A day before Peng Zhang's father was scheduled for a complex spinal surgery in Beijing, he slipped the surgeon a red envelope filled with $4,000 cash.

Key points: Xi Jinping wants to outlaw the gifting of red envelopes in hospitals

Xi Jinping wants to outlaw the gifting of red envelopes in hospitals Issues arise when traditions clash with perceptions of questionable behaviour in the West

Issues arise when traditions clash with perceptions of questionable behaviour in the West Mr Xi's anti-corruption campaign has snared more than 1.5 million government officials

Mr Zhang, 34, was taken aback when the surgeon refused his gesture — on top of the hefty $15,000 hospital bill — that was intended to ensure his father was provided the best care available during the procedure.

"I tried to give her the red envelope again before she discharged my father from the hospital, but she turned me down again," Mr Zhang said.

"She is such a great doctor."

In China, it is common for patients to discreetly gift medical practitioners red envelopes of cash — known as hongbao in Chinese — in the hopes of being prioritised in a medical system struggling to cope with the country's 1.4 billion people.

Patients often feel inclined to hand out hongbaos for a range of much-needed healthcare services from dental treatments to births to major heart operations.

Hongbaos are in fact a well-known part of China's gift-giving tradition during cultural events like Lunar New Year, weddings, and birthdays.

But while the red envelopes may very much be part of Chinese culture, President Xi Jinping has been trying to outlaw the practice for the purpose of bribery as part of his ongoing, signature anti-corruption crackdown since 2012.

Mr Xi's pledge to crack down on "tigers and flies" — a slang phrase to refer to powerful officials embezzling millions of dollars to local civil servants indulging in expensive banquets — has reportedly snared more than 1.5 million government officials over the past five years.

Hongbaos are also part of China's gift-giving tradition during Lunar New Year. ( ABC News: Jennifer Wong )

But despite an official decree from China's National Health and Family Planning Commission in February 2014 banning the exchange of money in red envelopes in larger hospitals where the practice is rife, the gift-giving tradition has proved very hard to regulate.

Aside from red envelopes, people in China are also known to give expensive cigarettes, gift cards, groceries, and even luxury handbags to a range of civil servants including kindergarten teachers, police officers, and government officials.

People in China 'have no faith in the system'

Many patients across China choose to travel for hours to top hospitals in first-tier cities. ( Reuters: Kim Kyung-Hoon )

Dan Hough, Professor of Politics at the University of Sussex, told the ABC that anyone who has spent time in China can recognise that corruption is a challenge from "the lowest levels to the highest levels" of society.

"There's almost certainly a very clear idea that we do want to stop some of the most obvious types of corruption," he said.

"[But it's also] about making sure that the socio-economic system continues to produce the goods [and] economic growth in a way that the CCP [Communist Party of China] can control and can steer."

When asked whether the red envelopes could be considered a form of bribery, Dr Hough said the problem arises when cultural norms clash with questionable practices in the West.

"The red envelope is part of a culture of gift-giving that's existed for hundreds of years," he said.

"The question comes, of course, as to where the line is drawn between being a nice chap giving somebody a present [versus] actually expecting something in return, which can be seen as inappropriate."

People in China are also known to gift expensive cigarettes to civil servants. ( Weibo )

But unless it was a token gift and of limited value, such as a bottle of wine, Leslie Holmes, professor emeritus of political science at the University of Melbourne, said corruption specialists would see it as "improper" — particularly if it was in the form of cash.

"If they are giving it in advance, and it's very clearly meant to prioritise them, give them extra access and so on, then I'd call it bribery," Dr Holmes told the ABC.

"Certainly Xi Jinping seems to consider it bribery — it's one small part of his anti-corruption campaign."

Many patients across China bypass their community medical centre and travel for hours to top hospitals in first-tier cities like Beijing, Shanghai, and Guangzhou to access better health care.

On top of already expensive hospitals fees, many try to slip hundreds and even thousands of dollars to doctors and surgeons so they can feel reassured that the medical professionals will do a good job, as opposed to cutting corners.

Experts say many doctors also expect red envelopes from their patients. ( Reuters: Aly Song )

Other patients, perhaps on a waiting list with 100 other people who have an appointment with the same doctor that day, may hope to receive a more comprehensive treatment or diagnosis.

"The challenge in China is that people have no faith," Dr Hough said.

"They have no faith in the system, social capital levels are really low, and they have very little faith in people doing what they say they're going to do."

China's Social Credit System — a proposed national system designed to value and engineer better individual behaviour by establishing the scores of 1.4 billion citizens — is aimed to tackle that perceived lack of trust within society.

'If you don't give money, they'll remember you'

People usually wait for several hours to see a doctor in a popular hospital. ( Reuters: Kim Kyung-Hoon )

Shenshen Cai, a lecturer in Chinese studies at Swinburne University of Technology, said doctors typically expected gift money from the patients, especially in larger hospitals and for doctors that come highly recommended.

"Doctors are very pragmatic I think nowadays," she said.

"In TV dramas, there are model doctors who never take money from patients and they care about everybody's conditions, but things are actually not like that. It's just government propaganda.

"Many patients give them money and if you don't give [money], they'll remember you," she said.

While doctors should have a high moral standard, Dr Cai believes China's economic reform and opening up policies of 1978 have been a major driver of capitalist values.

Red lucky money envelopes being handed out in Melbourne's Chinatown. ( Flickr: CoinDesk )

"I think things started to change after the opening up policy," she said.

"Everyone just wants to make money."

While China is a communist country in theory, Dr Hough said it was one of the most capitalist countries in the world.



"In essence, money matters and money talks, and for that reason, you do find that money is at the core of everything that happens, in terms of social status [and] prestige," he said.

"Therefore, if you can pay for something, you will, because it's seen as being the best way to get it.

"The notion of public good — doing something because that's your obligation — is not really well developed in China at all."

But in China, where the public health system only covers a limited amount of medical costs and treatments, not everyone can afford such extravagant gratuities.

Gift-giving practice rife — even in kindergartens



Chinese President Xi Jinping has been campaigning to outlaw the practice for the purpose of bribery. ( AP: Mark Schiefelbein )

Former politics lecturer from Tsinghua University, Qiang Wu, said red envelopes, bribery, as well as guanxi — a Chinese concept of networking and relationships that could be perceived in the West as nepotism — gained popularity during the economic hardships of the 1970s.

After the start of China's economic reforms in 1978 as more people wanted to improve their standard of living, people began to use guanxi even more to pursue better opportunities, he said.

An increasing number of people are also sending electronic red envelopes via WeChat. ( ABC News: Jennifer Wong )

People in China now use guanxi to jump hour-long queues and get better property deals — even enrolling children in a highly sought after school sees parents turning to guanxi.

Dr Cai adds that China's gift-exchanging culture can even be seen in kindergartens, with parents typically giving teachers gift cards rather than cash to prioritise their children.

"The parents hope the teachers will better look after their children," she explained.

"Parents communicate with each other and decide to give money because other people are giving [teachers] money too.

"They think 'I have to give them [a gift] as well, otherwise my kids won't be treated well in the kindergarten'."

Chinese parents give kindergarten teachers presents so that their children are prioritised. ( Flickr: Rex Pe )

While acknowledging that it would take time for the gifting culture to change, Dr Holmes believes the first step might be to raise awareness.

"An educational campaign would be the most obvious way of doing it, to make it clear that China is moving forward, it's now in the 21st Century, and some of the traditions [and] cultural patterns need to change," he said.

"But we all know that culture takes a long time to change."

The ABC has approached China's National Health and Family Planning Commission for comment.