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China's hospitals business is littered with the remnants of abandoned private and foreign ventures, evidence of the challenges of getting a foothold in a health care system dominated by a socialist past. However, times are changing. In December, China's State Council confirmed that it foresees investors playing a much bigger role in heath care in the country now that 100% non-Chinese ownership of hospitals and other health services is allowed. It's good news for the most part, according to Roberta Lipson, co-founder of Chindex International, a supplier of US medical equipment in China. "It confirms that the Chinese government will support private investors with preferential policies or even the playing field with public hospitals," she says.

Up until now, the record for foreign ventures in China's health care sector has been discouraging, says Sheldon Dorenfest, president and CEO of the Dorenfest China Health care Group, a Chicago-based consultancy set up in 2006. Dorenfest, who has worked directly with a dozen Chinese hospitals and has visited 100 hospitals in 17 cities for a number of years, has never been an investor himself. "If I had invested, I would have been pouring money down the drain," he says. "There are many foreigners who did invest in private or foreign ventures, and many 'dead bodies.'"

For sure, even now, hurdles remain, not least because of onerous red tape, difficulties recruiting medical staff, and the huge advantages public institutions have over private rivals in terms of resources and political influence, not to mention greater public acceptance. A good example among many of the struggles that foreign health care firms have faced in China, Dorenfest says, is the defunct Beijing International Heart Hospital (BIHH), which in his words is "a tale of just about everything gone wrong." Eight doctors from the Arizona Heart Institute and six other US doctors and foreign investors teamed up with Tai He Corporation, a private Chinese real estate developer, to set up a 60-bed joint venture hospital in Beijing in 2002. The project obtained free land use rights but ran into problems in dealing with various Chinese government constituencies, whose help it needed to get up and running.

"By the time it could get off the ground, its license had expired," says a senior manager of a health care consultancy familiar with the project. "The foreigners involved [in that project] are great examples of what not to do. They oversimplified how things work in China, invested too little and then ran out of money. They raised some more money but it was not enough. The license expired and had to be renewed. When push came to shove, the project took too long and its investors deserted them." By 2006, the hospital project was no longer.

What's worrying experts is that BIHH is far from unique, and many investors continue to face many of the same challenges it did. Peter Liu, president of the Non-Public Medical Institution Association in Beijing who is currently working with American-backed investors on a joint venture hospital project, says, "Our team has been waiting for five or six years to open our foreign joint venture hospital and we still do not know when we can open."

'A Few Words of Encouragement'

Nonetheless, the government's US$125 billion health care reform launched in 2009 is making progress. Now, an increasing number of Chinese -- mostly people working for private or state-owned companies -- are eligible for Urban Employees Basic Medical Insurance, China's best established and most comprehensive health insurance plan, and schemes have been set up for both rural and urban low-income earners. The result: The number of China's 1.3 billion citizens who are covered by public insurance has increased to 90% from 45% in 2006.

But while the depth, scope and amount of medical expenses reimbursed is rising, the costs are still high for most Chinese. As annual per capita health care spending has been increasing year on year, reaching a forecasted US$186 (RMB 1,219) in 2010 from US$143, according to Business Monitor International, about 40% of all medical bills are premiums and out-of-pocket payments. What's more, the cost of an average outpatient hospital visit in 2007 cost RMB 136, which rose to RMB 160 in 2009, according to the China Health Statistical Yearbook.

Currently, the foreign presence in the sector is small. Of the country's 20,291 hospitals, only around 4,200 (or 6.5% of all hospital beds) are in private Chinese hands, and just a dozen or so are foreign joint ventures, according to an estimate by McKinsey. And now, of the wholly foreign-owned hospital proposals, priority is being given to Hong Kong, Taiwan and Macao investors, says Jin Wang, a partner and China health care specialist at McKinsey in Shanghai.

But all such changes are in the pilot stage. "So far, I have not heard of any approval of a 100% foreign-owned hospital," says Liu, who has been involved in hospital management in both China and the US for more than 20 years. "This is typical of the Chinese government. They give a few words of encouragement and test the water to see how people react, and the market responds before they assess and determine further actions." As he sees it, the reforms are far from the revolutionary measures that health care experts had hoped for when they were first announced.

And the approval process is still time consuming and involves plenty of red tape, despite the fact that investors now only need to seek approval for hospital ventures at the provincial level, rather than central government approval as well. "To open and build a hospital, you probably need at least 180 'chops' [or stamps of approval] from different government agencies," says Lipson of Chindex. A pioneer in the industry, Lipson opened the first foreign hospital joint venture in China in 1993, called United Family Hospitals. The chain today includes two full-service outpatient and inpatient hospitals in Beijing and Shanghai and clinics in Guangzhou and Wuxi, and employs 160 full-time physicians, 100 of whom are foreign.

Doctor, Doctor

Assuming a foreign firm gets beyond the bureaucratic labyrinth, plenty of other challenges remain. That includes doctors -- McKinsey estimates that there are currently 2.3 million doctors in China today. One reason for the shortage is that that doctors are generally not allowed to practice at more than one hospital. Pilot programs -- for example, in Kunming and Guangdong provinces -- to change that have been underway since last year, and some local health bureaus are taking applications for doctors to practice in multiple locations. "If you cannot get good doctors, how can you get more people to go to private hospitals?" says Liu.

Claudia Sussmuth Dyckerhoff, McKinsey's Shanghai director, agrees. "Any doctor who wants career advancement would rather stay with a public, class 3 hospital, where he or she can be more specialized, get good experience and have a bigger case load," she says, referring to the three-tier classification system in China, with class 3 being the largest of the hospitals in terms of beds (500 or more) and doctors, and rated the highest in terms of quality.

It is an open secret that many doctors already moonlight at other medical institutions, but that hasn't helped private hospitals much. Many doctors are reluctant to shift to the private sector because their professional rankings can only be enhanced by their performance at the public hospitals.

Apart from the human resource issues, private hospitals also face a huge financial handicap as a result of being ineligible for social medical insurance as the public institutions are. "If all your patients have to pay out of their own pockets or need to have private insurance, it would have a negative affect on the overall inflow of patients," points out Sussmuth Dyckerhoff.

Private hospitals, including foreign joint ventures, are now allowed to participate in the social insurance scheme, but details, including treatment fees, are unclear and are likely to be approved on a case-by-case basis by local heath bureaus. At any rate, social health insurance reimbursements tend to be extremely low, so patients still often need to take out private insurance in order to afford the services offered at foreign joint venture hospitals, which are pricier than their public counterparts.

Public medical facilities have another advantage: They are supported by many subsidies and capital injections from the government. They also are tax exempt. Given the lack of subsidies and preferential treatment, most non-public hospitals are small. A recent report by PricewaterhouseCoopers (PwC) notes that joint venture hospitals in the country tend to have less than 50 beds, restricting their economies of scale, often leaving them without the capacity to meet the increasing health care needs of the growing affluent Chinese populations.

Capital Injections

Perhaps most important of all is the public's trust that private hospitals must win. According to an online survey in December last year by the Communist Party newspaper People's Daily, 63% of the 3,174 respondents preferred public rather than private hospitals. About 25% said they believe private facilities lack professional medial standards and ethics, and some 23% said rampant misleading advertising has made them wary of private hospitals, while nearly the same amount cited the lack of insurance coverage as the reason why private hospitals are less attractive than public ones.

Dorenfest notes that it is indeed a concern that private-hospital investors often lack medical expertise, and some are building hospitals for the sole purpose of being able to stake a claim to a piece of real estate.

According to Dorenfest, the greatest promise for private players is in niche markets, such as dental clinics, obstetrics and gynecology hospitals, eye hospitals and cosmetic surgery. Many private firms are also focusing on building their brands as superior service providers, offering access to cutting-edge medical equipment and star doctors to patients able to pay extra. It's a niche that is proving particularly popular among expatriates and overseas Chinese who are put off by the long waiting times of public hospitals. Facilities catering to high-end clientele include Beijing United and Singapore-based ParkwayHealth Group. Affluent Chinese account for about 40% of Beijing United's clients, Lipson says. The same is true for ParkawayHealth China, which moved to China in 2005 after acquiring a foreign joint venture clinic called World Link. It now has expanded to seven foreign joint venture clinics in Shanghai and one in Chengdu.

While facilities like Beijing United and ParkwayHealth have found a niche market, they've had limited success in providing more than outpatient and restricted inpatient services, according to a report titled, "Emerging Trends in Chinese Health care," by PricewaterhouseCoopers (PwC). Rates at the expatriate-focused hospitals are much higher than in the US and "their model is focused on catering to expats with offshore insurance, and the expats with offshore insurance do not care what the rates are," says David E. Wood, Beijing-based managing director of PwC China. Wood, who has been a hospital management and health care consultant in the US and China for more than 30 years, says the providers have to keep rates high in order to be able to afford the physicians they hire from abroad.

Wood says his market research has found that in order to attract more of China's burgeoning middle class rates, fees need to be no greater than five or seven times what Chinese public hospitals charge, rather than the 35 times expat-oriented facilities currently charge, he says. "If you charge that much, you cannot attract middle class Chinese patients," according to Wood, who was CEO of Beijing United from 2000 to 2003. "If you want to have a hospital for millionaire Chinese and expats, forget it. It does not work. You have to be focused on the growing middle class Chinese. Meet their needs and meet their expectations, and you will be successful. They are a large and growing segment of the population."

Wood cites his experience as CEO of New Century International Children's Hospital in Beijing, which was founded in 2005 as a private joint venture between local Chinese investors and Beijing Children's Hospital. "Our pricing model was five to seven times the public hospital rates. We had all Chinese medical staff and all Chinese hospital staff. That is the model for China," he says. The hospital was profitable within 13 months of opening, attracting both local Chinese and expats. It had 100 beds with a high level of occupancy, according to Wood.

One current foreign joint venture targeting middle-class patients is being led by Thomas Frist, founder of the US hospital chain HCA, and Charles A. Elcan, his son-in-law. With private investment, not connected with HCA, they began building a first-class hospital in Ningbo, south of Shanghai, last summer to serve Chinese socially insured patients, with some beds set aside for private patients.

Other investors in China's hospital sector are biding their time. "It is still too early. I have not found the right business opportunity to invest in," says Dorenfest. "I can see that in the next two to three years, there is a good possibility that those opportunities will emerge."