From Barefoot Doctors to Healthcare in the Cloud: Telemedicine Opportunities in China – Part 1

Not only is China’s healthcare sector growing at an above average rate, the Chinese central government recently pushed Telemedicine, publishing “The Telemedicine Opinions”. This set of visionary notices identifies Telemedicine as “essential” to China’s healthcare system and sets a framework for its implementation, mainly aiming to stimulate private initiatives in this field. Opportunities for foreign healthcare to provide telemedicine services in China are not far to be found.

By Zhen Nie and Eline Van den Mooter – This is the first blog of a series that will elaborate on “The Opinions” published by the Chinese government, and current applications of Telemedicine in China.

Back in time…

Before 1980, basic and primary healthcare were part of the so-called “Iron Rice bowl” – a series of publicly provided services. “Barefoot doctors” were commonly used for the first point of diagnosis and care. These caretakers had very basic training, especially in the field of nursing and midwifing, but were crucial in the Chinese healthcare system.

As of 1980, China started opening up to the West and introduced several reforms, also in the healthcare system. This resulted in the end of the Barefoot Doctors.

However, the Chinese Central Government didn’t only not provide an alternative solution, it dramatically under-invested in its primary care system during the decades that followed.


Only 30 years later, consequences have arisen and revealed an impaired healthcare system.

China has been left with chaotic patient data, underfunded rural health centers, a nationwide shortage of doctors, and a distrust of patients towards their doctors.

Despite all this, the main problem is related to patients’ behavior in accessing healthcare, more specifically, when and where: they seek medical help long after they should have and they turn to the biggest public hospitals in Tier III cities… Leaving the government with an outlook of massive investments in urban hospital capacity and the risk of immense reimbursements due to an explosion in the level of activities in public hospitals.

Time for re-education. Behavioral changes in patient’s healthcare access have become a priority for the Chinese central government. Four areas of behavioral change have been identified to remove pressure from the overburdened public hospitals:

  • Relocate initial diagnosis
  • Reduce time-to-diagnosis and time-to-therapy
  • Limit the time of long-term chronic diseases monitoring
  • Facilitate the purchasing of medicine at local pharmacies

Telemedicine has the potential to induce this behavioral change as it offers a first point of access to diagnosis, care and follow up outside of the hospital walls.

It goes without saying that Telemedicine cannot be the ultimate solution to the Chinese healthcare system. However, it can create some breathing room deferring patients whose care can be easily delivered outside the public hospital system. On an equally important note, it allows patients from remote rural areas to access high quality healthcare.

The Telemedicine Opinions

On August 29th 2014, the National Health and Family Planning Commission of the People’s Republic of China (NHFPC) published an official guideline, also commonly referred to as “the Telemedicine Opinions”.

“The Opinions” consist of a set of interpretations and associated guidelines regarding telemedicine and online sales of pharmaceuticals, primarily aimed at institution-to-institution telemedicine arrangements.

Only five months later, the NHFPC issued a second document: a more technical (and visionary) blueprint addressing the creation of a connected healthcare network in China to offer remote healthcare access to patients and allow medical institutes to interconnect.

Although the actual implementation of these guidelines remain in some cases unclear, “The Opinions” state the clear intention of the Chinese central government to pave a path for a Healthcare system in which Telemedicine is an essential building block. With this official notice, the Chinese central government aims to stimulate and support private investors to take initiatives in the field of Telemedicine in China. It is not the intention of the Chinese authorities to actively initiate plans or investments themselves.

“The Opinions” also try to define Telemedicine and under that definition, it includes:

  • remote laboratory diagnosis
  • remote in vivo diagnostics and imaging testing (including imaging, ultrasound, nuclear medicine, electrocardiograms, electromyography and electroencephalograms, etc.)
  • remote patient monitoring
  • remote outpatient services
  • remote case discussions
  • administrative services

Note that internet based consultation and education, as well as remote surgery are not included in the definition.

As mentioned above, “The Opinions” also foresee the construction of a uniform national telemedicine service network to enable large medical institutions and medical practitioners to interconnect and extend their services to regional and rural healthcare platforms.
The Opinions therefore include:

  • the supervision and administration system for telemedicine services
  • a list of recommended configurations for remote diagnostic systems
    • remote imaging consultation systems,
    • remote ECG consultation systems,
    • remote pathology consultation systems,
    • remote operation room guidance systems,
    • remote ICU systems,
    • Data sharing and exchange platforms.
  • protection of patient privacy and data security

Online consultation for example, is not included in the definition of Telemedicine as such, but through the above principles, “The Opinions” do give some general guidance, especially with regard to the protection of patient privacy and data security.

It mentions that if a care provider wants to provide online consultation to a patient not registered at the former’s medical institute, two conditions must be met. Firstly, the medical institution needs to give its prior written consent, and secondly the consultation needs to be executed through the IT-platform of the institute.

This guideline is actually a good example of the fact that the implementation of “The Opinions” is sometimes both as unclear as they are impractical.

Important for foreign healthcare providers is the section on “Regulatory Compliance expectations”. “The Opinions” state that “medical institutions” must strictly comply with Chinese laws, regulations, information standards and technical practices. The aim is to ensure the quality and safety of medical services and protect the legal interest of patients.

Although the term “medical institutions” might imply a focus on domestic healthcare providers, the NHFPC does realize their increasingly important role in the Chinese healthcare system.

This can be derived from one of the last sentences in “The Opinions”, stating that for Telemedicine services performed between medical institutions within and outside of China, “The Opinions” are applicable as well.

An important side mark is that the “Tentative Measures regulation” (2000) is still applicable as well, stating that cooperation with foreign medical institutes regarding any diagnostics of any form are subject to authority approval.

“The Opinions” clearly outline that non-medical institutions are not authorized to deliver Telemedicine services. This restriction might become a roadblock in addressing the aging problem with telemedicine, as senior care facilities are often non-medical institutions.

The NHFPC recognizes this problem and has already identified five non-medical institutions in Beijing, Hubei and Guangdong to use Telemedicine in their senior care services (Notice of Pilot Programs for Using Telemedicine in Elder Care Institutions).


Back to the future

Necessity and limitations of the current Healthcare system inspired the Chinese government to take measures and lay the foundation of an entirely innovated healthcare system.

Although the implementation of “The Telemedicine Opinions” are still in some cases neither clear nor practical, it will be also thanks to these uniform, national guidelines, in combination with the size and growth of the Chinese healthcare system, that this market gains the potential to become one of the largest Telemedicine markets in the world.

From TforG’s discussion with China care providers, we can conclude that various Telemedicine initiatives have been launched and implemented, but currently still more on a case by case basis. We will discuss some of these applications in the second article of this series on Chinese Telemedicine.

The good news is that there is still a large pool of opportunities to be explored… European and American Telemedicine technology and service providers interested in expanding in China should not be hesitant and try to identify potential domestic partners.

About Zhen Nie

Zhen is in charge of Asian Operations at TforG, with more than 6 years of experience in project management and business consulting for local and international companies. She works in a continuous basis with an extensive network of Key Opinion Leaders and Health Policy makers in Asian markets. She graduated at the University of Antwerp and has a Master Degree in Finance. Tel: +32 3 201 64 24 Mobile: +32 485 89 98 84 Email: