風險與潛力並存 國際資本注入中國醫療行業

HONG KONG – Investing in China’s health care sector is not for the faint of heart.

香港——膽小的人不適合投資中國醫療行業。

The country’s pharmaceutical supply chain is rife with corruption. Doctors and hospital staff have been attacked and even killed by patients who have been refused treatment. Farmers unable to pay for surgical amputations have made headlines by sawing off their own limbs.

中國的藥品供應鏈腐敗橫生；患者因被拒診而襲擊醫生和醫院工作人員；沒錢進行手術截肢的農民，因爲鋸斷自己的腿腳而登上新聞頭條。

Despite all this, Chinese health care is quickly becoming one of the most popular sectors for investors looking for the next great untapped market. Foreign and local private equity groups, drug companies, hospital operators and even construction companies are pouring record amounts of money into China to invest in hospitals, clinics, pharmaceutical businesses and medical equipment manufacturers. Mergers and acquisitions in China’s health care sector rose to a record $11.3 billion in the first 11 months of this year, up 13 percent from the $10 billion in the same period a year earlier, according to Dealogic data.

儘管如此，對於尋求下一個尚未被開發的巨大市場的投資者來說，中國的醫療行業正在迅速成爲最受歡迎的領域之一。國內外的私募股權機構、醫藥公司、醫院運營商乃至建築公司，都在將創紀錄的鉅額資金注入中國，投資醫院、診所、製藥公司和醫療設備製造商。Dealogic的數據顯示，今年前11個月，中國醫療行業的併購金額增至創紀錄的113億美元（約合700億元人民幣），較去年同期的100億美元提高13%。

For all the challenges of China’s health care system, demand for more and better medical products and services is surging. That is because of a combination of demographics and economics: The world’s biggest populace is both rapidly aging and increasingly affluent. The consulting firm McKinsey & Company estimates that health care spending in China will grow to $1 trillion by 2020, up from just over $350 billion in 2011.

儘管中國的醫療體系面臨諸多挑戰，但對於更多、更好的醫療產品和服務的需求正在快速增長。這既有人口結構方面的原因，也有經濟方面的原因：作爲全世界人口最多的國家，中國在迅速老齡化的同時，民衆也越來越富裕。諮詢公司麥肯錫(McKinsey & Company)預測，到2020年，中國的醫療支出將從2011年略高於3500億美元的水平，提高到1萬億美元。

“We’ve started noticing all sorts of players who don’t normally play in the health care space becoming very interested — they could see the demographics, the aging population,” said Mark Gilbraith, the head of PricewaterhouseCoopers’ China health care and life sciences practice, based in Shanghai. “Within China, deals are more about gaining access to untapped markets.”

“我們已經開始注意到，各類通常不涉足醫療領域的參與者，也變得很感興趣——他們可以看到人口數據顯示出的趨勢，即人口老齡化，”普華永道(PricewaterhouseCoopers)駐上海的中國醫療和生命科學業務負責人馬克·吉爾佈雷斯(Mark Gilbraith)說。“在中國，交易所涉及的更多是獲得渠道，進入未被開發的市場。”

The surge in deal making and investor interest coincides with a wave of sweeping overhauls that the Chinese government has introduced in recent years, as it tries to improve the accessibility and affordability of a health care system that has been widely described as being in a state of crisis. While recent decades brought a significant opening of the country’s economy, the reduction of socialist-style state funding left the health care system to fend for itself. The result is a half-liberalized but highly bureaucratic public hospital system that often compromises patient care in favor of profit.

交易達成的數量和投資者興趣的激增，與中國政府近年推行的廣泛改革浪潮同時出現。中國的醫療體系廣泛被指處於危機狀態，中國政府試圖通過改革來解決看病難、看病貴的問題。儘管近幾十年來，中國經濟的開放程度大幅提升，但由於社會主義式的國家資助出現減少，中國醫療體系只得自謀生路。結果便造就了部分自由化、卻高度官僚化的公立醫院體系。這一體系常常爲了獲利而損害對病患的照顧。

China had 13,440 public hospitals as of October 2013, and these provided 90 percent of the country’s medical services, Xinhua, the official news agency, reported in April.

今年4月，官方通訊社新華社報道，截至2013年10月，中國有13440家公立醫院，佔據着中國醫療服務市場90%的份額。

“Unlike most public hospitals in the world, Chinese public hospitals are an embodiment of both government and market failures,” Winnie Yip, a professor in the Blavatnik School of Government at the University of Oxford, and William Hsiao, a professor at the Harvard School of Public Health, wrote in an article published in August in the British medical journal The Lancet.

“不同於世界上的大部分公立醫院，中國的公立醫院既體現了政府的失敗，也體現了市場的失敗，”牛津大學布拉瓦尼克政府學院(Blavatnik School of Government)的葉志敏教授(Winnie Yip)和哈佛大學公共衛生學院(Harvard School of Public Health)的蕭慶倫教授(William Hsiao)在合撰的一篇文章中寫道。文章於今年8月發表在英國醫學期刊《柳葉刀》(The Lancet)上。

While the government limits to 15 percent the markup on drugs that hospitals can charge, doctors increase revenue by prescribing unnecessary drugs or unneeded and expensive diagnostic tests. Moreover, the professors wrote, pharmaceutical and medical equipment makers provide benefits to hospitals and physicians for using their products.

儘管政府規定，醫院對藥品的加價不能超過15%，但醫生可以通過開不必要的藥品，或是不需要的昂貴診斷檢查來增加收入。此外，這兩位教授還寫道，製藥企業和醫療設備製造商會向使用其產品的醫院和醫生提供好處。

As a result, by 2011, China’s spending on drugs was 43 percent of the total health expenditure, compared with an average of 16 percent in the dozens of countries with advanced economies in the Organization for Economic Cooperation and Development. At the same time, drug revenue accounted for 41 percent of total hospital revenue in China.

因此，2011年，中國在藥品上的支出佔到了全部醫療支出的43%，相比之下，經濟合作與發展組織(Organization for Economic Cooperation and Development)數十個發達國家的平均比例爲16%。與此同時，藥品收入在中國醫院總收入中的比重達41%。

“Many public facilities act as private entities, putting profit above patient welfare,” Professors Yip and Hsiao wrote.

“許多公立機構的行爲方式與私營機構無異，把盈利置於患者的福利之上，”葉教授和蕭教授寫道。

The Chinese government has tried in recent years to extend basic subsidized health insurance to all its citizens and, according to official estimates, more than 90 percent of the population is covered. But the quality of this coverage varies widely across the nation, as does the ability of individuals to get access to care.

最近幾年，中國政府已經設法讓基本醫療保險覆蓋所有居民。官方的數據顯示，覆蓋率已超過90%。但中國各地醫療保險的質量參差不齊，個人享受醫療服務的便利性也差異巨大。

These disparities were vividly illustrated in recent news reports, including the case of Liu Dunhe, a farmer in the southeastern Anhui Province who, uninsured and lacking the money to pay for an operation, decided to perform surgery on himself. Over the course of six hours on the night of April 20, Mr. Liu, who was suffering from severe necrosis after his feet were frostbitten, amputated his feet.

這些差異在最近的新聞報道中得到了生動的展示，比如安徽省農民劉敦和的例子。由於沒有保險也沒錢做手術，劉敦和決定自己動手。4月20日夜裏，他在六個小時的過程中，鋸掉了因爲凍傷而嚴重壞死的雙腳。

Widespread corruption in the health care system, especially involving the prescribing of drugs, is also an issue, and one that has ensnared multinational investors. In September, a Chinese court fined the British pharmaceutical giant GlaxoSmithKline nearly $500 million for bribery and jailed five of its executives, including a Briton. The government had accused Glaxo of bribing hospitals and doctors by channeling illicit kickbacks through travel agencies and drug industry associations to inflate drug prices.

醫療衛生體系普遍存在的腐敗行爲，尤其是涉及藥品處方的腐敗行爲，也是一個問題。它已經讓一些跨國投資者蒙受損失。9月，醫藥巨頭葛蘭素史克(GlaxoSmithKline)因行賄被中國一家法院處以近5億美元的罰款，該公司的五名高管被判刑，包括一名英國人。官方指控葛蘭素史克向醫院和醫生行賄，通過旅行社和製藥行業協會輸送回扣，提高藥品價格。

China’s government is increasingly concerned about the problems of the health care system. Part of its solution has been to open the door wider to foreign investment in the sector. The latest example came in August, when the authorities expanded a pilot program begun a month earlier to allow wholly foreign-owned hospitals to operate in seven major cities and provinces. Previously, foreign ownership was capped at 70 percent.

中國政府越來越擔心醫療體系的種種問題，其中一個解決辦法是進一步放開該領域的外國投資。最近的例子是，今年8月，當局擴大了一個月前開始的一個試點項目，允許純外資醫院在幾個主要的城市和省份經營。之前，醫院的外資持股上限是70%。

A number of recent deals have followed as a result of this liberalization. In September, the American private equity giant TPG teamed with a unit of the Fosun Group, a big Chinese investment company, in a $420 million deal to privatize Chindex International, a Nasdaq-listed operator of hospitals and clinics in China and Mongolia.

這種開放措施在近期促成了多筆交易。今年9月，美國私募股權巨頭德州太平洋集團(TPG)與中國大型投資公司復星集團(Fosun Group)的一家子公司合作達成了一筆4.2億美元的交易，對納斯達克上市的美中互利工業公司(Chindex International Inc.)實施了私有化。該公司在中國和蒙古國經營着一些醫院和診所。

More recently, UPMC, a hospital operator based in Pittsburgh, and Massachusetts General Hospital, which is affiliated with Harvard University, said they had signed or were exploring deals to manage or build hospitals in China.

不久前，匹茲堡的醫院經營企業UPMC，以及哈佛大學(Harvard University)附屬的馬薩諸塞州綜合醫院(Massachusetts General Hospital)都透露，它們要麼已經簽約在中國管理或建設醫院，要麼正在尋求這方面的合作。

“Investing in China’s health sector faces many challenges,” said Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations in New York. He cited the large amount of capital required and the comparatively lower rates of return, as well as uncertainties over how privately owned hospitals will fit into China’s national medical care payment system.

紐約的對外關係委員會(Council on Foreign Relations)專注於全球醫療衛生的高級研究員黃延中說，“投資中國的醫療領域會遇到許多挑戰。”他提到，需要付出大量資本、回報率相對較低，此外私有的醫院如何納入中國的全國性醫療支付系統也存在不確定性。

Still, he said, more private investment would benefit the entire sector, including the troubled state-funded hospitals.

他說，不過，更多私人投資會令整個行業受益，包括處境艱難的公立醫院。

“Increased competitive pressures would incentivize the public hospitals to kick off more meaningful reform efforts,” Mr. Huang said. “Private investment can play an important, even critical, role in China’s health care reform.”

“競爭壓力的加劇會刺激公立醫院開展更有意義的改革措施，”黃延中說，“私人投資在中國的醫療改革中可以起到重要、甚至關鍵性的作用。”