AILING SYSTEM
Once the stalwart of rural healthcare, the role of village doctor has struggled to adapt along with China’s decades-long medical reform – for better and worse
Saying “the computer system is down” is Wang Jianhua's go-to line. A village doctor in eastern Sichuan Province, Wang said this is how he gets patients to buy medications directly from him – and pocket the profit – rather than through their medical insurance.
Wang told the reporter he has been using this “trick” for over five years. “As long as I don't use the villager's medical insurance account, supervisors won't come and investigate my secret deals,” the doctor said.
Wang, who has been practicing for 35 years, has plenty of excuses to justify his actions: the reimbursement procedure is too complicated; prices for some medicines covered by the insurance system are sometimes higher; patients trust him and are willing to pay out of pocket.
Also, it's more convenient. If villagers insist on using their medical insurance, they have to travel kilometers to the township health center.
Wang is not the only village doctor scamming the system. In Cuikou Village, Shandong Province, over 2,000 villagers, including a 5-year-old child, were suspiciously diagnosed with having strokes over the past few years. The village doctor surnamed Zhu was accused of conducting medical insurance fraud. Patients discovered Zhu had secretly amended their medical records. Authorities suspended her license and are investigating.
Since the founding of the People's Republic of China in 1949, village doctors have played an important role in medical services at the grassroots level. Xu Yucai, former deputy director of the Health Bureau of Shanyang County, Shaanxi Province compared a village doctor to capillaries in the human body.
“If a person's major blood vessels burst, you get symptoms straight away. The body responds immediately, and the person will see a doctor,” Xu told our reporter in late October. “But if the capillaries in the body fail, you may have to wait for the breakdown of a large area before you get symptoms, and by then it's more difficult to treat. It's even more difficult to manage this grassroots issue,” Xu said.
Changing Roles
Wang operates his village clinic with his wife from the first floor of their house. They treat patients all hours of the day and night.
Wang followed in his father's footsteps. Graduating from a medical school in 1950, Wang senior served among China's first generation of “barefoot doctors” – former farmers who were recruited and trained to provide basic medical services in rural China between the 1960s and 1980s.
According to Wang, his father was known as a hard worker. “Village doctors treated many ailments, and were very popular,” Wang said, adding he also treated villagers for parasites and distributed polio vaccinations.
Under China's planned economy, rural medical services were mainly financed by a cooperative medical scheme. Most funding came from production teams, with smaller contributions from local farmers.
In a 2018 article for Harvard Public Health magazine, Winnie (Chi-man) Yip, professor of the Practice of Global Health Policy and Economics at Harvard's Department of Global Health and Population, described the barefoot doctor program as a “low-cost strategy that achieved high health outcomes.”
“Its core principle was to keep people healthy. And the program reached everybody – it was universal healthcare at its very core. Just as impressive, barefoot doctors were part of the community, understood the community, cared about the community and were trusted by the
community,” Yip wrote in her Harvard Public Health article.
By the end of 1975, more than 1.5 million villagers had been given brief training courses to become "barefoot doctors" in China. They worked with more than 3.9 million midwives and medical workers who received short-term training, according to data from health authorities.
By the late 1980s, the rural cooperative medical scheme had been terminated along with the commune system, which had put all land and labor under the collective control of production teams. Although the title “barefoot doctor” was abolished in 1985, many villagers still referred to them as such for years afterwards.
Those who passed a national qualification test were licensed as village doctors. Many took over village clinics from the old communes with a financial target, and worked for a profit.
According to Professor Yip, from the late 1980s to the early 2000s, village doctors in China were mostly self-employed. “Village doctors could earn a decent living since they could make money through prescribing drugs, giving injections and other treatments,” Yip told Newschina.
While conducting field research in Shandong Province more than 20 years earlier, Yip found village doctors were often among the richest people in the village. “But that does not mean they provided the best medical services,” she said. When village doctors became selfemployed and ran clinics for profit, over-prescription of drugs was common. “During that time, the threshold for being a village doctor was not high, and doctors would prescribe as many medicines as possible [to make profit],” Yip said.
In 2009, a national medical reform proposed “ensuring basic healthcare, enhancing grassroots medical care system, building up a healthcare system” to make general healthcare more accessible. “Grassroots medical care” refers to the three-tier rural healthcare network made up of county-level medical and health institutions, township level clinics and village clinics. Village clinics are crucial to the network, as village doctors are the primary source of basic medical services to village communities.
Wang Jianhua never turns off his mobile phone and is on call 24 hours a day. As the village is over five kilometers from the township clinic, villagers first turn to Wang for their healthcare needs.
Brain Drain
Miao Yanqing, deputy director of the Rural Health Research Office of the Health Development Research Center of the National Health Commission, told Newschina that despite the national medical reform's achievements, the quality of grassroots medical care has not improved. In some cases, it has decreased.
The primary issue is aging village doctors. According to a survey of 1,828 village doctors by charity organization Fosun Foundation (Shanghai) conducted in 2021, more than 70 percent of village doctors are over 40.
In addition, according to the official Statistical Bulletin on the Development of Health Undertakings in China, the number of clinics nationwide decreased from 639,000 in 2016 to 609,000 in 2020. The number of certified village doctors and healthcare workers declined from one million in 2016 to 792,000 in 2020.
While the number of village doctors who passed the national licensing exam for “practicing assistant physician” increased over the same
period from 320,000 to 465,000, not all of them worked in village clinics.
According to Xu Yucai, under the rural reform, smaller villages with fewer people were merged into larger administrative villages. As the number of separate villages decreased, so did the number of clinics.
Outflow of Patients
Fewer village residents are seeking medical care services at local clinics. “In fact, the number of diagnoses and treatments in village clinics has been on the decline since peaking at around 2.01 billion in 2013,” Xu said. “In 2020, that number was 1.43 billion, down by 19.4 percent compared with the peak in 2013, and 13.9 percent compared with 2010.”
Xu found that many patients opt to visit county hospitals. From 2010 to 2020, while the number of village doctors decreased, the number of visits and admissions in hospitals at the county level (including county-level cities) increased by 68.1 percent and 83.4 percent, while the number of visits to township health centers increased by 26.4 percent and the number of inpatients decreased by 6.8 percent. His observations coincided with Wang Jianhua's experience, who said he noticed a decline in the number of patients around 2009.
An important reason is that many people left rural villages for jobs in towns and cities. As Yip points out, rural population outflow stems from the underdevelopment of rural areas compared with cities. “China established its rural medical system gradually over the past decade, but the development of rural areas is still much slower than in cities, so the gap is getting bigger, and more people are moving to cities,” Yip said.
In addition, as the number of large hospitals in cities grows, medical resources and patients follow.
Another reason is reimbursement policy. A system called New Rural Cooperative Medical Care, which focuses on treating serious disease, was piloted in 2003. By 2010, it was nationwide. However, outpatient fees at village clinics were not covered initially. “Only medical fees paid during hospitalization are reimbursed, so many villagers check into township and county hospitals,” Wang said.
“During the early stages of the new system, only hospitalization expenses, not outpatient expenses, could be reimbursed,” Huang Erdan, a researcher at the Health Development Research Center of the National Health Commission, told Newschina. Huang explained that the system was initially designed around “social mutual assistance,” which involves villagers sharing healthcare costs by contributing to a pooled fund. “It covers serious illnesses. According to international standards, the fewer people use the insurance, the more effective it is for those truly in need. If people are reimbursed even for minor illnesses, that would be equivalent to paying back the money everyone pays in, which is illogical,” Huang said.
However, some hospitals admit patients needlessly and prescribe unnecessary treatments. Hospitals collect the insurance, while patients get reimbursed. “Hospitals conspired with patients,” Huang said. “Generally, New Rural Cooperative Medical Care did actually stimulate the development of township health centers and county hospitals.”
Dwindling Income, Rising Costs
To encourage rural residents to join the cooperative healthcare system, in 2008 the rural cooperative medical care system allowed village and township clinics to partially reimburse outpatient costs.
However, the new reimbursement policy restricted village doctors in prescribing medicines. In 2009, the National Essential Medicine List went into effect, an important component of the new medical reform. Village clinics could no longer make purchases directly from pharmaceutical companies. They could only buy listed medicines from the township health center and sell them to patients at cost. The new policy sharply diminished the incomes of village doctors.
Huang Erdan told Newschina: “The initial intention was to let the State dictate the production of medicines for chronic and common diseases, and then deliver them to grassroots clinics at very low prices.”
But the new policy was not universally well-received. Liu Zhigang, a village doctor in northeastern China, told Newschina in October. “The whole medicine list has changed, some drugs for common diseases have disappeared from the list, and there are many new drugs we're not familiar with,” he said.
Liu said some patients end up paying higher prices for drugs even with the reimbursements.
Huang agreed, saying that after over a decade of the National Essential Medicines system, not only has it fallen short of providing free medical treatment for rural residents, some drug prices have increased. This situation has resulted in doctors resorting to ruses – like Wang Jianhua saying the “computer system is down” – to get patients to pay for drugs out of pocket.
Without the income from medicine sales, village doctors must depend on government subsidies, which is determined by the village's population.
“The larger the population, the more medical services village doctors must provide, the higher subsidies from the government,” Nie Chunlei, chief of the Department of Primary Health with National Health Commission told Newschina. However, as more villagers move to towns and cities or sought better medical services there, many village doctors were making “total annual income of around 30,000 yuan (US$4,700) in 2021, the same amount they made 10 years ago,” Nie said. He added that if the village population is below 800, a village doctor can barely make ends meet.
Incentives and Interests
The National Essential Medicines system has been relaxed in some areas, including Yunnan Province, Guangxi Zhuang Autonomous Region and Inner Mongolia Autonomous Region, allowing village clinics to procure drugs not on the list. In recent years, more and more village doctors have resigned due to work pressure and low wages across the country.
“We've been occupied with considering the interests of rural patients and not those of rural doctors,” Huang said, adding that the 2009 medical reform “eliminated” higher income for village doctors, resulting in a brain drain of young and capable village doctors.
Huang Erdan proposed enacting more services and specific evaluation systems for rural doctors. “There should be different management systems for older and younger village doctors,” Huang told Newschina. His suggested measures include guaranteed pensions, better management of older village doctors still capable of practicing, and an enhanced appraisal system for young village doctors.
According to Huang, another way to address the issue is more training. “Village doctors should at least be licensed as practicing assistant physicians, and have the ability to diagnose common diseases,” Huang said. Also, doctors need to serve their communities in new ways, such as making daily rounds for elderly patients with chronic illnesses or cancer, Huang added.
However, making these changes will not be easy. “This is a systemic problem. Governance should be modernized, especially grassroots governance,” Xu Yucai said.
Huang Erdan said village doctors should be general practitioners who are motivated to carry out healthcare services for villagers. “Some people say that there is no need for village doctors because of the dwindling rural population. I think this is wrong, since village doctors are very useful in treating minor illnesses. This is particularly true for villagers in remote areas,” Huang said.
At present, a “medical community” model, which integrates county and rural services, is being promoted nationwide. For example, Shaxian County in Sanming, Fujian Province packages medical insurance funds to cover county hospitals, township health centers and village clinics. Personnel management is unified, and village doctors are dispatched from towns to villages.
“Doctors receive a fixed annual salary under a review system,” Huang said.
“If we only focus on institutional reform, salary and income and don't think about how to address the public's needs, such as how to improve the coherence of the medical services system, and we don't consider specific scenarios, the entire treatment process becomes fragmented,” Huang said, adding that it is also difficult for institutions and government departments to agree on specific reforms.
Despite multiple policies over the years, Huang said China is still working out the same healthcare reform it started in the 1980s.
“China's medical system is still transitioning from the Soviet public ownership model to the social-medical insurance model. The reform has lasted over 40 years, so the transformation process has not been easy at all,” Huang said.