Factors influencing the provision of public health services by village doctors in Hubei and Jiangxi provinces, China
Yan Ding a, Helen J Smith b, Yang Fei a, Biao Xu c, Shaofa Nie d, Weirong Yan e, Vinod K Diwan e, Rainer Sauerborn a & Hengjin Dong f
a. Institute of Public Health, Heidelberg University, Heidelberg, Germany.
b. International Health Group, Liverpool School of Tropical Medicine, Liverpool, England.
c. School of Public Health, Fudan University, Shanghai, China.
d. Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
e. Institute for Global Health, Karolinska Institute, Stockholm, Sweden.
f. Centre for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, 866 Yuhangtang Road, Hangzhou 310058, China.
Correspondence to Hengjin Dong (e-mail: firstname.lastname@example.org).
(Submitted: 01 July 2012 – Revised version received: 18 October 2012 – Accepted: 19 October 2012 – Published online: 16 November 2012.)
Bulletin of the World Health Organization 2013;91:64-69. doi: 10.2471/BLT.12.109447
In rural China, health services are delivered through a three-tiered system of village clinics, township health centres and county hospitals.1 Village clinics are at the bottom tier, where village doctors serve as patients’ first line of contact with the health system.2 Beginning in the 1960s, the Chinese government began a village doctor training programme to create a front-line workforce that provides public health services, such as vaccinations, and basic medical services, such as drugs and outpatient clinical care.3–5 The initial level of training was just a few months but village doctors now must have 2 to 3 years of professional training, equivalent to a high school diploma. Newly appointed village doctors are encouraged to obtain an assistant practicing physician certificate and all village doctors are required to pass an assessment every other year, and a village doctor certification examination every five years to continue practising.5
Local government agencies are required to subsidize village clinics for providing public health services.4 In the last two decades, however, reduced government health spending, together with weak supervision of village doctors by county health bureaus, has undermined preventive health services provision and disease surveillance activities.2,6 Over the same period, marketization of the health sector compelled village doctors to shift their focus to medical services, through which they earn most of their income.3,6 Because of their fee-for-service activities, village doctors are not considered government employees, despite the government’s initial role in training this workforce.3,5
The Chinese central government launched the Health System Reform Plan in 2009 to revitalize the provision of basic public health services. Key targets involve improving the ability of the three-tiered system to strengthen disease control and health promotion, as well as providing a package of basic public health services. This package includes establishing health records for all citizens; screening for major diseases for elderly people, women and children; managing chronic non-communicable diseases; providing health education; increasing vaccine coverage for 15 vaccine-preventable diseases; implementing prevention and control programmes for major infectious diseases and geochemical endemic diseases; and ensuring that births occur in hospitals.7,8 To motivate village doctors to provide these preventive services, the government pledged per-person subsidies of 15 renminbi (RMB) for 2009 and 2010, and 25 RMB for 2011.9 Central and local governments are responsible for providing different shares of the subsidy, depending on the region, with the western provinces receiving substantial contributions and the wealthier eastern provinces receiving no contribution from the central government.10
To understand village doctors’ perspectives about the subsidy and delivering public health services, we conducted focus groups and interviews with stakeholders in two provinces in central China during 2011. This research was conducted as part of the Integrated Surveillance System in Rural China project, which aims to improve the early detection of epidemics in rural China by integrating syndromic surveillance with the existing case report system.11
Setting and approach
In two counties each in Hubei and Jiangxi provinces, we conducted 10 focus group discussions with village doctors and in-depth one-on-one interviews with key informants comprising directors of township health centres and of county Centers for Disease Control and Prevention (CDCs) during 2011 (Box 1). We focused on village doctors’ perspectives on and experiences with the provision of public health services and adopted thematic framework analysis to inductively analyse and interpret the data. Ethics approval for this study was obtained from Heidelberg University, Fudan University and Tongji Medical College.
Box 1. Methods
Sampling and data collection
In each county we selected the director of the county Centers for Disease Control and Prevention (CDC) and one director each from three township health centres. Since these directors have direct contact with village doctors, they can provide insights into these doctors’ efforts to offer public health services. In total, four directors from county CDCs and 12 directors from township health centres composed this group of key informants.
We used a semi-structured topic guide to explore key informants’ views on the public health services provided by village doctors, the subsidies received by village doctors for providing these services, the willingness of village doctors to provide the services and the management of village doctors. After we conducted initial interviews, we broadened the focus of the detailed topic guide to include all professional practices and income sources for village doctors. Each interview was conducted in Mandarin in the participant’s office or meeting room, without others present. A senior researcher conducted the interviews to minimize the influence of the interviewer’s professional background and personal characteristics on the participant’s responses.12 All interviews were tape recorded with participant consent. Each interview lasted approximately 30 minutes.
Focus group discussions
In each county we selected three towns on the basis of their distance from the county centre and their level of economic development to ensure a representative sample with respect to these factors. In each town we organized a single focus group discussion attended by village doctors whose age and sex distribution was representative of the pool of village doctors affiliated with the local township health centre. In one county, village doctors from all three towns attended the same focus group discussion because the doctors were available to participate at the same time. Ten focus group discussions were conducted, each with approximately 10 participants.
We used the same semi-structured topic guide to facilitate all focus group discussions. The topic guide addressed the type of public health services provided, the amount of time spent on providing these services and the public health subsidy, and it sought participants’ perspectives and concerns. The topic guide was gradually adjusted on the basis of initial focus group discussions to encourage openness about income-generating activities and value recognition. Focus group discussions took place in the meeting rooms of township health centres and a doctoral student trained in qualitative research methods served as moderator. All other staff from county CDCs and township health centres left the room before the focus group discussion started. All focus group discussions were tape recorded with participant consent and were conducted in Mandarin. Each focus group discussion lasted around 50 minutes.
We collected data between March and June 2011.
Because of the study’s applied nature and its relevance to policy decisions, we adopted thematic framework analysis to inductively derive common themes across participant accounts.13 All recordings were transcribed verbatim in Mandarin and were not translated into English, to avoid loss of meaning.14 A bilingual researcher read through the transcripts several times and listed recurring viewpoints, in Mandarin, relevant to the questioning. On the basis of these viewpoints, we developed an initial thematic framework in English. We used MAXQDA (VERBI GmbH, Berlin, Germany) to code and retrieve data with a coding system developed on the basis of the framework. The framework and codes were modified as other important issues emerged. Two researchers discussed and rearranged the coded data into categories and identified possible themes. Tables were used to organize the data by theme and we then compared opinions and experiences among the three participant groups and across the four counties. When necessary, we reviewed the raw data and took the context into consideration, to make sure that the themes were consistent and coherent.
In 2010, there were 620 700 and 1 021 411 individuals in the Hubei study counties and 317 200 and 383 405 in the Jiangxi study counties. Villages varied in size, from several hundred to approximately 4000 inhabitants. Farming was the predominant occupation among residents. Hubei and Jiangxi ranked thirteenth and fourteenth, respectively, among the 31 Chinese provinces, municipalities and self-governed areas in terms of farmers’ average annual income; in the study counties, annual farmer income ranged from 5255 RMB to 6778 RMB (national average, 5919 RMB). Most villages had one clinic but some had more. The typical village clinic had 1 to 3 village doctors, although some clinics had up to 8.
During 2009–2010, approximately 3 RMB of the 15-RMB per-person subsidy were received by village clinics (with the rest shared by county CDCs and township health centres), depending on the number and quality of health records established by affiliated village doctors. In addition, according to province policy, in Jiangxi each village clinic received 300 RMB and each village doctor received 1200 RMB (if they were under the supervision of general township health centres) or 1500 RMB (if they were under the supervision of central township health centres), and in Hubei each clinic received 1000 or 1200 RMB but village doctors received no additional subsidies. Village doctors are entitled to claim other financial support from the government, including reimbursements for clinic construction costs (5000 RMB per clinic in Hubei and 10 000 RMB per clinic in Jiangxi) and new equipment (up to 3000 RMB). Village clinics are, in name, part of the government health system but they are owned by village doctors, who are responsible for profits and losses of the clinics and do not receive the government social pension.
The public health subsidy for each village doctor is distributed through township health centres on the basis of their assessment of the doctor’s performance in providing public health services. Village doctors expressed two concerns about this distribution structure. First, township health centres could impose economic penalties on them for public health work that was not completed or not done well. However, township doctors explained that they were subject to scrutiny from county-level institutions and that withholding subsidies was not a consideration. Second, the use of township health centres as intermediaries in the distribution chain could delay or prevent subsidy receipt. In one county, a township health centre director confirmed that village doctors received no subsidy in 2010 because of local government financial constraints.
The main concern of village doctors appeared to be that providing public health services was time-consuming and limited their ability to perform fee-for-service medical care; the majority acknowledged that policy requirements, rather than other considerations, drove them to provide public health services. The strength of the policy requirements was viewed differently by one township director, who expressed concern that the requirements did not necessarily impact village doctors because they are not employed by the government.
Although some township directors believed that village doctors did not take their public health responsibilities seriously, most key informants asserted that indifference has decreased since the introduction of the subsidy. All village doctors claimed they work hard to implement public health services. Some indicated that they worked at night to complete their public health activities, although they admittedly did so to maintain their fee-based medical service during the day. In one county, the director of the CDC acknowledged that village doctors prioritized providing medical services and that it was therefore common for them to spend time working on public health services at night.
Village doctors frequently mentioned that, despite their contribution to public health, they felt their effort was not valued by the government. One doctor emphasized the importance of feeling valued and how this feeling can influence their willingness to provide services, and village doctors across all four counties indicated a willingness to prioritize public health if they received a more substantial subsidy. Although the subsidy increased in 2011, all study participants considered it insufficient when compared with the amount of work expected of village doctors.
Finally, village doctors noted that, because they contribute a lot to public health but only receive a modest subsidy, have a modest income and lack a pension, they expected the government to include them in a social pension programme and to provide them with a greater than average income. Several township directors remarked on the latter concern by stating that the annual income earned by village doctors from medicines and medical and public health services was already above average (range: 8000–40 000 RMB) and that, for some village doctors, it exceeded the annual earnings of township doctors, who generally have completed 3 to 4 years of college, have an assistant practicing physician certificate and receive a basic salary plus a public health subsidy from the government.
Evaluation and lessons learnt
Box 2 highlights key lessons from this qualitative study. An interesting finding is that although village doctors prioritize medical services for which they can charge, they do their best to deliver preventive services that are part of the basic public health package. They claim that providing public health services involves a significant investment of time that has a negative impact on other income-earning activities. Village doctors also question the extent to which they and their public health work are valued, but some reports indicate that policy-makers hold village doctors and their public health role in high regard.5,7 A possible explanation for this discrepancy is that, because village doctors tend to equate value and recognition with remuneration, they feel undervalued if they consider the subsidy insufficient.
Box 2. Summary of main lessons learnt
- Factors to consider in future activities to improve the quality and extent of public health services provided by village doctors include actual and potential sources of village doctor income (i.e. medical services, social pension and other government support), the relationship between village clinics and township health centres and the amount of public health subsidy.
- A quantitative evaluation of the relationship between the public health subsidy amount and the willingness of village doctors to provide public health services is needed.
- It is important to subsidize supervision of village clinics by township health centres and to ensure that the performance-related deductions from village doctors’ subsidies are re-allocated to rural public health services.
An important question arising from our study is why the government does not make a larger investment in providing public health services through village doctors. One explanation is that the current government strategy is to invest in the demand side of the health system rather than the supply side.5 Another explanation is that, after the severe acute respiratory syndrome epidemic, the government invested heavily in infectious disease control at the expense of other aspects of the public health system.15 Some authors suggest that the central government would like to invest more in village doctors,5 but continued reliance on local governments to fund at least part of the subsidy may limit the amount available for distribution, especially in poor areas, which results in insufficient remuneration and, potentially, substandard quality of public health services.3–5
Supervision of village doctors does not appear to be as effective as it could be. Village doctors complained that the outcome of supervision by township staff sometimes influenced the amount of subsidy they received and township directors mentioned that supervision can be difficult to conduct. Other studies confirmed difficulties in supervising village clinics3,5 and acknowledged that public health services are weak in villages partly because of limited supervision.3
Our findings suggest that, apart from the financial element of the subsidy, the relationship between village clinics and township health centres is central to improving public health services provided by village doctors. Further research is required to document the relationship between the quality of the public health services provided by village doctors and the level of incentives they receive, to provide an objective metric by which township officials can evaluate the performance of village doctors. It is also important to find ways to re-allocate subsidies deducted from village doctors for poor performance to other rural public health services. Finally, introduction of a pension programme is also an important consideration. There appears to be sufficient political will for this: at the time this study was conducted, the central government started advocating for a pension programme for village doctors.16
In this study, we did not include central or provincial policy-makers among our study participants, nor did we obtain the perspectives of health-care consumers. While our findings are probably generalizable to other provinces in central China, the situation is likely to be different in eastern China, where local governments have the resources to invest more in rural health care, including public health services, compared with western China, where the central government tends to finance a greater proportion of the subsidy.
We are grateful to the study participants in Jiangxi and Hubei province in China, especially CDC staff in the study counties. We also thank Yaqiong Wu, Li Tan, Lu Long, Yi Tian, Qi Zhao, Yipin Zhu and Miao Yu for their help in the field work.
Yan Ding and Hengjin Dong contributed equally to the study.
Much of this work was conducted while Hengjin Dong was the junior group leader of Health Economics and Technology Assessment at the Institute of Public Health, Heidelberg University, Heidelberg, Germany.
This work was supported by a grant under the European Union Framework Programme 7 (project number 241900).
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