respondents understood the Chinese healthcare system, and the majority were able to articulate their perceptions of institutional changes and their effects on clinical experiences or access to care. For those participants who sought clarification during the interview, the researcher provided brief explanations, such as their access to healthcare, the change of healthcare pathway and introduction of out-of-pocket payments. These prompts helped respondents to contextualise their experiences within the broader institutional reforms associated with marketisation, ensuring the discussions remained relevant and grounded in the research focus. The analysis was based on the responses of the participants through a series of structured steps. Initially, all interviews were recorded and transcribed verbatim by the researcher. Then thematic analysis was employed to examine the way participants described and experienced the influence of healthcare reform. Coding was conducted inductively and iteratively, guided by both the research aim, to investigate the relationship between institutional change and doctor-patient interactions, and principles of interpretive description. Emergent themes were closely examined to identify patterns in how institutional framework (e.g. access to healthcare, care coordination, and payment systems) shaped clinical roles and patient experiences. Key segments of data were translated after the coding process, focusing on the portions that would be used in the final analysis. Coding in Chinese to ensure accurate understanding of the data and minimization of errors caused by translation [ 34 ]. One interview was fully translated and shared with the supervisory team to ensure the quality of the interview and to verify that it was conducted appropriately. For other interviews, key parts that were identified as significant were translated and constantly shared with the supervisory team to ensure the analysis adhered to the correct methodological approach. To protect the privacy and confidentiality of the participants, each doctor and patient was assigned a unique code—Dn (n = 1 to 13) for doctors and Pn (n = 1 to 15) for patients. For sections that could potentially identify participants, identifiable information has been redacted with (*) and supplemented with descriptive content in brackets to preserve the sentence’s full context and meaning. 3. Results Three main themes emerged from the interviews concerning the privatisation of doctor and patient responsibilities following the marketisation of China’s healthcare system. Privatised Responsibility in Accessing Healthcare Marketisation of healthcare transformed the previously cooperative relationships among the three-tier healthcare institutions into competitive ones [ 2 , 20 ]. The primary care and referral systems, which once operated alongside each other within the cooperative hierarchical structure, have been weakened, which has altered patient’s pathways through the system. The patients interviewed reported freedom to access any healthcare institution and being entirely responsible for their choice. One patient shared her experience of choosing a hospital. Yes, it’s about making my own choice, because I can go anywhere. If it’s just a cold or fever, I might go to a small hospital or even a pharmacy to get some medicine. If it feels more serious, or I’m not sure, or if I’m not confident handling it myself, I go to a big hospital for peace of mind. (P1) As patients could choose any healthcare institution directly without initial registration, they were free to prioritize top-tier hospitals. As one said: I would definitely choose a large hospital first; small clinics are unreliable. (P15) The resulting influx of patients has intensified the workload on doctors in tertiary hospitals. Interviewed doctors were overwhelmed by the number of patients they must attend to every day, which compromised their ability to meet role expectations of patients. One doctor highlighted that the extensive workload in his clinic significantly restricted the time available for each patient, hindering the quality of care provided. I have to see 30 to 40 patients in a half day clinic, and the consultation time for each patient may be five to ten minutes… there will be a lot of surgeries, and I will be very busy, I do not have much time to think of the patients’ feeling or comfort them when they feel sad. (D5) In smaller cities and hospitals, the scarcity of medical resources means that some conditions cannot be effectively treated locally, compelling patients to seek medical care in larger cities with more advanced healthcare facilities. This phenomenon is described in China with a specific term, ‘yi di jiu yi,’ which refers to medical treatment and drug purchase activities at medical institutions outside the insured area [ 35 ]. Interviews were conducted with patients who have experienced seeking medical care in different locations. One such patient described her experiences with seeking medical care in another city, noting that it presented significant challenges because she needed to consider multiple factors, including medical information, hospital data, insurance, and living arrangements, thereby revealing a more comprehensive scope of patient responsibilities. My hometown is in a small city, few hospitals know about my issues, so I went to four or five hospitals across different cities. The whole thing was that they have all given me diagnosis, at first the hospital in my hometown didn’t give one, said it wasn’t very clear. I kept asking around, searching information myself, different hospitals have different requirement, I checked my insurance, and where to eat food, is basic, but necessary. (P3) After the patients decide which hospital and department they need to visit, they must select a specific doctor (if applicable), consultation time, and sometimes the level of expertise (this step in Chinese is called: gua hao). Based on patient descriptions, the responsibility for choosing a doctor during the registration process also falls on the patients. One shared his strategies for selecting a doctor during the registration process, which included his consideration on assessing whether the health condition matches the scope of the consultation with the registered doctor, the doctor’s specialization and experience, and availability. The process is pretty similar in most hospitals, in that you have to register as the first step. But how to choose an appropriate doctor, right? It’s very tricky. In my opinion, you can’t just register with a specialist, because they may be busy, many appointments, you have to wait for a long time, and you may recover by yourself when you get an appointment. But you also can’t just say, register with a random one. I would check online. (P14) To avoid long waiting times and gain quicker access to healthcare services, a practice of ‘relationship-based care’ has emerged. This approach involves patients using their personal connections and acquaintances to obtain a more favourable position in accessing medical treatment and establishing doctor-patient relationships. A patient recounted his experience of getting in touch with a doctor as, I reached a famous doctor through (a personal relationship*), otherwise I couldn’t get that appointment…It is very common to use personal relationships to find a doctor. (P15) Another patient also mentioned relationship-based care. Her account further revealed the purposes behind this behaviour: on one hand, to gain quicker access to medical resources, and on the other, to ensure a better healthcare experience. I will contact my doctor friends, I often use acquaintances as a chain of medical experience, will be able to see the doctor more quickly, in addition, part of it, the doctor will be because I was referred by an acquaintance, the whole experience will be a little better. (P14) Relationship-based care has triggered patient’s concerns about healthcare equity. As a patient mentioned, she harboured concerns about the doctor because she lacked a personal connection with them, therefore, she worried about the quality of care she would receive. This concern is also due to the fact that I don’t have any acquaintances in this place, I haven’t heard of this doctor, and I don’t know if I can rely on him or not. (P3) As these experiences relay, the privatisation of responsibilities in accessing healthcare appears to have transformed the way patients access healthcare. Due to the absence of primary care, patients independently choose their healthcare pathway, often leading to a disproportionate influx at tertiary hospitals. This scenario places substantial burdens on both patients and doctors, undermining their trust in the healthcare system. Privatised Responsibility in Care Coordination The research revealed that both doctors and patients currently bear responsibilities in care coordination. This typically involves patient navigation within hospitals, assessing and updating care plans, managing referrals to appropriate hospitals, and coordinating post-treatment. With the absence of a structured referral system, responsibility for patient navigation has shifted to doctors. According to their accounts, they were tasked with the initial assessment of a patient’s condition and are responsible for making subsequent treatment decisions tailored to the patient’s actual situation. The patients come here on their own registration, so as a doctor, the first thing I have to do is to judge, whether he should have registered with me or not. I need a preliminary judgement. Then sometimes when I listen to his description and think, for example, he has (a symptom*), then I have to make a further judgement and may have to send him for some tests. After further examination, it may not belong to my side, then the patient needs to go to another department. (D11) This respondent’s subsequent narrative explains the tasks doctors undertake during the navigate process, which adds to their administrative load and require them to spend more time coordinating care for patients. Some patients just come to the wrong place, registered wrong, so what to do, they are already here, I cannot directly let people go, I will need to explain, you came to the wrong place, I’m not here to see this disease, you go to another building, go to which department, you go to register that. Patients sometimes say to me, ‘Doctor, please give me a look, it’s not easy for me to come here, so I have to continue to explain that I can’t do it here, you have to go that department’. (D11) During the process of responsibility privatisation, patients bear decision-making responsibilities and need to self-evaluate the potential impacts of their care plan. The doctor gave me two choices, it’s okay to treat it with him, but his treatment plan is to apply medication and treat it more conservatively. However, he also told me that I can go to (a hospital name*), where they can directly operate, and it will be faster. It’s my choice. I’m thinking about the hassle of referrals and the fact that I have to go through all these processes all over again, so I’ve been evaluating the pros and cons. (P14) During the navigation and referral process, patients are responsible for tracking their own medical records, referrals, and any related documents to ensure continuity of care, thus bringing increased responsibilities for record-keeping and communication. Patients’ experiences reveal that a healthcare system lacking in collaboration and referrals sometimes fails to effectively share this information, necessitating that patients themselves maintain it. This patient’s experience further reveals that moving between different medical institutions may also involve undergoing repeat tests. I kept the receipts from each inspection. Records, diagnoses, all that. Because I might need them next time. If I get referred to another hospital, I may need another checkup, too, generally speaking, I’ll need to. Because they don’t share with each other. (P14) For patients, this situation also signified that they have taken on increased responsibilities in managing navigation and referral, needing to advocate more actively for themselves and seek information about the referral pathway. What I’m thinking is that I must register and get into this hospital first and then figure out what to do. So, it might have been that the department that I got registered in wasn’t the right one to begin with, so I went through a series of referrals, these later on. The process is, you keep going around inside the hospital, just listening to the doctors, or just asking around on your own. (P13) The privatisation of assessment and care planning responsibilities leaves both doctors and patients feeling vulnerable, wishing to reduce the responsibilities they bear in doctor-patient interactions and hoping that the other party takes on more responsibilities. As one doctor summarised, I will go ahead and follow the standard, the standard process of this treatment. But give advice to the patient, like, saying, where do you should go next. This is not good for me. You do not know what people will think. And there’s a lot of things that need to be explained, and sometimes it’s hard to explain, so, I’ll just, make and get the standard treatment good. (D9) Interviews with patients confirmed the fact that some doctors were trying to lessen their responsibilities. One patient said that during her care plan making, the doctors consistently tried to minimize their own decision-making role, transferring the responsibility for decisions to the patient. I did not know how long I should stay in the hospital, which made me very anxious. I went to ask the doctor, and he said, ‘depend on you’. Then I asked if I should do another CT scan to check the brain and he responded, ‘you can have it whenever you want’. I was really confused. I’m not a doctor; I don’t have medical knowledge. How can I be expected to make all these decisions? (P3) These extracts reveal the kinds of responsibilities doctors and patients are taking during care coordination, which include care planning, assessments, referrals, and follow-ups. Doctors now shoulder administrative tasks typically handled by primary referral systems, such as evaluating patient conditions and directing patients to suitable departments. Conversely, patients face privatised responsibilities that require them to make informed medical choices, actively seek information, advocate for themselves, and track their medical records and referrals to ensure continuous care. Privatised Financing of Medical Cost The current healthcare system transferred the responsibility for medical costs to individual patients. Currently, although the release of Opinions on Deepening the Reform of the Medical Security System by the State Council in 2020 aimed to enhance people’s welfare [ 16 ], a significant portion of medical expenses still falls directly onto patients [ 36 ], creating for some a financial burden. This extract from one patient interview illustrates the personal cost associated with treatment. Health insurance didn’t cover much. Well, the first treatment cost was reimbursed, but I required several visits, the first one was fully covered, but after that, they only reimbursed about 100 yuan, in the following visits, the amount they covered became less and less. (P15) This patient indicated that complex reimbursement requirements are a major barrier to patients claiming their expenses. Partial reimbursements often failed due to complicated procedures, resulting in patients bearing the costs themselves. This patient added, These clauses are complex, sometimes I’m not sure if I can get reimbursement, maybe I’m lazy or busy, I’ll miss the time to get the money back. (P15) In some cases, patients must bear the full cost of medications and treatments which are not covered by health insurance, placing the financial burden directly on individuals. This situation poses significant barriers for those lacking financial resources, as they must find ways to fund their healthcare needs independently. A patient described his experience of paying out of pocket for an injection, showing the strain that medical costs put on him. Each dose cost about 400 or maybe 500 yuan. I needed 6 doses every day, and it would be over 3,000 yuan. But I was running out of money. Sometimes, I could only get injection if I managed to borrow money in the morning. If I had money that day, I would come to the hospital to pay and then I could get the injection. Undergoing (a disease*) is really tough. You see in TV shows, someone said, ‘doctor, no matter how much it cost, I don’t care, I just want the patient to live.’ That’s not true, reality is cruel. Many fellow patients genuinely cannot afford treatment and end up giving up. I have seen this very clearly. (P6) The privatisation of medical costs has undoubtedly placed financial pressure on patients. One patient who was hospitalized, expressed dissatisfaction with the medical expenses, I was really anxious, as I lived in hospital for 7 days, money went by so fast for around two to three thousand RMB every day. (P3) A doctor indicated that the privatisation of financial responsibilities was one of the main factors transforming the current doctor-patient relationship into a consumer-purchaser relationship. This shift turns the doctor-patient interaction into a transactional relationship, leading patients to view treatment outcomes as purchasable goods, without considering the many uncontrollable factors that can affect these outcomes. If the patient thinks, I’m the one who paid a lot of money to come to the doctor, I’m the one who came to buy your services, I spent money, I spent so much money, I should get better. (D2) Privatised responsibility also puts doctors in a difficult position, caught between patients’ financial constraints and the hospital’s fiscal pressures. Interviews with doctors revealed their awareness of the issue as a societal problem, which is challenging to address at the interpersonal level. Confronted with their patients’ financial hardships, this doctor felt ‘helpless’ because, he was unable to make decision for the patients, nor could he compensate for the deficiencies in the healthcare system. This is a deeper social problem, I know some patients fall into financial hardship, they even sell all of their properties, even if the disease is cured, how can they live then if they have nothing. But for me, a doctor, shall I ask them not to treat, or I should say nothing but respect their choice, I do not know which one is good, I’m just doing what a doctor could do. (D6) The dilemma doctors now face is entirely the construction of an ideologically driven policy. The explicit aim of the state’s retreat from public hospitals was to enhance service efficiency, enabling hospitals to be self-sustaining and financial independent from state funding. In line with this objective, the burden of generating additional income for hospitals has shifted to doctors. The extract below emphasizes that medical marketisation has not disappeared but has been further consolidated and, indeed, has gradually intensified the competitive environment, placing additional pressure on doctors. The problem with hospitals is that they still aim to be profitable, as there’s no motivation without profit. In recent years, X hospital has suffered significant losses, unable to pay salaries to its staff. Therefore, it (the hospital*) requires us (the doctors*) to find ways to generate revenue and increase profits. They set performance indicators, and, if doctors don’t meet the standard, it’s up to hospital to figure out a solution. (D2) The privatisation of responsibility for medical costs presents challenges for doctors within the healthcare system. One doctor mentioned that he was trying to share these responsibilities with patients. This doctor stated that he tried to understand the patient’s financial situation and, when prescribing, he tended to prescribe medications that were covered by health insurance. This one involves the experience of the doctor. It’s not necessary, it’s extra, but then, it’s something to keep an eye on. That is, when I give a prescription, I ask the patient about his financial situation, and then I try to cover it in the reimbursement area, but this is not guaranteed. Of course, it depends on the actual situation. (D11) The marketised healthcare system shifts part of the financial responsibilities to individuals. Patients’ ability to afford these costs now directly influences their access to necessary medications and restricts their equal opportunities to receive adequate medical care. 4. Discussion In a healthcare market characterised by an unequal distribution of resources, a weak referral system, and rising out-of-pocket expenses, three responsibilities, which include accessing healthcare, coordinating care, and managing financial costs, have been privatised for doctors and patients. Our research clarifies the content and influence of each responsibility. With access to healthcare now privatised, patients have the freedom to select any hospital or doctor, granting them choice but also placing full responsibility for hospital selection and treatment upon them. In a competitive healthcare market, the highest-tier providers in the healthcare system, already benefit from superior resources, reputation, and the capability to handle complex medical cases. These advantages grant them a competitive edge in the market. Concurrently, as a result of marketisation, patient preferences—driven by perceptions of higher-quality care, advanced technology, and skilled professionals—further reinforce their dominance and lead to market-induced healthcare centralization [ 2 , 20 ]. Our research confirmed that patients still prefer visiting large hospitals, citing greater reliability as a key factor [ 27 ]. Lacking the expertise to accurately diagnose their conditions, many patients opt for tertiary hospitals as their first choice because these hospitals are generally considered to have the best medical resources. This preference often results in overcrowding in tertiary hospitals. Facing the increased patients, doctors are forced to reduce consultation time with each patient, leading to insufficient doctor-patient communication. Patients face increased waiting times and frustration, while doctors feel burnt out due to heavy work pressure; both sets of factors previously identified as negatively affecting doctor-patient relationships [ 2 , 37 – 40 ]. At the same time, this study found that the uneven distribution of medical resources compels patients seeking higher-quality care to personally assume additional responsibilities. It revealed that the privatisation of registration responsibilities has increased inequities in access to healthcare, for example, by creating the practice of ‘yi di jiu yi’ (seeking medical treatment away from a patients’ usual location) with its lack of local and familiar medical resources and the need for patients to independently determine which hospital and doctor are most appropriate for their condition. This reflects underlying differences in insurance coverage, financial burdens, administrative barriers, and regional disparities in healthcare quality [ 2 , 41 , 42 ]. Privatised responsibility in accessing healthcare drives the phenomenon of ‘relation-based care’. Individuals and families with significant social resources and personal connections, often find it easier to access quality medical services compared to those with fewer resources, who may struggle to receive adequate care [ 3 ]. This phenomenon can be understood from two perspectives: firstly, the shift from a nationalized to a marketised healthcare system has transformed doctors into ‘commodities’ within the healthcare market. From a patient’s perspective, a doctor’s skills are seen as valuable resources. Experienced doctors, therefore, become scarce commodities over which patients compete [ 18 , 20 ]. Secondly, patients’ attempt to build personal relationships with doctors through financial incentives, hoping to secure superior care. This approach seeks to convert monetary gifts into preferential treatment, blending economic transactions with doctor-patient relationships [ 43 ]. For doctors, accepting gifts poses risks of violating professional and legal standards, complicating their professional responsibilities, eroding patient’s trust, and challenging the fairness of the healthcare system [ 2 , 43 ]. The weak hierarchical system has transferred many administrative duties traditionally managed by referral systems onto both doctors and patients [ 2 , 3 ], thus privatising medical coordination responsibilities. For doctors, the privatisation of coordination, navigation and referral responsibilities requires additional time for communication, providing emotional support to patients, documentation, and follow-ups. These additional duties often compete with doctors’ clinical responsibilities and increase their workloads. For patients, privatised responsibilities in coordination and decision-making for follow-up healthcare management are limited by their health literacy [ 44 ]. Patients with limited understanding of medical terms and healthcare procedures are disadvantaged as they may receive suboptimal care or fail to complete treatment plans. In a system characterized by privatised responsibilities, both doctors and patients experience both pressure and vulnerability in these roles, leading to a desire for the other party to take on more decision-making responsibility. Doctors often shift responsibilities to avoid the high pressures of their roles and the potential for medical complaints, which can stem from misunderstandings or dissatisfaction with care outcomes. Patients often struggle because they lack the necessary knowledge to comprehend fully their care plans, navigate complex referral systems, or effectively advocate for themselves within the healthcare system. This lack of understanding can lead to frustration and dissatisfaction, potentially escalating into conflicts [ 45 ]. Consequently, both doctors and patients often feel unsupported by the healthcare system, which can erode trust and satisfaction on both sides of the doctor-patient relationship [ 8 ]. The current payment system has shifted healthcare financing responsibilities towards privatisation. Despite reports that 95% of the population was covered by National Medical Insurance by 2020 [ 46 ], substantial challenges persist due to limited reimbursement rates and the narrow scope of the services covered. Personal or family income levels directly influence the ability to afford care. Income levels dictate the quality and timeliness of medical treatment available, leading to inequalities in healthcare utilization. Those with higher incomes can afford better and more immediate care, while those with lower incomes often experience restricted access and increased financial stress. China’s marketised healthcare system also encourages hospitals to chase profit, and doctors are tasked to generate profits for hospitals which not only transforms doctor-patient relationships into transactional interactions but also commodifies treatment outcomes. This leads patients to approach healthcare services with consumerist expectations—demanding choices, immediate access, transparency, and measurable results, conflict with traditional doctor-patient trust [ 2 ]. Moreover, this privatisation of responsibilities also requires doctors within the current healthcare system to balance hospital profitability with patient financial burdens, which is likely to affect decision making and strain doctor-patient relationships: while patients naturally seek to minimize their healthcare expenditures, doctors are compelled to focus on profitability to sustain their practices and support their hospitals. As previous research has shown, economic pressures and moral dilemmas contribute to ethical burden on doctors [ 47 , 48 ]. Conclusion Institutional norms shape the distribution of responsibilities of both doctors and patients in healthcare. This research proposes a theoretical framework for understanding the impact of marketisation on these responsibilities, extending research on the effects of healthcare marketisation on doctor-patient relationships. Through the concept of ‘privatised responsibilities’, which encompassing access to care, care coordination, and healthcare financing, this research suggests that market principles in health systems exert undue pressure on both doctors and patients. Policymakers should reconsider the use of market-driven approaches to addressing problems related to the unequal distribution of healthcare resources, weak referral systems, and limited medical insurance reimbursements. The conceptualisation and findings presented here offer a foundation for future research on the broader impact of healthcare marketisation. Limitation Although our research examines the marketisation in healthcare reshapes doctor-patient responsibilities and highlights its potential negative impacts, offering a comprehensive alternative prescription lies beyond its scope. Nonetheless, the pilot nature of the research and findings is readily acknowledged. Future research should engage with larger more representative populations and consider focusing on the responsibilities and challenges faced by patients with specific diseases within the healthcare system. Furthermore, all fieldwork interviews were conducted in Chinese, and although the researcher made efforts to translate responses into English accurately, some nuances of participants’ experiences may have been inadvertently overlooked during the translation process. Declarations Ethics approval and consent to participate This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval for this study was granted by the University of Sheffield Research Ethics and Integrity (Version 8.3 – October 2024; Reference Number: 043134). All participants provided informed consent. Consent for publication Informed consent was obtained from all participants for this study. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to the potential risk of identifying participants from interview content, but are available from the corresponding author on reasonable request. Competing interests The authors declare that the authors have no conflict of interests. Funding details The authors have not received any financial support or funding from external organizations for this research. Authors’ contributions Dr. Haoyang Liu conceptualised and designed the study, obtained ethical approval, and conducted the semi-structured interviews. She also transcribed the data, carried out the analysis, and drafted the manuscript. Prof. Alan Walker supervised the research process, provided detailed revisions, and contributed to enhancing the overall quality of the study. Both authors contributed to the research and approved the final manuscript. Acknowledgments We are grateful to all the participants in this study, and to Prof Paul Martin for his help with the manuscript. References Wu Y (2008) The evolution of government functions in my country’s medical and health sector: a review and a prospect. China Health Policy Res 1:27–31. Yao Z (2017) The privatization of medical service responsibilities and the deterioration of the doctor-patient relationship since the reform and opening up. J Southeast Univ Philos Soc Sci 19:24–32. Shi R (2022) National health construction and the production of medical-patient disputes—a comparative study between the Republic of China period and contemporary times. Sociol Rev China 4:73–90. 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Gu X (2022) Towards the public healthcare insurance: The reform of basic healthcare system and organisational institution. Soc Sci Res 102–109. Roter DL, Hall JA (1992) Doctors talking with patients/patients talking with doctors: Improving communication in medical visits. Westport, CT, US. He AJ, Qian J (2016) Explaining medical disputes in Chinese public hospitals: the doctor–patient relationship and its implications for health policy reforms. Health Econ Policy Law 11:359–378. Finset A (2012) “I am worried, Doctor!” Emotions in the doctor–patient relationship. Patient Educ Couns 88:359–363. Zhang H, Ma W, Zhou S, Zhu J, Wang L, Gong K (2023) Effect of waiting time on patient satisfaction in outpatient: An empirical investigation. Medicine (Baltimore) 102:e35184. Xie L, Hu H, Evolution and trend of the cross-pooling healthcare policy of basic medical insurance in China: Based on content analysis of policy document. Chin. J. Health Policy 14:45–50. Nana G, Aolong L, Hongbing H (2023) The effect of direct settlement of medical insurance for nonlocal medical treatment on residents’ health. J Finance Econ 49:94–108. Guo W (2018) Whose red envelopes do you accept? ——A cultural sociological interpretation of informal “transactions” between doctors and patients. J. Sociol. Stud. 1:15–55. Van der Gaag M, Heijmans M, Spoiala C, Rademakers J (2022) The importance of health literacy for self-management: A scoping review of reviews. Chronic Illn 18:234–254. Kelly J, Al-Rawi Y (2021) Recognising, understanding and managing high conflict behaviours in healthcare. Postgrad Med J 97:123–124. Xinhua News Agency (2023) National Medical Insurance Administration: basic medical insurance participation rate has stabilized at around 95%. In: Gov. Website Peoples Repub. China. https://www.gov.cn/lianbo/bumen/202305/content_6874798.htm. Accessed 6 Jan 2024. Emanuel EJ, Pearson SD (2012) Physician autonomy and health care reform. JAMA 307:367–368. Shanafelt TD, Noseworthy JH (2017) Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc 92:129–146. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 13 Nov, 2025 Read the published version in International Journal for Equity in Health → Version 1 posted Editorial decision: Revision requested 05 Oct, 2025 Reviews received at journal 23 Jul, 2025 Reviewers agreed at journal 10 Jul, 2025 Reviewers invited by journal 08 Jul, 2025 Submission checks completed at journal 18 May, 2025 First submitted to journal 13 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6371752","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":482474256,"identity":"20ba88da-9fd5-4625-a523-86a4443efbd2","order_by":0,"name":"Haoyang Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBklEQVRIiWNgGAWjYBACAygtw8bA2HAgocIGyGZsPECMFh42BubGBx/OpIG0NBCnhYGBvdlwZtthMA+vFnP2w8ckfu6o5eGTSGyT5m07b7e2/TDQlhqbaFxaLHvS0iR7zxznYQNp4Tl3O3nbmUSglmNpuQ24HHYgx0yCt+0YVEvZ7WSzA0AtjA2HcWs5/8ZM8i9cC9u5ZLPzDwlouZFjBvRCDUhLs+GMtgN2ZjcI2XLjWbK1bNsBHjaeh6BATk4wuwG0JQGfX84nH7z5tq1OTr49/QEwKu3szc6nP3zwocYGpxYgYJFgYDgM5yWCVSbgVg4CzB8YGOrgPHv8ikfBKBgFo2AkAgC5EWclkFTaFwAAAABJRU5ErkJggg==","orcid":"","institution":"University of Sheffield","correspondingAuthor":true,"prefix":"","firstName":"Haoyang","middleName":"","lastName":"Liu","suffix":""},{"id":482474257,"identity":"d10404c7-9d96-46e2-8a9e-ec661ad1e29d","order_by":1,"name":"Alan Walker","email":"","orcid":"","institution":"University of Sheffield","correspondingAuthor":false,"prefix":"","firstName":"Alan","middleName":"","lastName":"Walker","suffix":""}],"badges":[],"createdAt":"2025-04-03 19:38:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6371752/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6371752/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12939-025-02690-1","type":"published","date":"2025-11-13T15:58:27+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":96105103,"identity":"0f8b7ce2-6455-450c-b8a1-59221953d4fb","added_by":"auto","created_at":"2025-11-17 16:08:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":471437,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6371752/v1/7a2acdb7-0fcd-4884-bc38-4c4fc92574c0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Marketisation in China’s Health System: A Thematic Exploration of Impacts on Doctor-Patient Relationships","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eSince its establishment in the 1950s, the Chinese healthcare system has undergone significant transformations, shifting from a government-dominated model to market-driven one, so that now it represents a hybrid model combining the state and the market: the government provides political leadership and control, while the market governs the operation of the system [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. While government leadership theoretically mitigates excessive commodification and maintains ethical oversight, in practice the dominance of market-oriented incentives frequently leads doctors to prioritise revenue generation, potentially reducing consultation time and fostering transactional interactions. For patients, despite the government\u0026rsquo;s commitment to accessibility and equity, healthcare is often experienced as a consumer-driven commodity, heightening expectations and financial pressures [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Moreover, contrary to the expectation that the reforms would improve healthcare quality, access to medical resources has significantly deteriorated, highlighting a critical gap between policy intentions and outcomes [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The proportion of personal health expenditure rose from 361.9 yuan (approximately \u0026pound;40.2) in 2000 to 6425.3 yuan (approximately \u0026pound;713.9) in 2024, reflecting an average annual growth rate of 12.73%. Meanwhile, out-of-pocket spending accounted for 27.7%, exceeding the 15\u0026ndash;20% range recommended by the World Health Organization [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Doctors\u0026mdash;as frontline medical providers\u0026mdash;have gradually faced criticism for being profit-driven. Medical disputes have continued to escalate. Hospitals in some regions reported that 89.84% of emergency department doctors have experienced verbal abuse, insults, threats, or even physical violence [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], which highlights the increasing tensions in doctor-patient relationships. Dominant perspectives within health policy, epidemiological and biomedical frameworks, while valuable for clinical outcomes, offer little assistance in understanding the complexities and inequalities concerning accessibility within healthcare systems [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Therefore, this paper explores the impact of the systemic healthcare organization on doctor-patient relationships.\u003c/p\u003e\u003cp\u003eFirst, it reviews the changes in China\u0026rsquo;s healthcare system and its marketisation. Then it outlines the qualitative interview approach involving 28 frontline doctors and their patients, who were directly experiencing the current healthcare system under the influence of marketisation. This research reveals that marketisation has led to the privatisation of responsibilities for both doctors and patients, significantly increasing the pressures on them. It reveals that, within the marketised healthcare system, the responsibilities undertaken by doctors and patients, including healthcare assessment, care coordination, and financial obligations, are treated as their own responsibility. The findings are examined considering their broader implications, offering guidance for optimising medical policies on doctor-patient responsibilities and ensuring the accessibility of medical resources across diverse social and cultural contexts.\u003c/p\u003e\u003cp\u003e\u003cem\u003eInstitutional Frameworks and Doctor-patient Relationships\u003c/em\u003e\u003c/p\u003e\u003cp\u003eHealthcare systems function as a central institution in society, structured to maintain public health, support economic stability, and uphold social order [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The development of national healthcare systems directly influences the doctor-patient relationships and how responsibilities are distributed between doctors and patients [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn Western contexts, the influence of institutional frameworks on doctor-patient relationships has often been studied through the lens of market. Numerous politicians and policy-makers argued that marketisation, primarily characterised by neoliberal ideologies, emphasises competition, consumer choice, and cost-efficiency, have introduced transactional dynamics into healthcare interactions, reshaping patient identities from passive recipients of care to active consumers who make informed choices and bear responsibility for their healthcare outcomes [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Some concerns raised that marketization may lead to a decline of professional autonomy, potentially leading to a decline in altruistic or service-oriented attitudes toward patients [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBy contrast, models featuring strong government control, such as the UK\u0026rsquo;s National Health Service (NHS), reflect different institutional pressures. The NHS system historically prioritises equity and accessibility, embedding doctor-patient relationships in a framework of public trust and collective responsibility [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, it introduces specific constraints, including bureaucratic rigidity, long waiting times, and restricted patient choice, which may adversely affect patient satisfaction and trust [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Research in Northern England implied a clear reduction in doctors\u0026rsquo; autonomy and offer little resistance to it [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe hybrid institutional model, combining elements of state control with market-driven operation, is particularly evident in China\u0026rsquo;s contemporary healthcare system. Ideally, this model is intended to provide a balanced approach to healthcare governance through government leadership, while promoting operational flexibility and innovation through market-based incentives [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. While some research [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] revealed that, in this framework, doctors assume dual responsibilities, they are expected to achieve public welfare objectives set by the government while simultaneously meeting institutional revenue targets shaped by market principles. Patients, in turn, face increased financial burdens and are required to assume greater responsibility in healthcare decision-making, thereby adopting more consumer-oriented behaviours. It is worth noting that China\u0026rsquo;s healthcare system has experienced all three of the aforementioned models, thereby offering a valuable case for examining how institutional context influence doctor-patient relationships.\u003c/p\u003e\u003cp\u003e\u003cem\u003eNational Healthcare Construction and Changing Doctor-patient Responsibilities in China\u003c/em\u003e\u003c/p\u003e\u003cp\u003eChina\u0026rsquo;s healthcare system has undergone three major reforms, each of which has brought corresponding changes to doctor-patient relationships and the distribution of responsibilities.\u003c/p\u003e\u003cp\u003eAfter the 1950s socialist revolution, China established a unique intimate relationship between its people and the state through the direct allocation of resources. At that time, most hospitals and community health centres in China were publicly owned and operated under the jurisdiction of district, municipal, and regional governments, the collective \u0026lsquo;work unit\u0026rsquo; (or \u0026lsquo;danwei\u0026rsquo; system) provided primary care as its foundation, offering free healthcare and facilitating bidirectional referrals among its three-tier institutions: city hospitals, district (county) hospitals, and work unit healthcare groups [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Doctors served as salaried national public service providers and did not have any direct economic relationships with patients (although undeclared payments by patients were said to be common). Their main responsibility was patient care. Medical resources were mainly allocated through public channels, and patients passively accepted unified arrangements and were charged only minimal healthcare fees [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Doctor-patient relationships during this era coupled with the ideology of collectivism, fostered a sense of organizational solidarity that far surpassed any divisions caused by disparities between doctors and patients in modern healthcare [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHowever, the state-funded healthcare system placed significant financial strain on the national budget [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Beginning in the late 1970s and accelerating through the 1980s and 1990s, China implemented a series of economic reforms that introduced market mechanisms into public services, including healthcare [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. By the turn of the century, the welfare-based work unit system had been largely abandoned [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Marketisation, driven by neoliberal ideology, begins with the purposeful intention of the state to retreat in terms of both funding and provision [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Starting in 1980 the Chinese government deliberately decreased its contribution to healthcare spending, which declined from 36.2\u0026ndash;15.21% in 2002 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. From 1998 to 2014, the state provided only 6\u0026ndash;8% of financial support for the budget deficits of hospitals, with the remaining approximately 90% of the shortfall being made up from revenues from medical services, and the sales of pharmaceuticals and medical devices [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. As a result, the welfare orientation of healthcare has been reduced, public hospitals were encouraged to generate their own income through service fees, drug sales, and operate with financial self-sufficiency and compete for patients and revenue [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Doctors have shifted from being \u0026lsquo;national public service providers\u0026rsquo; to practitioners in a healthcare market [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This marked the beginning of healthcare marketisation, with patients increasingly seen as consumers and medical services as products.\u003c/p\u003e\u003cp\u003eIt is at this stage that the doctor-patient relationship in China has changed. As hospital revenues were directly linked to doctor\u0026rsquo;s salaries, physicians were compelled to align their practices with the hospitals\u0026rsquo; profit-driven objectives and earned benefits from patients. Financial pressure transferred to patients, in nationwide, the annual per-capita cost of outpatient and inpatient care experienced a significant increase of approximately 14%, from 1993 to 2002, per capita outpatient costs rose from CN\u0026yen;21.5(UK\u0026pound;2.39) to CN\u0026yen;99.6(UK\u0026pound;11.07), and inpatient costs from CN\u0026yen;933.4(UK\u0026pound;103.71) to CN\u0026yen;3597.7(UK\u0026pound;399.74) \u0026lsquo;Hard to see the doctor, expensive to see the doctor\u0026rsquo; have become a common view in the public [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Widespread scepticism about the ethical standards of healthcare professionals prevails [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The deterioration of doctor-patient relations and increasingly fierce conflicts have triggered the latest round of healthcare reforms [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSince 2000s, the Chinese healthcare system represents a hybrid model, combining state-led political control with market-based operational mechanisms[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Although the current system declares a leading governmental role, competitive market forces continue to exert substantial influence [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. This hybrid model triggered three key characteristics. First, the unequal distribution of healthcare resources has become more apparent. Marketisation introduced competition among hospitals, weakening their collaborative efforts and undermining the intended three-tiered medical treatment structure, in which most diseases were intended to be treated in primary or secondary hospitals, with only severe or complex cases referred to tertiary hospitals [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Hospitals increasingly rely on revenue generation for operations, concentrating resources in economically developed regions and larger institutions [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In 2023, the number of medical and health technicians per 1,000 residents in urban areas stood at 10.20, compared to 6.55 in rural areas, a ratio of 1.56 to 1. Moreover, the majority of healthcare resources are located in the eastern, more developed provinces [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Second, the referral system remains weak. Data from the Sixth Health Service Survey indicate that over half of two-way referrals fail to materialise [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Tertiary hospitals, equipped with superior resources and advanced medical equipment, enjoy a competitive edge in the healthcare market. As a result, they receive a disproportionate share of patients, accounting for more than 50% of total medical services [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Finally, medical insurance reimbursement remains incomplete: patients are only reimbursed for a proportion of costs, patients continue to shoulder rising out-of-pocket expenses. In recent years, annual medical costs have increased by around 8%. Between 2011 and 2021, the national average hospitalisation cost per visit rose from 6,632 yuan (\u0026pound;736.89) to 11,003 yuan (\u0026pound;1,222.50), an increase of approximately 66%. The average outpatient cost grew from 180 yuan (\u0026pound;20.00) to 329 yuan (\u0026pound;36.56), marking an increase of about 83% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this context, we sought firsthand knowledge about how doctors\u0026rsquo; and patients\u0026rsquo; responsibilities are shaped and allocated within China\u0026rsquo;s contemporary healthcare system.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThis study adopted interpretive description as its methodological approach, which seeks to transcend traditional qualitative methodologies such as grounded theory, phenomenology, and ethnography, offering a flexible framework for applied health research [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Previous studies verified that interpretive description is an effective qualitative methodology for applied research, as it builds upon, rather than disregards, existing experiential knowledge related to the subject of interest [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. This also aligns with our study, allowing for exploration and rich description of emerging doctor-patient relationships, particularly within complex healthcare system.\u003c/p\u003e\u003cp\u003eQualitative interviews enabled flexibility, allowing for in-depth exploration of the participants\u0026rsquo; perspectives [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. As the research aimed to explore how doctors and patients experience the impact of marketisation on their relationship within the healthcare system. The fieldwork employed semi-structured interviews with frontline doctors from 13 public hospitals and patients across five provinces in China. The selection of participants was purposive, ensuring a diverse range of insights into the healthcare reforms. All participating doctors held valid Chinese practicing physician certificates, with their experience ranging from 2 to over 20 years. This variation allowed for a blend of in-depth, seasoned perspectives from more experienced doctors and fresh viewpoints from younger doctors who are recent entrants to the field. For the patient participants, the criteria focused on individuals with personal medical treatment experiences who were willing to share their healthcare journeys. Special attention was given to patients under long-term treatment, as they have been managing their illnesses for decades and were most directly affected by the healthcare reforms. These participants provided the most direct insights into the effects of the healthcare system. A total of 28 semi-structured interviews were conducted, involving 13 doctors and 15 patients, providing key insights for the research. The study received ethical approval and followed standard ethical procedures, including informed consent, confidentiality, and voluntary participation.\u003c/p\u003e\u003cp\u003e The semi-structured interviews were primarily composed of open-ended questions, conducted in the participants\u0026rsquo; native Chinese language. The interviews were structured into three main parts: introductory questions to build rapport, participants\u0026rsquo; perceptions of doctor-patient relationships, and questions specific to working experience for doctors and questions of healthcare experience for patients. Particular attention was given to exploring how systemic changes shaped two sides of the healthcare experience.\u003c/p\u003e\u003cp\u003eMost respondents understood the Chinese healthcare system, and the majority were able to articulate their perceptions of institutional changes and their effects on clinical experiences or access to care. For those participants who sought clarification during the interview, the researcher provided brief explanations, such as their access to healthcare, the change of healthcare pathway and introduction of out-of-pocket payments. These prompts helped respondents to contextualise their experiences within the broader institutional reforms associated with marketisation, ensuring the discussions remained relevant and grounded in the research focus.\u003c/p\u003e\u003cp\u003eThe analysis was based on the responses of the participants through a series of structured steps. Initially, all interviews were recorded and transcribed verbatim by the researcher. Then thematic analysis was employed to examine the way participants described and experienced the influence of healthcare reform. Coding was conducted inductively and iteratively, guided by both the research aim, to investigate the relationship between institutional change and doctor-patient interactions, and principles of interpretive description. Emergent themes were closely examined to identify patterns in how institutional framework (e.g. access to healthcare, care coordination, and payment systems) shaped clinical roles and patient experiences.\u003c/p\u003e\u003cp\u003eKey segments of data were translated after the coding process, focusing on the portions that would be used in the final analysis. Coding in Chinese to ensure accurate understanding of the data and minimization of errors caused by translation [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. One interview was fully translated and shared with the supervisory team to ensure the quality of the interview and to verify that it was conducted appropriately. For other interviews, key parts that were identified as significant were translated and constantly shared with the supervisory team to ensure the analysis adhered to the correct methodological approach.\u003c/p\u003e\u003cp\u003eTo protect the privacy and confidentiality of the participants, each doctor and patient was assigned a unique code\u0026mdash;Dn (n\u0026thinsp;=\u0026thinsp;1 to 13) for doctors and Pn (n\u0026thinsp;=\u0026thinsp;1 to 15) for patients. For sections that could potentially identify participants, identifiable information has been redacted with (*) and supplemented with descriptive content in brackets to preserve the sentence\u0026rsquo;s full context and meaning.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eThree main themes emerged from the interviews concerning the privatisation of doctor and patient responsibilities following the marketisation of China\u0026rsquo;s healthcare system.\u003c/p\u003e\u003cp\u003e\u003cem\u003ePrivatised Responsibility in Accessing Healthcare\u003c/em\u003e\u003c/p\u003e\u003cp\u003eMarketisation of healthcare transformed the previously cooperative relationships among the three-tier healthcare institutions into competitive ones [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The primary care and referral systems, which once operated alongside each other within the cooperative hierarchical structure, have been weakened, which has altered patient\u0026rsquo;s pathways through the system.\u003c/p\u003e\u003cp\u003eThe patients interviewed reported freedom to access any healthcare institution and being entirely responsible for their choice. One patient shared her experience of choosing a hospital.\u003c/p\u003e\u003cp\u003eYes, it\u0026rsquo;s about making my own choice, because I can go anywhere. If it\u0026rsquo;s just a cold or fever, I might go to a small hospital or even a pharmacy to get some medicine. If it feels more serious, or I\u0026rsquo;m not sure, or if I\u0026rsquo;m not confident handling it myself, I go to a big hospital for peace of mind. (P1)\u003c/p\u003e\u003cp\u003eAs patients could choose any healthcare institution directly without initial registration, they were free to prioritize top-tier hospitals. As one said:\u003c/p\u003e\u003cp\u003eI would definitely choose a large hospital first; small clinics are unreliable. (P15)\u003c/p\u003e\u003cp\u003eThe resulting influx of patients has intensified the workload on doctors in tertiary hospitals. Interviewed doctors were overwhelmed by the number of patients they must attend to every day, which compromised their ability to meet role expectations of patients. One doctor highlighted that the extensive workload in his clinic significantly restricted the time available for each patient, hindering the quality of care provided.\u003c/p\u003e\u003cp\u003eI have to see 30 to 40 patients in a half day clinic, and the consultation time for each patient may be five to ten minutes\u0026hellip; there will be a lot of surgeries, and I will be very busy, I do not have much time to think of the patients\u0026rsquo; feeling or comfort them when they feel sad. (D5)\u003c/p\u003e\u003cp\u003eIn smaller cities and hospitals, the scarcity of medical resources means that some conditions cannot be effectively treated locally, compelling patients to seek medical care in larger cities with more advanced healthcare facilities. This phenomenon is described in China with a specific term, \u0026lsquo;yi di jiu yi,\u0026rsquo; which refers to medical treatment and drug purchase activities at medical institutions outside the insured area [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Interviews were conducted with patients who have experienced seeking medical care in different locations. One such patient described her experiences with seeking medical care in another city, noting that it presented significant challenges because she needed to consider multiple factors, including medical information, hospital data, insurance, and living arrangements, thereby revealing a more comprehensive scope of patient responsibilities.\u003c/p\u003e\u003cp\u003eMy hometown is in a small city, few hospitals know about my issues, so I went to four or five hospitals across different cities. The whole thing was that they have all given me diagnosis, at first the hospital in my hometown didn\u0026rsquo;t give one, said it wasn\u0026rsquo;t very clear. I kept asking around, searching information myself, different hospitals have different requirement, I checked my insurance, and where to eat food, is basic, but necessary. (P3)\u003c/p\u003e\u003cp\u003eAfter the patients decide which hospital and department they need to visit, they must select a specific doctor (if applicable), consultation time, and sometimes the level of expertise (this step in Chinese is called: gua hao). Based on patient descriptions, the responsibility for choosing a doctor during the registration process also falls on the patients. One shared his strategies for selecting a doctor during the registration process, which included his consideration on assessing whether the health condition matches the scope of the consultation with the registered doctor, the doctor\u0026rsquo;s specialization and experience, and availability.\u003c/p\u003e\u003cp\u003eThe process is pretty similar in most hospitals, in that you have to register as the first step. But how to choose an appropriate doctor, right? It\u0026rsquo;s very tricky. In my opinion, you can\u0026rsquo;t just register with a specialist, because they may be busy, many appointments, you have to wait for a long time, and you may recover by yourself when you get an appointment. But you also can\u0026rsquo;t just say, register with a random one. I would check online. (P14)\u003c/p\u003e\u003cp\u003eTo avoid long waiting times and gain quicker access to healthcare services, a practice of \u0026lsquo;relationship-based care\u0026rsquo; has emerged. This approach involves patients using their personal connections and acquaintances to obtain a more favourable position in accessing medical treatment and establishing doctor-patient relationships. A patient recounted his experience of getting in touch with a doctor as,\u003c/p\u003e\u003cp\u003eI reached a famous doctor through (a personal relationship*), otherwise I couldn\u0026rsquo;t get that appointment\u0026hellip;It is very common to use personal relationships to find a doctor. (P15)\u003c/p\u003e\u003cp\u003eAnother patient also mentioned relationship-based care. Her account further revealed the purposes behind this behaviour: on one hand, to gain quicker access to medical resources, and on the other, to ensure a better healthcare experience.\u003c/p\u003e\u003cp\u003eI will contact my doctor friends, I often use acquaintances as a chain of medical experience, will be able to see the doctor more quickly, in addition, part of it, the doctor will be because I was referred by an acquaintance, the whole experience will be a little better. (P14)\u003c/p\u003e\u003cp\u003eRelationship-based care has triggered patient\u0026rsquo;s concerns about healthcare equity. As a patient mentioned, she harboured concerns about the doctor because she lacked a personal connection with them, therefore, she worried about the quality of care she would receive.\u003c/p\u003e\u003cp\u003eThis concern is also due to the fact that I don\u0026rsquo;t have any acquaintances in this place, I haven\u0026rsquo;t heard of this doctor, and I don\u0026rsquo;t know if I can rely on him or not. (P3)\u003c/p\u003e\u003cp\u003eAs these experiences relay, the privatisation of responsibilities in accessing healthcare appears to have transformed the way patients access healthcare. Due to the absence of primary care, patients independently choose their healthcare pathway, often leading to a disproportionate influx at tertiary hospitals. This scenario places substantial burdens on both patients and doctors, undermining their trust in the healthcare system.\u003c/p\u003e\u003cp\u003e\u003cem\u003ePrivatised Responsibility in Care Coordination\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe research revealed that both doctors and patients currently bear responsibilities in care coordination. This typically involves patient navigation within hospitals, assessing and updating care plans, managing referrals to appropriate hospitals, and coordinating post-treatment.\u003c/p\u003e\u003cp\u003eWith the absence of a structured referral system, responsibility for patient navigation has shifted to doctors. According to their accounts, they were tasked with the initial assessment of a patient\u0026rsquo;s condition and are responsible for making subsequent treatment decisions tailored to the patient\u0026rsquo;s actual situation.\u003c/p\u003e\u003cp\u003eThe patients come here on their own registration, so as a doctor, the first thing I have to do is to judge, whether he should have registered with me or not. I need a preliminary judgement. Then sometimes when I listen to his description and think, for example, he has (a symptom*), then I have to make a further judgement and may have to send him for some tests. After further examination, it may not belong to my side, then the patient needs to go to another department. (D11)\u003c/p\u003e\u003cp\u003eThis respondent\u0026rsquo;s subsequent narrative explains the tasks doctors undertake during the navigate process, which adds to their administrative load and require them to spend more time coordinating care for patients.\u003c/p\u003e\u003cp\u003eSome patients just come to the wrong place, registered wrong, so what to do, they are already here, I cannot directly let people go, I will need to explain, you came to the wrong place, I\u0026rsquo;m not here to see this disease, you go to another building, go to which department, you go to register that. Patients sometimes say to me, \u0026lsquo;Doctor, please give me a look, it\u0026rsquo;s not easy for me to come here, so I have to continue to explain that I can\u0026rsquo;t do it here, you have to go that department\u0026rsquo;. (D11)\u003c/p\u003e\u003cp\u003eDuring the process of responsibility privatisation, patients bear decision-making responsibilities and need to self-evaluate the potential impacts of their care plan.\u003c/p\u003e\u003cp\u003eThe doctor gave me two choices, it\u0026rsquo;s okay to treat it with him, but his treatment plan is to apply medication and treat it more conservatively. However, he also told me that I can go to (a hospital name*), where they can directly operate, and it will be faster. It\u0026rsquo;s my choice. I\u0026rsquo;m thinking about the hassle of referrals and the fact that I have to go through all these processes all over again, so I\u0026rsquo;ve been evaluating the pros and cons. (P14)\u003c/p\u003e\u003cp\u003eDuring the navigation and referral process, patients are responsible for tracking their own medical records, referrals, and any related documents to ensure continuity of care, thus bringing increased responsibilities for record-keeping and communication. Patients\u0026rsquo; experiences reveal that a healthcare system lacking in collaboration and referrals sometimes fails to effectively share this information, necessitating that patients themselves maintain it. This patient\u0026rsquo;s experience further reveals that moving between different medical institutions may also involve undergoing repeat tests.\u003c/p\u003e\u003cp\u003eI kept the receipts from each inspection. Records, diagnoses, all that. Because I might need them next time. If I get referred to another hospital, I may need another checkup, too, generally speaking, I\u0026rsquo;ll need to. Because they don\u0026rsquo;t share with each other. (P14)\u003c/p\u003e\u003cp\u003eFor patients, this situation also signified that they have taken on increased responsibilities in managing navigation and referral, needing to advocate more actively for themselves and seek information about the referral pathway.\u003c/p\u003e\u003cp\u003eWhat I\u0026rsquo;m thinking is that I must register and get into this hospital first and then figure out what to do. So, it might have been that the department that I got registered in wasn\u0026rsquo;t the right one to begin with, so I went through a series of referrals, these later on. The process is, you keep going around inside the hospital, just listening to the doctors, or just asking around on your own. (P13)\u003c/p\u003e\u003cp\u003eThe privatisation of assessment and care planning responsibilities leaves both doctors and patients feeling vulnerable, wishing to reduce the responsibilities they bear in doctor-patient interactions and hoping that the other party takes on more responsibilities. As one doctor summarised,\u003c/p\u003e\u003cp\u003eI will go ahead and follow the standard, the standard process of this treatment. But give advice to the patient, like, saying, where do you should go next. This is not good for me. You do not know what people will think. And there\u0026rsquo;s a lot of things that need to be explained, and sometimes it\u0026rsquo;s hard to explain, so, I\u0026rsquo;ll just, make and get the standard treatment good. (D9)\u003c/p\u003e\u003cp\u003eInterviews with patients confirmed the fact that some doctors were trying to lessen their responsibilities. One patient said that during her care plan making, the doctors consistently tried to minimize their own decision-making role, transferring the responsibility for decisions to the patient.\u003c/p\u003e\u003cp\u003eI did not know how long I should stay in the hospital, which made me very anxious. I went to ask the doctor, and he said, \u0026lsquo;depend on you\u0026rsquo;. Then I asked if I should do another CT scan to check the brain and he responded, \u0026lsquo;you can have it whenever you want\u0026rsquo;. I was really confused. I\u0026rsquo;m not a doctor; I don\u0026rsquo;t have medical knowledge. How can I be expected to make all these decisions? (P3)\u003c/p\u003e\u003cp\u003eThese extracts reveal the kinds of responsibilities doctors and patients are taking during care coordination, which include care planning, assessments, referrals, and follow-ups. Doctors now shoulder administrative tasks typically handled by primary referral systems, such as evaluating patient conditions and directing patients to suitable departments. Conversely, patients face privatised responsibilities that require them to make informed medical choices, actively seek information, advocate for themselves, and track their medical records and referrals to ensure continuous care.\u003c/p\u003e\u003cp\u003e\u003cem\u003ePrivatised Financing of Medical Cost\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe current healthcare system transferred the responsibility for medical costs to individual patients. Currently, although the release of Opinions on Deepening the Reform of the Medical Security System by the State Council in 2020 aimed to enhance people\u0026rsquo;s welfare [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], a significant portion of medical expenses still falls directly onto patients [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], creating for some a financial burden. This extract from one patient interview illustrates the personal cost associated with treatment.\u003c/p\u003e\u003cp\u003eHealth insurance didn\u0026rsquo;t cover much. Well, the first treatment cost was reimbursed, but I required several visits, the first one was fully covered, but after that, they only reimbursed about 100 yuan, in the following visits, the amount they covered became less and less. (P15)\u003c/p\u003e\u003cp\u003eThis patient indicated that complex reimbursement requirements are a major barrier to patients claiming their expenses. Partial reimbursements often failed due to complicated procedures, resulting in patients bearing the costs themselves. This patient added,\u003c/p\u003e\u003cp\u003eThese clauses are complex, sometimes I\u0026rsquo;m not sure if I can get reimbursement, maybe I\u0026rsquo;m lazy or busy, I\u0026rsquo;ll miss the time to get the money back. (P15)\u003c/p\u003e\u003cp\u003eIn some cases, patients must bear the full cost of medications and treatments which are not covered by health insurance, placing the financial burden directly on individuals. This situation poses significant barriers for those lacking financial resources, as they must find ways to fund their healthcare needs independently. A patient described his experience of paying out of pocket for an injection, showing the strain that medical costs put on him.\u003c/p\u003e\u003cp\u003eEach dose cost about 400 or maybe 500 yuan. I needed 6 doses every day, and it would be over 3,000 yuan. But I was running out of money. Sometimes, I could only get injection if I managed to borrow money in the morning. If I had money that day, I would come to the hospital to pay and then I could get the injection. Undergoing (a disease*) is really tough. You see in TV shows, someone said, \u0026lsquo;doctor, no matter how much it cost, I don\u0026rsquo;t care, I just want the patient to live.\u0026rsquo; That\u0026rsquo;s not true, reality is cruel. Many fellow patients genuinely cannot afford treatment and end up giving up. I have seen this very clearly. (P6)\u003c/p\u003e\u003cp\u003eThe privatisation of medical costs has undoubtedly placed financial pressure on patients. One patient who was hospitalized, expressed dissatisfaction with the medical expenses,\u003c/p\u003e\u003cp\u003eI was really anxious, as I lived in hospital for 7 days, money went by so fast for around two to three thousand RMB every day. (P3)\u003c/p\u003e\u003cp\u003eA doctor indicated that the privatisation of financial responsibilities was one of the main factors transforming the current doctor-patient relationship into a consumer-purchaser relationship. This shift turns the doctor-patient interaction into a transactional relationship, leading patients to view treatment outcomes as purchasable goods, without considering the many uncontrollable factors that can affect these outcomes.\u003c/p\u003e\u003cp\u003eIf the patient thinks, I\u0026rsquo;m the one who paid a lot of money to come to the doctor, I\u0026rsquo;m the one who came to buy your services, I spent money, I spent so much money, I should get better. (D2)\u003c/p\u003e\u003cp\u003ePrivatised responsibility also puts doctors in a difficult position, caught between patients\u0026rsquo; financial constraints and the hospital\u0026rsquo;s fiscal pressures. Interviews with doctors revealed their awareness of the issue as a societal problem, which is challenging to address at the interpersonal level. Confronted with their patients\u0026rsquo; financial hardships, this doctor felt \u0026lsquo;helpless\u0026rsquo; because, he was unable to make decision for the patients, nor could he compensate for the deficiencies in the healthcare system.\u003c/p\u003e\u003cp\u003eThis is a deeper social problem, I know some patients fall into financial hardship, they even sell all of their properties, even if the disease is cured, how can they live then if they have nothing. But for me, a doctor, shall I ask them not to treat, or I should say nothing but respect their choice, I do not know which one is good, I\u0026rsquo;m just doing what a doctor could do. (D6)\u003c/p\u003e\u003cp\u003eThe dilemma doctors now face is entirely the construction of an ideologically driven policy. The explicit aim of the state\u0026rsquo;s retreat from public hospitals was to enhance service efficiency, enabling hospitals to be self-sustaining and financial independent from state funding. In line with this objective, the burden of generating additional income for hospitals has shifted to doctors. The extract below emphasizes that medical marketisation has not disappeared but has been further consolidated and, indeed, has gradually intensified the competitive environment, placing additional pressure on doctors.\u003c/p\u003e\u003cp\u003eThe problem with hospitals is that they still aim to be profitable, as there\u0026rsquo;s no motivation without profit. In recent years, X hospital has suffered significant losses, unable to pay salaries to its staff. Therefore, it (the hospital*) requires us (the doctors*) to find ways to generate revenue and increase profits. They set performance indicators, and, if doctors don\u0026rsquo;t meet the standard, it\u0026rsquo;s up to hospital to figure out a solution. (D2)\u003c/p\u003e\u003cp\u003eThe privatisation of responsibility for medical costs presents challenges for doctors within the healthcare system. One doctor mentioned that he was trying to share these responsibilities with patients. This doctor stated that he tried to understand the patient\u0026rsquo;s financial situation and, when prescribing, he tended to prescribe medications that were covered by health insurance.\u003c/p\u003e\u003cp\u003eThis one involves the experience of the doctor. It\u0026rsquo;s not necessary, it\u0026rsquo;s extra, but then, it\u0026rsquo;s something to keep an eye on. That is, when I give a prescription, I ask the patient about his financial situation, and then I try to cover it in the reimbursement area, but this is not guaranteed. Of course, it depends on the actual situation. (D11)\u003c/p\u003e\u003cp\u003eThe marketised healthcare system shifts part of the financial responsibilities to individuals. Patients\u0026rsquo; ability to afford these costs now directly influences their access to necessary medications and restricts their equal opportunities to receive adequate medical care.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eIn a healthcare market characterised by an unequal distribution of resources, a weak referral system, and rising out-of-pocket expenses, three responsibilities, which include accessing healthcare, coordinating care, and managing financial costs, have been privatised for doctors and patients. Our research clarifies the content and influence of each responsibility.\u003c/p\u003e\u003cp\u003eWith access to healthcare now privatised, patients have the freedom to select any hospital or doctor, granting them choice but also placing full responsibility for hospital selection and treatment upon them. In a competitive healthcare market, the highest-tier providers in the healthcare system, already benefit from superior resources, reputation, and the capability to handle complex medical cases. These advantages grant them a competitive edge in the market. Concurrently, as a result of marketisation, patient preferences\u0026mdash;driven by perceptions of higher-quality care, advanced technology, and skilled professionals\u0026mdash;further reinforce their dominance and lead to market-induced healthcare centralization [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Our research confirmed that patients still prefer visiting large hospitals, citing greater reliability as a key factor [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Lacking the expertise to accurately diagnose their conditions, many patients opt for tertiary hospitals as their first choice because these hospitals are generally considered to have the best medical resources. This preference often results in overcrowding in tertiary hospitals. Facing the increased patients, doctors are forced to reduce consultation time with each patient, leading to insufficient doctor-patient communication. Patients face increased waiting times and frustration, while doctors feel burnt out due to heavy work pressure; both sets of factors previously identified as negatively affecting doctor-patient relationships [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR38 CR39\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAt the same time, this study found that the uneven distribution of medical resources compels patients seeking higher-quality care to personally assume additional responsibilities. It revealed that the privatisation of registration responsibilities has increased inequities in access to healthcare, for example, by creating the practice of \u0026lsquo;yi di jiu yi\u0026rsquo; (seeking medical treatment away from a patients\u0026rsquo; usual location) with its lack of local and familiar medical resources and the need for patients to independently determine which hospital and doctor are most appropriate for their condition. This reflects underlying differences in insurance coverage, financial burdens, administrative barriers, and regional disparities in healthcare quality [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePrivatised responsibility in accessing healthcare drives the phenomenon of \u0026lsquo;relation-based care\u0026rsquo;. Individuals and families with significant social resources and personal connections, often find it easier to access quality medical services compared to those with fewer resources, who may struggle to receive adequate care [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This phenomenon can be understood from two perspectives: firstly, the shift from a nationalized to a marketised healthcare system has transformed doctors into \u0026lsquo;commodities\u0026rsquo; within the healthcare market. From a patient\u0026rsquo;s perspective, a doctor\u0026rsquo;s skills are seen as valuable resources. Experienced doctors, therefore, become scarce commodities over which patients compete [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Secondly, patients\u0026rsquo; attempt to build personal relationships with doctors through financial incentives, hoping to secure superior care. This approach seeks to convert monetary gifts into preferential treatment, blending economic transactions with doctor-patient relationships [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. For doctors, accepting gifts poses risks of violating professional and legal standards, complicating their professional responsibilities, eroding patient\u0026rsquo;s trust, and challenging the fairness of the healthcare system [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe weak hierarchical system has transferred many administrative duties traditionally managed by referral systems onto both doctors and patients [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], thus privatising medical coordination responsibilities. For doctors, the privatisation of coordination, navigation and referral responsibilities requires additional time for communication, providing emotional support to patients, documentation, and follow-ups. These additional duties often compete with doctors\u0026rsquo; clinical responsibilities and increase their workloads. For patients, privatised responsibilities in coordination and decision-making for follow-up healthcare management are limited by their health literacy [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Patients with limited understanding of medical terms and healthcare procedures are disadvantaged as they may receive suboptimal care or fail to complete treatment plans.\u003c/p\u003e\u003cp\u003eIn a system characterized by privatised responsibilities, both doctors and patients experience both pressure and vulnerability in these roles, leading to a desire for the other party to take on more decision-making responsibility. Doctors often shift responsibilities to avoid the high pressures of their roles and the potential for medical complaints, which can stem from misunderstandings or dissatisfaction with care outcomes. Patients often struggle because they lack the necessary knowledge to comprehend fully their care plans, navigate complex referral systems, or effectively advocate for themselves within the healthcare system. This lack of understanding can lead to frustration and dissatisfaction, potentially escalating into conflicts [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Consequently, both doctors and patients often feel unsupported by the healthcare system, which can erode trust and satisfaction on both sides of the doctor-patient relationship [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe current payment system has shifted healthcare financing responsibilities towards privatisation. Despite reports that 95% of the population was covered by National Medical Insurance by 2020 [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], substantial challenges persist due to limited reimbursement rates and the narrow scope of the services covered. Personal or family income levels directly influence the ability to afford care. Income levels dictate the quality and timeliness of medical treatment available, leading to inequalities in healthcare utilization. Those with higher incomes can afford better and more immediate care, while those with lower incomes often experience restricted access and increased financial stress.\u003c/p\u003e\u003cp\u003eChina\u0026rsquo;s marketised healthcare system also encourages hospitals to chase profit, and doctors are tasked to generate profits for hospitals which not only transforms doctor-patient relationships into transactional interactions but also commodifies treatment outcomes. This leads patients to approach healthcare services with consumerist expectations\u0026mdash;demanding choices, immediate access, transparency, and measurable results, conflict with traditional doctor-patient trust [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Moreover, this privatisation of responsibilities also requires doctors within the current healthcare system to balance hospital profitability with patient financial burdens, which is likely to affect decision making and strain doctor-patient relationships: while patients naturally seek to minimize their healthcare expenditures, doctors are compelled to focus on profitability to sustain their practices and support their hospitals. As previous research has shown, economic pressures and moral dilemmas contribute to ethical burden on doctors [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eInstitutional norms shape the distribution of responsibilities of both doctors and patients in healthcare. This research proposes a theoretical framework for understanding the impact of marketisation on these responsibilities, extending research on the effects of healthcare marketisation on doctor-patient relationships. Through the concept of \u0026lsquo;privatised responsibilities\u0026rsquo;, which encompassing access to care, care coordination, and healthcare financing, this research suggests that market principles in health systems exert undue pressure on both doctors and patients. Policymakers should reconsider the use of market-driven approaches to addressing problems related to the unequal distribution of healthcare resources, weak referral systems, and limited medical insurance reimbursements. The conceptualisation and findings presented here offer a foundation for future research on the broader impact of healthcare marketisation.\u003c/p\u003e"},{"header":"Limitation","content":"\u003cp\u003eAlthough our research examines the marketisation in healthcare reshapes doctor-patient responsibilities and highlights its potential negative impacts, offering a comprehensive alternative prescription lies beyond its scope. Nonetheless, the pilot nature of the research and findings is readily acknowledged. Future research should engage with larger more representative populations and consider focusing on the responsibilities and challenges faced by patients with specific diseases within the healthcare system. Furthermore, all fieldwork interviews were conducted in Chinese, and although the researcher made efforts to translate responses into English accurately, some nuances of participants\u0026rsquo; experiences may have been inadvertently overlooked during the translation process.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eEthics approval and consent to participate\u003c/h3\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval for this study was granted by the University of Sheffield Research Ethics and Integrity (Version 8.3 \u0026ndash; October 2024; Reference Number: 043134). All participants provided informed consent.\u003c/p\u003e\n\u003ch3\u003eConsent for publication\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eInformed consent was obtained from all participants for this study.\u003c/p\u003e\n\u003ch3\u003eAvailability of data and materials\u003c/h3\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to the potential risk of identifying participants from interview content, but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eThe authors declare that the authors have no conflict of interests.\u003c/p\u003e\n\u003ch3\u003eFunding details\u003c/h3\u003e\n\u003cp\u003eThe authors have not received any financial support or funding from external organizations for this research.\u003c/p\u003e\n\u003ch3\u003eAuthors\u0026rsquo; contributions\u003c/h3\u003e\n\u003cp\u003eDr. Haoyang Liu conceptualised and designed the study, obtained ethical approval, and conducted the semi-structured interviews. She also transcribed the data, carried out the analysis, and drafted the manuscript. Prof. Alan Walker supervised the research process, provided detailed revisions, and contributed to enhancing the overall quality of the study. Both authors contributed to the research and approved the final manuscript.\u003c/p\u003e\n\u003ch3\u003eAcknowledgments\u003c/h3\u003e\n\u003cp\u003eWe are grateful to all the participants in this study, and to Prof Paul Martin for his help with the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWu Y (2008) The evolution of government functions in my country\u0026rsquo;s medical and health sector: a review and a prospect. China Health Policy Res 1:27\u0026ndash;31.\u003c/li\u003e\n\u003cli\u003eYao Z (2017) The privatization of medical service responsibilities and the deterioration of the doctor-patient relationship since the reform and opening up. 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Left Coast Press, Walnut Creek, CA.\u003c/li\u003e\n\u003cli\u003eBurgess H, Jongbloed K, Vorobyova A, Grieve S, Lyndon S, Wesseling T, Salters K, Hogg RS, Parashar S, Pearce ME (2021) The \u0026ldquo;sticky notes\u0026rdquo; method: adapting interpretive description methodology for team-based qualitative analysis in community-based participatory research. Qual Health Res 31:1335\u0026ndash;1344.\u003c/li\u003e\n\u003cli\u003eMcKenna L (2022) Translation of research interviews: Do we have a problem with qualitative rigor? Nurse Author Ed 32:1\u0026ndash;3.\u003c/li\u003e\n\u003cli\u003eThe State Council of the People\u0026rsquo;s Republic of China (2024) Cross-provincial medical treatment, easy online filing! (Detailed operation instructions included) The meaning of yidijiuyi. In: State Counc. Peoples Repub. China. https://www.gov.cn/fuwu/2023-02/10/content_5741028.htm. 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Chronic Illn 18:234\u0026ndash;254.\u003c/li\u003e\n\u003cli\u003eKelly J, Al-Rawi Y (2021) Recognising, understanding and managing high conflict behaviours in healthcare. Postgrad Med J 97:123\u0026ndash;124.\u003c/li\u003e\n\u003cli\u003eXinhua News Agency (2023) National Medical Insurance Administration: basic medical insurance participation rate has stabilized at around 95%. In: Gov. Website Peoples Repub. China. https://www.gov.cn/lianbo/bumen/202305/content_6874798.htm. Accessed 6 Jan 2024.\u003c/li\u003e\n\u003cli\u003eEmanuel EJ, Pearson SD (2012) Physician autonomy and health care reform. JAMA 307:367\u0026ndash;368.\u003c/li\u003e\n\u003cli\u003eShanafelt TD, Noseworthy JH (2017) Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc 92:129\u0026ndash;146.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Healthcare, Marketisation, Privatisation, Doctor-patient responsibilities, China","lastPublishedDoi":"10.21203/rs.3.rs-6371752/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6371752/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eAs a result of systemic reforms China\u0026rsquo;s healthcare system is now an uneasy mixture of state control and market mechanisms. Marketisation has not only reshaped healthcare delivery but has also fundamentally shifted the responsibilities of doctors and patients within the system. This paper reveals the increasing responsibilities borne by individual doctors and patients because of this trending.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis qualitative study involved thematic analysis of semi-structured interviews with 28 doctors and patients from various provinces in China. Participants were selected to represent diverse experiences within the health system. Thematic analysis was conducted to identify and interpret key patterns within the data.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThree main dimensions of privatisation emerged from the analysis: accessing healthcare, care coordination, and healthcare financing. Findings indicate that marketisation has significantly increased the responsibilities placed on individual doctors and patients, effectively transferring systemic burdens to these individuals. Doctors face intensified pressures to manage care within fragmented health services, while patients confront greater personal responsibility in navigating access to care, coordinating their treatments, and handling healthcare expenses. These shifts exacerbate existing inequalities and complicate doctor-patient interactions.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe marketisation of healthcare responsibilities places significant burdens on both doctors and patients, transferring systemic responsibilities to individuals in access to healthcare. The concept of \u0026lsquo;privatised responsibilities\u0026rsquo; offers a useful theoretical framework for further investigation of healthcare marketisation and its broader social implications. Based on these insights, we make policy recommendations aimed at defining more clearly the government\u0026rsquo;s role in ensuring equitable and accessible healthcare.\u003c/p\u003e","manuscriptTitle":"Marketisation in China’s Health System: A Thematic Exploration of Impacts on Doctor-Patient Relationships","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-10 07:07:05","doi":"10.21203/rs.3.rs-6371752/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-05T06:06:53+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-23T16:54:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"28345279710552107886172839721300802595","date":"2025-07-10T14:10:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-08T07:05:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-19T01:01:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal for Equity in Health","date":"2025-05-14T02:07:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"33790971-5ff8-47e9-a349-d2f5e2100e50","owner":[],"postedDate":"July 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-17T16:03:11+00:00","versionOfRecord":{"articleIdentity":"rs-6371752","link":"https://doi.org/10.1186/s12939-025-02690-1","journal":{"identity":"international-journal-for-equity-in-health","isVorOnly":false,"title":"International Journal for Equity in Health"},"publishedOn":"2025-11-13 15:58:27","publishedOnDateReadable":"November 13th, 2025"},"versionCreatedAt":"2025-07-10 07:07:05","video":"","vorDoi":"10.1186/s12939-025-02690-1","vorDoiUrl":"https://doi.org/10.1186/s12939-025-02690-1","workflowStages":[]},"version":"v1","identity":"rs-6371752","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6371752","identity":"rs-6371752","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}