Tuesday, 1 July 2014

China's rural doctor crisis: the 'barefoot' doctors are reaching retirement age and there's nobody to replace them

by Michael Woodhead
China is facing a crisis in its rural health workforce on three fronts: firstly, most village doctors are nearing retirement and there is no junior workforce to replace them. Secondly, the migrant worker trend means the rural population of half a billion people increasingly consists of older and poorer people who have higher medical needs due to chronic diseases and co-morbidities. And thirdly, government reforms mean that village clinics can no longer make an income from selling drugs and they are now also expected to provide unprofitable public health services. Consequently, young Chinese health professionals are not interested in being a village doctor. Who will fill this role?
This is the gloomy and alarming picture painted by a new snapshot of the rural health workforce, based on a survey of almost 2000 village doctors in five rural areas of China. Many village doctors are the original barefoot doctors recruited in the 1960s and 1970s, and most have only a minimal training in healthcare. Typically they are secondary school leavers who have completed the 'county health assistant' examination. Only about 20% have passed the national 'assistant doctor' certificate. The survey found that half the village doctors are nearing the age of retirement (60 for men, 55 for women). Also worryingly, the survey showed that the doctors nearing retirement tended to offer a wider range of medical services (including 'after hours') presumably due to their greater clinical experience than younger village healthcare workers. The younger village doctors also appeared to charge more and expected a more generous pension than the current measly level of 55 yuan a month.
Study author Dr Xu Huiwen and colleagues from the Beijing Normal University said the Chinese government now expected rural doctors to have a higher qualification, and in theory there was an ample supply of medical graduates to fill these roles. However, in contrast to the old village doctors, young graduates were often outsiders who were not trusted by the local people and they also made a low income. For this reason, village clinics found it hard to attract and retain new clinicians. In the future, rural patients may flock to township and country-level hospitals instead of seeking primary care locally. This will put an added burden on second-level hospitals and also increase the cost of healthcare to both patient and government.
The researchers said the Chinese government had recognised the rural health workforce problem and  had tried to fund rural health clinics. However, the funds were often not released by local country governments. They said the Chinese government must act urgently to address the recruitment of rural doctors by improving financial conditions, and especially by addressing the lack of a decent pension scheme. There also needs to be 'political' support as well as economic, they added.
"Ageing of village doctors is a serious and imperative issue in China, and will have a complex and profound impact on the rural health system," they concluded.
Update: Another study of village doctors has just been published that has come to the same conclusions. Published in the International Journal of Health Planning and Management, it found that 1) The village doctors are ageing 2) Younger people do not want to take on the job because of the poor salary (especially the pension), high workload and difficult working conditions. 3) Rural doctors are unwilling to take on new public health and e-health roles for little pay. The study authors say the government should improve working conditions, salaries and continuing education opportunities for village doctors. Recruitment should encourage local residents to train as doctors rather than trying to attract outsiders in to work in villages.

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