On Friday in Harbin, capital Heilongjiang province, a young man with tuberculosis and a bad back entered the No 1 Hospital attached to the Harbin Medical University.

It was 4 pm and the doctors were at their desks doing paper work when the man rushed into their room and attacked them with a knife.

Wang Hao, a 28-year-old medical intern, was killed and three doctors were seriously injured. A man surnamed Li, 17, was arrested. Although the incident is still being investigated, Li confessed that he was unhappy with the treatment he had received at the hospital.

Li made repeated visits to the hospital before he was diagnosed with tuberculosis and a chronic form of arthritis that mainly affects the lower back. He was then told that he would need to get treatment at a specialist tuberculosis clinic before the hospital would treat his back.

He left the hospital in a rage, only to return wielding a knife, attacking people at random.

Violence in China hospitals may appear to be senseless and unpredictable affairs, but it may be the result of institutional factors that lead to an erosion of trust in doctors.

Workplace violence in hospitals also happens in other countries. In Britain, about one-third of medical personnel are subject to verbal abuse or physical violence every year. In Thailand, the World Health Organization estimates the rate to be 54 percent. However, in August 2010, an editorial in the British medical journal The Lancet highlighted the extraordinary fact that health workers in China, including doctors and nurses, are commonly subjected to violence from patients and their relatives.

According to a recent official source, in 2010, there were over 17,000 violent incidents in Chinese hospitals and there were violent incidents in more than 70 percent of public hospitals in China. And even more worrying than the high rate of violent incidents is the fact the number is on the rise.

In public reports on cases involving violence in Chinese hospitals, almost every incident has been associated with medical malpractice disputes. In other words, patients resort to violence when they feel there is no proper mechanism to resolve malpractice disputes.

In many other countries, tort law, arbitration and mediation are the most common mechanisms to resolve medical malpractice disputes and determine the liability of the hospital, physicians and patients. In China, these mechanisms are not very effective due to poor institutional design.

This is because in China these mechanisms depend on authentication committees, which decide whether there has been a medical mistake or negligence. However, in many cases, the members of an authentication committee are selected from local doctors and remain anonymous to patients. At the same time, most Chinese hospitals are public hospitals managed by the local health bureau; as a result, the decision-making process is not perceived to be independent and credible.

Further, without a creditable malpractice system, hospitals have no incentive to buy malpractice insurance, which is widely used in the United States as an important mechanism to compensate patients.

A new initiative, people's mediation, was introduced recently to try and address some of these shortcomings in many places of China. Consisting of retired medical and legal professionals, people's mediation, which reports to the local justice bureaus, offers a low-cost, quick mediation service independent of local health bureaus.

According to recent official reports, people's mediation has been used for more than 14,000 medical malpractice disputes from January to October 2011; the success rate is reported to be more than 80 percent. The success of the reform shows that institutional design matters in dispute resolution, especially when it comes to emotional matters such as sickness and health.

People's mediation works because it is accessible and benefits from the people's trust in the increased transparency and independence. However, the decisions of people's mediation are not legally binding if either party is dissatisfied with the decision, and people's mediation is perceived to have insufficient authority over doctors to reduce negligence.

Hence there is need for further reform, and perhaps to take a step back. For example, given the limitations of people's mediation, a longer-term solution to reduce violence in hospitals would be to revert to a modified version of the old system, by improving the selection and operating process of the authentication committees, whose decisions were legally binding. This would help deter negligence and improve the quality of service provided by public hospitals. Also, it would provide hospitals with the incentive to buy insurance.

In times of sickness and emotional instability, perceptions are a critical determinant of behavior, and patients' perceptions that they are not being cared for properly can result in violence. It is important, therefore, that rational institutional design plays a part in providing incentives for cool-headed, peaceful resolutions to disputes.

Qian Jiwei is a research associate at the East Asian Institute and Leong Ching a researcher at the Lee Kuan Yew School of Public Policy, both at the National University of Singapore.

(China Daily 03/29/2012 page9)