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China’s village doctors take great strides
Village doctors have dramatically improved
access to health care in China’s rural communities over the last few decades.
Cui Weiyuan reports.
China’s barefoot doctors were a major
inspiration to the primary health care movement leading up to the conference in
Alma-Ata, in the former Soviet Republic of Kazakhstan in 1978. These health
workers lived in the community they served, focused on prevention rather than
cures while combining western and traditional medicines to educate people and
provide basic treatment.
Dr Philip Lee, then a professor of social
medicine at the University of California in San Francisco, wrote glowingly in
the Western Journal of Medicine about China’s primary health care system after
visiting the country in 1973 as part of a United States of America (USA)
medical delegation. He said prior to the founding of the People’s Republic of
China in 1949, epidemics, infectious disease and poor sanitation were
widespread. “The picture today is dramatically different … there has been a
pronounced decline in the death rate, particularly infant mortality. Major
epidemic diseases have been controlled … nutritional status has been improved
[and] massive campaigns of health education and environmental sanitation have
been carried out. Large numbers of health workers have been trained, and a
system has been developed that provides some health service for the great
majority of the people.”
Three barefoot doctors, part of a production
brigade near Shanghai.
Dr Zhang Zhaoyang, the deputy director general
of China’s Department of Rural Health Management, says the barefoot doctor
scheme had a profound influence on the Declaration of Alma-Ata. “WHO research
in the 1970s found problems relating to the health-cost burden and unequal
distribution of health resources. To try to solve the inequality, it did
research in nine countries, including four cooperation centres in China. China’s
experience inspired WHO to launch the health for all by 2000 programme.”
Zhang says the barefoot doctor scheme,
initiated by central government but largely administered locally, had its
origins in the 1950s. “The name barefoot doctor became popular in late 1960s
after an editorial in thePeople’s Daily by Chairman Mao in 1968,” he says. “The
name ‘barefoot doctor’ originated in Shanghai because farmers in the south were
often barefoot working in the paddy field. But China’s village doctors had been
there long before. In 1951, the central government declared basic health care
should be provided by health workers and epidemic prevention staff in villages.
In 1957, there were already more than 200 000 village doctors across the
nation, enabling farmers to receive basic health care at home and work every
day. The barefoot doctor scheme was simply the reform of medical education in
the 1960s. In areas lacking medicine or doctors, village doctors could go
through short-term training – three months, six months, a year – before
returning to their villages to farm and practise medicine.”
Zhang says the scheme has evolved over the
decades, though the term barefoot doctor is no longer used. “The scheme has
never stopped. In the early 1980s, the State Council (the Central People’s
Government, the highest executive organ in China) directed that barefoot
doctors, after passing an examination, could qualify as a ‘village doctor’.
Those who failed would be health workers and practise under the guidance of the
village doctors. The village doctors and rural health workers still undertake
the most primary health work – prevention, education, maternal and child health
care, collecting disease information. The quality of [care provided by] rural
doctors keeps increasing in line with social and economic development.”
Dr Liu Xingzhu, the programme director at the
Fogarty International Centre at the National Institutes of Health in the USA,
was a barefoot doctor from 1975–1977. Aged 19, his senior secondary school
classes were interrupted during the Cultural Revolution drive to equip people
with practical skills. “The county’s health bureau organized medical training
in my school and provided free accommodation and food. The trainers were the
best from the county’s central hospital in various fields. Many of the doctors
were dispatched from the urban hospitals during the Down to the Countryside
Movement (when Mao decreed ‘privileged’ urban youth go to rural areas to learn
from workers and farmers) and showed great professionalism. They were very good
trainers and doctors.
“After graduating in June 1975, I became a
barefoot doctor at the Suliuzhuang commune (in northwestern Shandong Province,
south of Beijing) serving 1800 residents. Despite the knowledge I learned from
the strict training, the conditions and equipment in the countryside were very
limited. I was given only a bag of some basic medicine with two syringes and 10
needles.”
Therein lay both the strength and weakness of
the barefoot doctor scheme. It provided the rural poor with health care not
known in pre-Revolution days, but the doctors’ limited training, equipment and
medical supplies meant they could not do a lot.
Another of the barefoot brigade, Dr Liu
Yuzhong, still offers basic health care to his fellow villagers after 43 years’
service. Now 69, he is known by patients as a caring, skilful doctor, though he
says, “I learned something of everything, but specialized in nothing.” He adds:
“There are great advantages to having a barefoot doctor in the village. The
patients are all my neighbours. I know each family’s situation, lifestyle and
habits. Since I see my patients very often, even if I cannot diagnose precisely
the first time, I can follow up closely and give a better diagnosis the next
time.”
When the rural cooperative health-care system
was dismantled in the 1980s as a result of China’s economic liberalization, Liu
Yuzhong was hired by the local Dingfuzhuang Health Centre on the eastern
outskirts of Beijing. “I was lucky because I had passed a Ministry of Health
exam in 1981 and acquired the certificate to practise as a village doctor.”
Liu Xingzhu believes health-care services did
suffer in the late 1970s and early 1980s when the agricultural sector was
privatized. “The barefoot doctors, who were paid collectively by the commune,
lost their source of income. Many turned to farming or industry. The most
direct effect was that few did inoculations or provided primary health care for
the peasants. Many diseases that had been eradicated emerged in the countryside
again.”
The user-pays system introduced in China in the
1980s left many out of pocket or unable to afford treatment. The government in
recent years has recognized the need to increase health spending and promote
new health insurance schemes, a reflection perhaps of China’s special
commitment to a primary health care system that “everyone can enjoy, reflects
social equality, is affordable for everyone and matches social and economic
development,” according to Zhang. Dr Lei Haicho of the Department of Health
Policy and Regulation at the Ministry of Health, says the New Rural Cooperative
Medical Scheme introduced in 2003 now covers more than 800 million rural
residents, while public financing of the health system has increased
substantially.
Zhang maintains, however, health-care standards
have risen steadily in China, thanks in part to the work of village doctors and
health workers, who, he says, receive excellent training and support. “The
maternal mortality rate in rural China has decreased from 150 per 100 000
before 1949 to today’s 41.3 per 100 000. The infant mortality rate for the same
period has decreased from 200 per 1000 to 18.6. China now has more than 880 000
rural doctors, about 110 000 licensed assistant doctors and 50 000 health workers.”
He believes primary health care has also helped reduce poverty in China. “Only
with a health body can people undertake education and production activities and
improve their living standards. Village doctors have played a significant role
in preventing people from becoming impoverished.”
Despite the challenges China faces in providing
a modern health-care service to all of its 1.3 billion people, the barefoot
doctors and their successors can still show the way to the rest of the world in
primary health care, according to Zhang Lingling. Writing in the Young Voices
in Research for Health 2007 essay competition sponsored by the Global Forum for
Health Research and the Lancet, the doctoral student at the Harvard School of
Public Health said: “The impact of barefoot doctors in rural health-care
services still exists. Today, both researchers and policy-makers have widely
acknowledged it is hard to bring people to work in rural areas. Even the
developed countries have experienced a difficult time attracting medical
professionals to rural places [so] training local people seems to be the
optimal solution [in] building sustainability in rural health-care services.”
Liu Xingzhu also believes the Chinese model can
inform other countries’ approach to primary health care. “Chinese experience
showed that to promote primary health care, the key issues are human resources
and medicine. Chairman Mao advocated there was no need for five years’
training; one year was enough to train a doctor. Short-term training focusing
on specific types of work, such as antiviral treatment or prenatal care, is
sufficient to meet the demands of primary health care, especially in the
countryside or poverty-stricken areas.”
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