Involving and informing patients in decisions about their medical care is a very important issue since patients are one of the untapped resources in healthcare. But in low and middle income countries like China, where universal coverage of healthcare services has not been reached, a big concern is whether patients with equal needs can get equal access to health services under shared decision making processes.

In China, a fee-for-service mechanism has been well established during the past two decades. Although the current health system reform aims to provide universal coverage of essential healthcare to the general population, a large number of patients have to pay out of their own pockets, especially for services that use advanced technology or are very expensive. When involving patients in shared decision making for their healthcare, the first consideration for patients is the cost, i.e. which choice is the most affordable for them. There is a huge income gap between the poor and the rich. As stated by the World Bank recently, China’s Gini coefficient [a measure of statistical dispersion that is commonly used as a measure of inequality of income or wealth] hit 0.47 in 2009, and is expanding. The annual average income per headin 2008 was 15,781 Chinese yuan in urban areas and CNY4761 in rural areas (1USD=7CNY). Under these circumstances, a patient will be more likely to make a decision on the basis of cost, rather than on which option is most beneficial to their health.

Under the fee-for-service mechanism, it is also difficult for patients to receive unbiased information for decision making. Potentially biased information from doctors may unintentionally or intentionally lead patients to choose high cost health services. The mass media is full of market orientated advertisements for new diagnostic tools, medicines, and interventions. Patients face an overwhelming amount of information, which is mainly misleading. Inequity in access to comprehensive information will influence patients’ decisions about healthcare. Vulnerable populations such as poor and less educated people) may be more likely to become the victims of misleading information.

Also, under the fee-for-service mechanism there is increasing tension between patients and doctors. Patients may not trust their doctors, and they may have doubts that the information and recommendations from their doctor is correct, even if doctors have provided patients with the most comprehensive information to help their decision making.

From my point of view, therefore, it might be too early to involve patients in decision making in countries where universal healthcare coverage has not been available. However, patients could still be actively involved in the self-management of chronic diseases, such as diabetes and hypertension, and health intervention programmes as well.

Biao Xu, is a professor of epidemiology, School of Public Health, Fudan University, Shanghai, China.