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.