The rise of the "work-procurement medical" model for uremia patients is closely related to the institutional shortcomings of my country's medical security system. For a long time, the household registration restrictions and off-site settlement barriers for medical insurance reimbursement have firmly bound patients to the insured place. Zhang Shun was once in a typical dilemma: using medical insurance in his hometown faced complicated medical procedures and high pressure to advance payment; he wanted to participate in insurance at the construction site but was excluded from the system because he did not have a "serious job". This dilemma has not been broken until recent years - in September 2021, the National Health Insurance Administration included uremia dialysis into the pilot program of cross-provincial settlement of chronic special diseases in outpatient clinics; in January 2022, Guangdong took the lead in canceling the household registration restrictions for flexible employment personnel; in January 2025, the National Development and Reform Commission issued a document to completely cancel the household registration restrictions for insured places of employment (some regions still have residence permits and other conditions).
The evolution of roles of private medical institutions is also worthy of attention. my country's dialysis services have been dominated by public hospitals for a long time (accounting for 95% of the share), but public hospitals have faced multiple constraints such as space and benefits to expand the scale of dialysis. Since 2015, the country has successively issued policies to encourage social capital to run medical care. In 2016, the "Basic Standards and Management Specifications for Hemodialysis Centers" clearly proposes to support the development of independent hemodialysis centers, but the implementation process is slow. As of the time of reporting, there are only 47 private dialysis centers across the country, which is far from the theoretical needs. The case in Huangchuan, Henan shows that even private centers with complete procedures (such as Shengde Yihechen) will have to go through two years of difficult approval and rely on the local government's "dare to innovate and dare to break through".
The imbalance of regional medical resources is another structural contradiction. Among Huangchuan County’s 870,000 population, theoretical dialysis needs nearly 500 people, but the county hospital has only 32 dialysis machines, serving more than 260 patients. Many people are forced to dialysis at night or go to other counties. Similar situations are common in 72 counties across the country with a population of more than 100,000 but without dialysis capacity. This imbalance has prompted some regions to explore diversified solutions: Ankang City cooperates with public and private hospitals to achieve "zero cost" for hemodialysis in poor patients through the charitable medical assistance "disease relief" project; while Guangzhou's "medical-factory" model attempts to enhance patients' payment ability from the root.
The practice of "procurement of medicine by using industry" in uremia is essentially an adaptive survival strategy under the conditions of imperfect systems. To truly solve the dilemma of this group, it is necessary to build a support system with the coordinated support of multiple subjects of the government, the market and society, and conduct institutional innovation and policy optimization from multiple dimensions.
Deepening reform of the medical insurance system is a basic task. At present, it is necessary to further break the administrative division barriers of medical insurance reimbursement, fully implement cross-provincial direct settlement of outpatient chronic diseases, simplify the registration procedures for medical treatment in other places, explore the "direct hospital reporting" model of dialysis expenses, and avoid the pressure of patients to advance payment. In response to the uneven reimbursement ratio, it is possible to consider establishing a nationwide unified uremia treatment guarantee standard and balance regional differences through central fiscal transfer payments. For the reimbursement limit policies in some regions, a scientific adjustment mechanism should be established to ensure that the basic treatment needs of patients can be met. In the long run, end-stage renal disease can be included in the "core service package" of national medical insurance to achieve full-scale protection of treatment costs and eliminate the risk of patients suffering from poverty due to illness.
The standardized development of private dialysis institutions is the key to alleviating the insufficient medical resources. The national level should refine the implementation rules for social medical services, simplify the approval process of independent hemodialysis centers, and provide support in land use, taxation, talents, etc. In response to the rejection of public hospitals, we can explore cooperation models such as "public construction and private business" and "private office assistance", such as the collaboration experience between Huangchuan County Hospital and Shengde Yihechen Center. For the mixed use of places exposed in the "medical-factory" model in Guangzhou, physical isolation standards must be clarified to ensure that production activities do not affect medical safety. In addition, chain and group operations are encouraged to reduce costs through economies of scale, as advocated by the 2016 National Health and Family Planning Commission document.
The innovative construction of the employment support system is the core of ensuring the dignity of patients. The government can learn from the employment policies of the disabled and provide incentives such as tax reductions and social security subsidies to enterprises hiring uremia to eliminate employers' concerns about medical risks. The labor department should develop flexible employment positions suitable for dialysis patients, establish adaptation standards for work intensity, time and medical needs, and avoid excessive labor in Guangzhou cases. In response to the problem of single skills in patients, vocational training institutions can offer remote courses to help them obtain new skills suitable for their physical condition such as e-commerce customer service and graphic design. More fundamentally, employment discrimination based on chronic diseases should be clearly prohibited in the Labor Law, and convenient channels for protecting rights should be established.
The improvement of the social support network can fill the system gap. The experience of Ankang City's "Take Away from Diseases and Worries" project shows that charitable organizations can effectively connect medical insurance with the patient's own payment part to achieve "zero payment" treatment for extremely poor groups. Such projects can expand the scope of diseases, introduce more social capital, and form a sustainable rescue mechanism. Mutual assistance organizations for uremia patients should be established at the community level to provide psychological support, experience sharing and emergency assistance to reduce individual loneliness. The media should strengthen the popularization of knowledge on chronic kidney disease prevention and control, reduce public misunderstandings and discrimination against uremia patients, and create an inclusive social environment.
Technological innovation and the sinking of medical resources are long-term solutions. Telemedicine technology can make it possible for experts from Grade A hospitals to guide grassroots dialysis and alleviate the shortage of professional talents. The research and development and promotion of portable and home-based dialysis equipment can reduce the burden on patients to and from medical institutions. For 72 counties that do not have dialysis capabilities, transitional plans such as "mobile dialysis vehicles" can be adopted instead of allowing patients to run around for a long time. In addition, early screening of chronic kidney disease will be strengthened, detection rate will be improved through artificial intelligence-assisted diagnosis, and the incidence of uremia will be reduced from the source.
The biggest inspiration of Guangzhou's "work-procurement medical" model is that patients with uremia need not only medical assistance, but also a reconstruction of social value. When Zhang Shun said, "I just want to make money hard and live better than before," he expressed his desire for a normal life. Any good policy design should respect this subjectivity and avoid simply treating patients as rescue objects. In the future model exploration, it is possible to consider moderately linking the reduction and exemption of medical expenses with patients' social contributions. For example, participating in mutual assistance between patients and health education, etc., you can accumulate points to deduct part of the expenses, forming a virtuous cycle.
In the elevator of the five-story building in Guangzhou, silent identity changes occur every day - workers on the fourth floor become patients on the third floor, and then turn back to workers, and this cycle is like this. This survival strategy of "procurement of medicine with industry" is not only a compliment to the resilience of life, but also a complaint of insufficient social security. The lives woven by uremia patients with sewing machines and dialysis machines expose deep contradictions in my country's chronic disease management system: fragmentation of medical insurance, lack of employment support, stubborn social discrimination and uneven distribution of medical resources.
From a broader perspective, the dilemma of the uremia population is not an exception. In the context of accelerating aging and increasing burden of chronic diseases, how to protect the right to survival and development of vulnerable patients is a common issue facing the whole society. Guangzhou's experiments show that even in the most difficult situation, human nature's pursuit of dignity will not be extinguished - when Zhang Shun walked among the crowd of migrant workers and felt "returning to the world of normal people", what we saw was a subjective awakening that transcends the disease.
However, individual tenacity cannot replace the responsibility of the system. Transforming this grassroots innovation into sustainable policy practice requires clarifying the boundaries of rules: protecting rather than exploiting patients' labor rights; providing a safe working medical environment; and ensuring the rational use of medical insurance funds. More fundamentally, through a multi-level security system, patients have the right to choose - decent work is a possibility, rather than a forced struggle to survive.
Amid the buzzing sounds of dialysis machines and sewing machines, we hear the question of social conscience: How should a civilized society treat its most vulnerable members? "Self-rescue work" for uremia patients should not become a normal solution, but a transitional bridge to a more complete system. Only when medical care, employment and social security form a collaborative network can patients truly gain the dignity of life that "the wind cannot blow, the rain cannot blow" - this is not only the expectation of Zhang Shun and others, but also the warmth that a healthy society should have.