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Keywords:

  • village doctors;
  • health policy

Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

As the most important public health service providers in rural China, village doctors are facing a new challenge of heavier workload resulting from the recent policy of public health service equalization. Studies on the shortage of village doctors, mainly based on the national statistics, have so far been very broad. This study conducted detailed field surveys to identify specific factors of and potential solutions to the shortage in village doctors.

Eight hundred forty-four village doctors and 995 health decision makers and providers were surveyed through a questionnaire, and some of them were surveyed by in-depth face-to-face interviews and focus group interviews. Opinions on the shortage in village doctors and the potentially effective approaches to addressing the problem were sought.

Some village doctors (51.3%) were at least 50 years old.

Some village doctors (92.3%) did not want their children to become a village doctor, and the main reasons were “low salary” and “lack of social security”. Village doctors felt that it was difficult to provide all the required public health services. Local residents indicated that they established good relationships with village doctors. Some health decision makers and providers (74.0%) thought that they needed more village doctors.

The shortage in village doctors presents a major obstacle toward the realization of China's policy of public health service equalization. The aging of current village doctors exacerbates the problem. Policies and programs are needed to retain the current and attract new village doctors into the workforce. Separate measures are also needed to address disparities in socioeconomic circumstance from village to village. Copyright © 2014 John Wiley & Sons, Ltd.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Health equity has increasingly become one of prominent objectives in the health care reform in the world and China is no exception (O'Donnell et al., 2008). In 2009, the Chinese government began the new health care reform (State Council of China, 2009). Soon after that, the government put forward five priorities in the following 3 years. One of the priorities was the promotion of gradual equalization of basic public health services among all urban and rural communities and thereby narrowing the gap in access to those services that exist across different areas, especially between rural and urban areas (Meng et al., 2012).

The package of basic public health services included numerous services. The central government defined the range of basic health services, and the local government could add services to the package during the implementation. In 2009, the Ministry of Health issued the “National Guide for Basic Public Health Services”, which stipulated nine categories in the package of basic health services; each category consisted of two to three specific services, and there were a total of 21 specific services in the package (Ministry of Health, 2009). For example, the guideline stipulated that the public health service organizations should document health records for the residents who have stayed in the area for 6 months or longer, especially for those who are children with an age of 3 years older or younger, pregnant women, the elderly, and residents with chronic diseases or serious mental illness. The government also pledged that the subsidies for public health services per person were 15 renminbi (RMB) per person per year across the entire nation (State Council of China, 2009).

In 2011, the basic health services increased to 11 categories containing 41 specific services. Furthermore, the content of a specific service was gradually expanded. Using the example of the service of documenting health records mentioned previously, one can see that the expanded services are requiring children from an age of 3 to an age of 6 years old to be included. Accordingly, the subsidies were increased to 25 RMB per person per year (Ministry of Health, 2011).

Many intertwined obstacles exist that hinder the realization of the policy goals of public health service equalization. They include shortage of manpower especially in rural areas, lack of funding, lack of an efficient monitoring system, lack of interest in receiving public health services among some residents, and inequity in public health services in different areas and different people (Yu et al., 2009; Wang and Ren, 2010). Given that reducing the disparities in health care between the rural and the urban areas is the primary purpose of the policy, this study focused on rural areas.

In rural China, the grassroots public health service providers are those working in the village health clinics, the bottom of the three-tier health care network. The three tiers are composed of, from top to bottom, county-level health care facilities, township hospital, and village health clinics (Gu et al., 1995). It is regulated that the government subsidizes village doctors for public health services that they provide.

Shortage of rural doctors is a worldwide issue in health care delivery (WHO, 2009). China's public health service equalization policy created additional challenges in this regard because it increases village doctors' workload without sufficient additional compensations. Village doctors (formerly “barefoot doctors”) provided medical services, as well as public health services such as vaccination until 2009 (Zhang and Unschuld, 2008). However, the new policy requires village doctors to undertake added public health responsibilities; the newly added public health services significantly increase the workload for the village doctors. Ding and colleagues (2013) pointed out that village doctors did not find the government subsidies to be sufficient remuneration for their efforts of providing public health services. Village doctors felt that providing public health services was time consuming, and time commitment is challenging for them to provide required public health services.

Most of the recent studies on village doctors have focused on medical service provision, such as prescription behavior and potentially unnecessary care (Reynolds and McKee, 2009; Dong et al., 2011; Wang et al., 2011). In addition, several studies on the quantity and supply of village doctors have been mainly based on the China Statistical Yearbooks that merely provide a broad but not in-depth analysis of the problem. Hu and colleagues (2010) reported that workforce shortage is one of the main problems in health care delivery in rural China. Furthermore, research in other developing countries has presented some approaches to increasing the numbers of village doctors, such as raising salaries, adding allowances on top of salaries, reducing the workload, offering additional training, and improving pensions (Willis-Shattuck et al., 2008; Nils et al., 2012). In rural China, research on soliciting the opinions of the village doctors, health care administrators, rural residents, especially using the in-depth field surveys, in regard to alleviating the village doctor shortage problem has been sparse.

Compared with studies simply based on the statistics book, field surveys enabled us to obtain more detailed information. We got not only demographics of village doctors as included in the statistics book but also opinions from relevant stakeholders about village doctors and the policy of basic public health service equalization. Based on the government structure in China, during the implementation of the policy of basic public health service equalization, it is the city level and county-level government agencies that lead the implementation of the policy, while health care organizations at different levels participate.

To understand whether and to what extent there is a shortage of village doctors under the new policy, whether the subsidies are sufficient, and to seek potential solutions, this study applied the field survey approach, including both quantitative and qualitative surveys, to examine the shortage in village doctors in the rural health care system of China.

Methods

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Study setting

This study, conducted in 2012, focused on rural areas. Rural areas are areas where agriculture is the most important and the population is scattered (WHO, 2009). The study was carried out in the rural areas of Changzhou in the Jiangsu province in Eastern China. In 2011, the national per capita GDP was 35 198 RMB in the mainland that year, and the per capita GDP of Jiangsu province was 81 658 RMB (National Bureau of Statistics, 2012). Changzhou was ranked the fourth in terms of per capita GDP among the 13 cities in the Jiangsu province, with a GDP per capita of 85,036 RMB (Bureau of Statistics of Changzhou, 2012).

The Jiangsu province is typical with regard to rural and urban settings in Eastern China. Cities such as Changzhou are comprised of counties and districts (county and district are at the same level of governmental administrative hierarchy); each county or district is comprised of townships and towns (township and town are at the same level), and each township or town is comprised of villages, with health providers located at each level of governance.

In a certain city, human resources, who are involved in the implementation of the policy, come from both health care organizations and nonhealth care organizations and can be divided into decision makers and public health service providers based on their roles in the activity. There is no clear absolute boundary between decision makers and providers, and some may have both responsibilities. However, those who come from upper level organizations have stronger influences than those from lower level organizations. Therefore, persons from city and county health agencies such as the city/county health bureau and the city/county Center for Disease Control (CDC) and Prevention mainly play the role of the decision makers, and the personnel from the township and village organizations mainly play the role of health providers.

This study was conducted in two stages. In the first stage of this study, we surveyed the most important basic public health providers in rural areas, the village doctors, to gather the basic information and their opinions on their job. All the village doctors in selected counties were surveyed by structured questionnaires. To further understand what village doctors do, we went to village health clinics to observe their work and interviewed some village doctors with open questions. We also interviewed some local residents as well.

In the second stage, we surveyed the representatives from the organizations related to the implementation of the policy including health care organizations and nonhealth organizations by structured questionnaires, and some of them were interviewed in the format of the focus group. In this stage, we examined the extent of shortage in village doctors in rural areas and the extent to which the shortage affects the implementation of the policy to equalize basic public health services. We also asked them to identify specific factors related to the shortage of village doctors and then propose recommendations for addressing the problem.

There were at least two reasons that we decided to survey other persons as well as village doctors. First, it would give us broader perspectives to the problem. Second, because people in both health care organizations and related nonhealth organizations are involved in implementing policies of basic public health service equalization, getting them all involved in the study strengthened our efforts to explore practical solutions to the village doctor shortage problem.

Sampling

The survey and face-to-face interview were conducted in the villages during the first stage of the study. Changzhou has seven districts and counties. There are rural areas in two districts (X and W) and two counties (L and J), respectively. Local government agencies in L, X and W participate in the project. There were 363 village health clinics in these three districts/counties. All the 849 village doctors in the 363 clinics were surveyed, and 844 village doctors completed and returned the questionnaire. We also conducted an in-depth individual interview of village doctors and residents in the villages. Eight villages of comparable scale (around 1000 households per village) were selected. We interviewed the leading doctor of the village clinic plus the two residents in their 40s who came to the clinic in each village.

In the second stage, we surveyed representatives from related organizations at all three levels within Changzhou city. In Changzhou, there are two levels of health administration decision makers: (i) at the city level, the deputy mayor of the city and the officers of the city health bureau and (ii) at the county (district) level, the deputy director of the county (district) and officers of county (district) health bureaus. Health care organizations include, at both city and the county (district) levels, the CDC and Prevention, the Center for Food and Drug Administration, the Maternal and Child Care Services Center, hospitals, township (town) health centers and village health clinics. In addition, the members of the local Committee of the Chinese People's Political Consultative Congress usually have a significant influence in the health-care-related decision making process. In this study, we surveyed people from all of these government agencies and health care organizations. Of the 1064 persons surveyed, 995 completed the questionnaire. The respondents were grouped into four levels: city, district (or county) level, township (or town) and village. Finally, we held three focus group interviews. A total of 43 people participated in the focus group interviews with each group having 10–15 participants. The participants included directors of various types of health care organizations and government agencies at different levels, as mentioned previously. These individuals were from the same organizations previously mentioned.

Data collection

Village doctors completed a structured questionnaire containing demographics and opinions on their current jobs. With regard to the in-depth individual interview in the village health clinics, questions were designed as open ended. For doctors, we asked their opinions on their own work such as the salary level and workload. For the residents, we asked whether and why they would like to visit the village doctors when they or their family members got sick and what additional services they expected from the village doctors.

The questionnaire used to survey health care decision making groups and providers included demographics and opinions on the barriers to fulfill the policy of public health service equalization.

For the focus group interviews, we designed an outline for the discussion. The outline included the most important barriers to fulfill the policy of public health service equalization and the potential approaches. Detailed notes were taken in the course of interviews.

Results

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

The density of village doctors in rural China

In 1980, the number of village doctors per 1000 rural residents in rural China was 1.79 as shown in Figure 1. In 2003, the number (0.98) was the lowest, and then, it slowly increased. In 2011, the number was 1.27, which was still lower than that in 1980.

image

Figure 1. Number of village doctors per 1000 rural residents in China, 1980–2011 data are from The Annual Chinese Statistics Book 2010 and 2012

Download figure to PowerPoint

Village doctor survey by a questionnaire

Characteristics of 844 village doctors are shown in Table 1. Some village doctors (51.3%) were at least 50 years of age or older including 8.5% of the respondents who were older than 65 years of age. Only 9.4% of village doctors had a college education or higher. The majority of village doctors received their medical education from village-doctor-specific training programs (70.4%), which is a method whereby a village selects and sends one or several young farmers to attend village-doctor-oriented certificate or associate degree programs in medical schools. They return to their villages after graduation to become village doctors. They attended the training programs at local township hospitals, county health schools, city medical schools, in other cities in Jiangsu province or in other provinces. When the village doctors were asked whether they wanted their children to become village doctors, 92.3% answered “No”, citing the main reason being low payment (Table 2).

Table 1. The characteristics of village doctors
VariablePercentage
  1. In percent

Age group 
<50 years48.7
50–59 years30.3
60–64 years12.5
>65 years8.5
Sex 
Male54.0
Female46.0
Education level 
College or higher9.4
Medical vocational school43.7
High school20.0
Middle school26.4
Primary school0.6
Recourses 
Assigned doctors in local township hospital28.5
Specific job training programs70.4
From outside Changzhou city in Jiangsu Province0.4
From other province0.7
Annual income as a village doctor 
<20 000 RMB27.0
20 000–40 000 RMB48.8
>40 000 RMB24.2
Table 2. Reasons for “Don't want my children to be a village doctor”
ReasonPercentage
  1. In percent

The salary is too low56.7
Too much workload8.5
Lack of social security27.5
Not respected by others0.3
It is hard to say because they have already had their jobs5.6
Other1.4

Individual interview of village doctors and residents

In the morning in a village (Village A), there were one doctor and one nurse in the village health clinic. The doctor was responsible for seeing patients, and the nurse was responsible for dispensing drugs, injecting and taking charge of billing for services provided. During our interview at the village health clinic, several patients continuously came to see a doctor. The doctor was about 60 years old. He told us “In most days, about 10 patients come to the clinic. Sometimes, I am asked to see patients at their homes. As a result, I just don't have time to enter all health records information of everyone in the village although it is required by the policy of public health services equalization.”

In another village (Village B), a 60-year-old village doctor in the health clinic told us, “If I quit my job, I have only 300 RMB subsidies a month… I must make a living. I have to do the tiresome job to pay the bill…There is such a heavy workload and extra work required by this new policy of equalization of public health services. Meantime, I get very limited subsidies for the extra work. It would be better if I know how to use computer and I am too old to learn these technologies.”

In Village B, a resident told us that “He has been a village doctor for about 30 years. Everyone in the village trusted and respected him very much. When we have trouble in getting people together to do something, the village doctor is always able to do so. It is a shame and unfair that his pension benefits are so little. Several decades ago, some of the residents with relatively higher education levels in the village were chosen to become either village doctors or teachers with comparable salaries, but now, the salary of teachers is much higher than that of village doctors and the gap in pension is even wider. The teachers' salary is more than 50 000 RMB a year, but the village doctors' salary is only about 30 000 a year.”

Another resident in his 50s said “The village doctor knows almost everyone in the village. He knows who is elderly, who is pregnant, whose kids should be vaccinated, and who went to urban areas to work. We all respect him for what he has done for us…I hope he can offer some seminars and workshops about health and we will be interested in participating…”

Survey of health decision makers and providers

Table 3 shows that 74.0% of the 995 people thought that more village doctors were needed in order to provide all the health services required by the new policy. However, only 58% of the people at the village level thought so. The result indicates that the higher the level of organizations that the respondents work at, the more likely they realized the village doctor shortage problem.

Table 3. Proportion of health decision makers and providers thinking that “the number of village doctors is enough”
LevelNumberProportion (%)
EnoughNot enough
  1. Two-sample Wilcoxon rank-sum (Mann–Whitney) test: mean ranks of whether “thinking the number of village doctors is enough” are 552.63 and 478.78, respectively, p = 0.0002, (STATA 11)

1 (city)20317.782.3
2 (county/district)37925.374.7
3 (township/town)34628.671.4
4 (village)6741.858.2
Total99526.074.0

When asked “What is the best way to stabilize village doctors”, nearly 33% of the respondents thought to increase the salary of village doctors, followed by the approach of assigning and rotating township hospital doctors and medical trainees to work in village health clinics on a temporary basis. Some (11.8%) thought that it was to improve social security for village doctors (Table 4).

Table 4. What is the best way to stabilize the village doctors
LevelLocal township hospital allocating doctorsSpecific job training programsImproving salaryImproving social securityOtherTotal
1 (city)19.732.534.512.31.0100.0
2 (district)30.625.927.214.32.1100.0
3 (township)29.524.034.49.52.6100.0
4 (village)25.413.452.27.51.5100.0
Total27.625.732.911.82.0100.0

Focus group discussion of health decision makers and providers

Almost all the respondents thought that at least four important obstacles existed, hindering the improvement in health care delivery in rural areas. They were lack of funding, ineffective administration of public health services, shortage in village doctors and poor quality of care provided by village doctors. Furthermore, a director of a district health bureau that we surveyed was concerned about the village doctor shortage, reflected especially by the aging village doctor problem: “Looking at the clinic in Village C in my district, only one doctor and one nurse work there. The doctor is over 70 years old but has to continue working because we are not able to find him a replacement. This is quite common in the Changzhou area where many doctors are over 60 years old and, in a few years, they will be over 70 years old and may not be able to deal with such heavy workload. Who will provide public health services if there are not enough new village doctors to replace them? Village doctors are the grassroots of our rural three-tier healthcare network.” Many participants pointed out that although the average income of residents in Eastern China was higher than that in the Middle and Western regions, the average income of the village doctors across the three regions were comparable. It is therefore understandable that being a village doctor did not seem to be an attractive occupation for many young people especially in Eastern China.

Most participants expressed their concerns about the quality of public health services required by the new policy. They thought that it was almost impossible for village doctors to do all of the required work with high quality, and it could be a case that village doctors put more attention to quantity rather than quality in order to meet the government's requirements.

Our results indicate that many factors associated with the shortage of village doctors were payment related including low salaries and bonuses, heavy workload, few opportunities for continuing education, unattractive pension plans and poor working environments. They believed that young doctors in hospitals or new medical graduates were not willing to become a village doctor because they found that living standards of the old village doctors were not attractive.

Regarding the resources available to new village doctors, the participants of the focus group recommended that of the four recourses available, assigning doctors in local township hospitals and providing specific job training programs are likely to be the most effective. Some participants said that “Several years ago, we recruit a doctor from a city from another province in the Central China, but he couldn't do a good job and the residents didn't like him. He finally quit the job.”

Discussion

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Shortage in and aging of village doctors

The World Health Organization (WHO) praised China's village doctor (formerly barefoot doctor) system as a successful example in developing countries (Zhang, 1994). With the collapse of the cooperative medical system in the early 1980s, the village doctors lost their infrastructure and financial support, and the number of village doctors gradually decreased (Zhang and Unschuld, 2008). In 2003, the government realized the problem and put forward the development of a new cooperative medical system, and the number of village doctors per 1000 rural residents increased, but the number, 0.98 per 1000, remains low.

With detailed information based on different types of field surveys, our study further confirms that the shortage in village doctors is an urgent problem during the current implementation of the policy of public health equalization in China. Our findings are consistent with those from other developing countries (Lethbridge, 2004). It is the case that village doctors used to focus on providing medical services, but now, a substantial increase in public health workload results in staff shortage.

Our findings also point out that the aging of this workforce only exacerbates the problem because many village doctors will retire in several years. Aging among village doctors is a nationwide problem in rural China. A large-scale cross-section study in five provinces (Liu, 2011) reported that the number of village doctors decreased from 1.13 per 1000 rural residents in 2002 to 0.81 per 1000 rural residents in 2010, while the percentage of village doctors of at least 60 years old in 2002 and 2010 was 3.1 and 13.6%, respectively.

The implementation of the public health equalization policy significantly increases the workload of village doctors and, in turn, affects the quality of their services. For example, the development of electronic health records is a major undertaking that also requires village doctors to have access to and learn how to use computers. Given that majority of village doctors are over 50 years old, the completion of this task becomes even more challenging.

Village doctors serve at the bottom of the three-tier health service network in rural regions, the health care safety net for millions of farmers and the main contributor to the significant improvement in rural health in the past decades in China (Zhang and Unschuld, 2008). Whether or not village doctors have the capacity to provide the required public health services is crucial to realize the new policy's goals and objectives. Our findings reveal that although most of the respondents at administrative levels thought village doctors are unable to accomplish all of required tasks, the respondents at the village level were more optimistic. One possible explanation for this difference is that more of the respondents in the city, county/district and township/town-level organizations, who generally have a higher education level and have more opportunities to obtain further education than those in village-level organizations, understand that village doctors need to provide routine medical services plus the basic public health services required by the new policy. However, many respondents at the village-level organizations may not anticipate the extent of the public health requirements of the new policy and thought that the village doctors only needed to provide medical services.

Approaches to alleviating shortage of village doctors

The central government decided to establish the new cooperative medical scheme (NCMS) in 2003, and the funding of NCMS provides substantial support to village doctors (State Council of China, 2002; State Council of China, 2003). As a result, the number of village doctors increased gradually from 2003. With the implementation of the policy of basic public health in 2009 (State Council of China, 2009) and following funding policy (Ministry of Health, 2011), the number of village doctors increased slightly faster than before. However, the number of village doctors per 1000 rural residents remains lower than that of 1985. In other words, the new policy moderately alleviates the problem, but further efforts are needed. We find that the reason of not having many new village doctors entering the workforce is that being a village doctor is not an attractive profession in terms of financial and career rewarding, which is consistent with findings of other studies (Ding et al., 2013; Shi et al., 2013)

Inadequate funding is always one of major obstacles for providing good health services in many rural areas (Wang et al., 2012). Although policies have focused on funding equalization of public health services (State Council of China, 2009; Ministry of Health, 2011), only a small portion of the government funding is used for compensating village doctors. Ding and his colleagues pointed out that approximately 3 RMB of the 15-RMB per-person subsidy was received by village clinics, and the rest is allocated to county CDCs and township health centers (Ding et al., 2013). More funding should be allocated to village doctors to improve their levels of salary and pension.

More are needed to encourage new doctors working as village doctors. Understanding the perceptions and opinions of the new health policy from people at different levels helps us to come up with possible solutions to the problem. The shortage of village doctors is the consequence of not being able to attract young people to become new village doctors. Salary and nonsalary factors, as being illustrated by human resource theories and confirmed by our findings, influence the attractiveness of a job or occupation (Huselid, 1995).

Socioeconomic and geographic environments vary across rural areas in China. Differences exist in different countries as well. Kwansah et al. (2012) report, in Ghana, that poor housing condition is one of the reasons that rural health workers are not satisfied with their job, but this factor was not identified in our study. Therefore, measures and options to attract village doctors may also be related to specific local factors that need to be considered.

The success in attracting new village doctors in China relies on several aspects. First, it is equally important to both retain current village doctors and recruit new ones because they are closely related issues. New incentives need to be provided to current village doctors, so young people see the bright future of being village doctors, which would encourage them in pursuing it as their career.

Geographic variations in socioeconomic environments need to be addressed. Being consistent with studies in China (Ge et al., 2011; Shi et al., 2013) and in Vietnam (Dieleman et al., 2003), our findings indicate that both financial and nonfinancial incentives are important to attract more rural doctors. Furthermore, different measures should be used to address these different factors (Liu, 2012). While an increase in salary can be effective in attracting young doctors to work in rural areas not far away from cities, it may not be enough to encourage young doctors working in remote areas. It is reported that the rational average of village doctor salaries is lower than that of elementary school teachers (Hu et al., 2011). One of the first solutions could be to reduce or eliminate the salary gap between village doctors and elementary school teachers. Other factors, such as continuing education opportunities for village doctors and good educational and socioeconomic environments for their children and families, are also important.

Third, it is important to understand the nature and characteristics of health service delivery in rural areas. Health service provision in rural villages is often broad in the sense that it covers both medical and public health services, treats patients with limited education and often requires home visits.

Therefore, the corresponding strategies may include a combination of offering specific job training programs for village doctors and assigning township hospital doctors to villages on a temporary basis. Because it takes time to complete the job training, this approach is a long-term solution, while assigning doctors to villages via township hospitals can serve as an effective short-term, temporary solution. In the long run, township hospital doctor assignments can be a part of the solution if the assignments are rotated among township hospitals' doctors because those doctors are less likely to stay in the villages for a long term. Moreover, providing incentives to township hospitals' doctors to go to the villages on a temporary basis should also be considered.

Instead of trying to attract doctors from other areas, recruiting local residents to become village doctors remains a better approach. It assures that the doctors return to their villages after their medical education because they are tied with their villages in many ways. Attracting doctors from elsewhere, on the other hand, is more challenging. For example, people speak numerous local dialects in their own geographic areas in China, which results in difficulties for doctors from another place to communicate with local residents if they cannot understand each other well; in particular, many rural residents do not learn the standardized spoken Chinese (i.e., Mandarin). In addition, it also takes time for an outsider to build trust with local residents.

The adjustment to social and environmental changes is important. Given the fact that many current village doctors are over 50 and have limited knowledge of information technology, they feel that it is especially challenging to conduct certain public health service tasks, such as creating health records for all residents in his/her village, required by the new policy. A potential solution is to train one to two young persons in the villages who understand computer technology better and to allow them to work on a part-time basis to help the village doctors in this regard.

Some provinces have implemented pilot programs to improve village doctors' salary and pension and pointed out that the pension for village doctors should not be less than the minimum subsistence level. For example, the government of the Zhejiang province provides the village doctors with the similar pension plan to workers in urban areas, and the Guangdong government offers a pension plan that reflects the length of being village doctors (Ministry of health, 2013). It is of premise that the central or local government improves the funding of village doctors; furthermore, it is essential that we should establish an operation mechanism to ensure that the governmental funding is being spent appropriately and not being diverted to other purposes.

There are several limitations in this study. First, the study only focused on Changzhou city in the Eastern China region, which might compromise the generalizability of our findings. Second, although our survey sample was not randomly selected, it did include 995 persons from all types of government officers, health care officers and health care providers at all levels, which we believe provided fairly comprehensive representation in regard to health care delivery in rural areas in China.

Conclusion

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Successful implementation and sustainability of the national policy of public health service equalization in China face challenges. Although increasing government funding is essential, how to allocate the fund to village doctors in a more rewarding manner is equally important. Further, shortage in village doctors is an eminent obstacle to fulfill the policy of equalization of public health services. Various efforts can be made to address the problem, such as increasing the salary of the existing village doctors, creating a positive perspective to young doctors and making the village doctor an attractive occupation to both retain current doctors and attract new doctors. Other approaches should also be exercised in both the short and long run. In the short run, township hospitals' doctors may be rotated and assigned to villages to work with village doctors, and over the long run, offering specific job training programs for village doctors is an effective approach. These approaches should be carried out with the increase in salary and training opportunities, based on local socioeconomic capacity and environments.

Governments need to consider whether there are sufficient resources prior to the implementation of new policies because even the policies with good intentions may not achieve the expected effects with resource and other constraints.

Acknowledgements

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

The authors thank Dr Gerald F. Kominski, Director of University of California—Los Angeles Center for Health Policy Research, for his useful discussion and comments.

This work was supported by Major Research Projects from the Ministry of Education (07JZD0017), Innovative Research Team in University from the Ministry of Education of China (IRT0912), National Natural Science Foundation of China (70733002, 70903014, 71373051), Doctoral Fund of the Ministry of Education of China (20120071110054), Projects from the 11th Five-Year Research Program of the Ministry of Science and Technology of China (2007BAI24B02), Health Research Projects from the Health Department of Jiangsu Province (H201044), Health Research Special Funding from the Ministry of Health (201002028) and China Scholarship Council.

The authors have no competing interests.

References

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
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