Health workers earned the same salary throughout China during the period of the command economy. Differences in earnings have grown substantially since then. Some health facilities supplement basic government salaries with substantial bonuses financed out of earned revenues, whilst others cannot pay basic salaries in full. Some health workers supplement their income through informal channels. The government’s response depends on the kind of informal payment. It uses moral pressure and the threat of the loss of professional privileges to discourage acceptance of cash payments from patients. It treats those who accept kickbacks from drug suppliers or health facilities as criminals. The government faces very difficult challenges in facilitating the adaptation of the health system to a market economy. Its strategy has been to create a broad policy framework within which individuals and enterprises can develop individual adaptation strategies. It has enacted rules to regularise new relationships that emerge. The strategy of gradual institutional reform has enabled the health sector to adjust to major change. However, it has allowed people to profit from opportunistic behaviour and resulted in inefficiencies and problems with access. It could eventually change social attitudes about what constitutes ethical behaviour by health workers. The challenge is to create a regulatory framework that permits health workers to earn a reasonable income, whilst encouraging them to provide effective and affordable health services that meet the needs of the population.
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