context: Rural grassroots healthcare has been crumbling since the dismantling of the collectivised ‘barefoot’ village doctor system, which contributed tremendously to early public health efforts. It lags behind further as urbanisation draws away the young and healthy, and patients lacking quality medical service crowd into urban hospitals. Multi-level care is the solution but deeper reforms have only just begun.
The number of rural village clinics decreased by 11,000 to less than 600,000 from 2020 to 2021, according to a NBS (National Bureau of Statistics) report released on 28 Feb 2022. The decline has continued for nine years in a row, points out Xu Yucai 徐毓才 frequent health reform commentator and former grassroots healthcare professional. Mass rural-urban outmigration of the young workforce has reduced local purchasing power while the ‘left-behind’ elderly and children increase pressure on the rural healthcare system. Additionally, regardless of the actual size of the population, local authorities have closed down many rural clinics to conform to the irrational rule of only one clinic per village. Similar closures occurred during the administrative reclassification and the merging of villages.
At the same time, village doctors are declining by roughly 50,000 persons annually, reports China Med. This has created severe challenges to rural public health and medical services, says Dai Xiuying 戴秀英 CPPCC National Committee member. Lacking a stable income, village doctors often rely on family doctor contract service fees and public health subsidies. But these have been affected by outmigration as they are calculated per patient visit. Moreover, subsidies are often docked by local officials. Many national policies aiming to ameliorate the situation have varying results in local implementation. Xu and Dai recommend
- improving the subsidies and pension system to ensure a living wage for village doctors
- a special operation to tackle subsidy embezzlement
- a supervision and evaluation system to make sure subsidies reach village doctors
- further promoting family doctor contracts
- rectifying local bureaucratism