Dilemma of village medical reform

  China News Weekly reporter/Yuan Suwen

  Issued at 2021.11.8, Issue 1019 of "China News Weekly"

  "It's been five years." Village doctor Wang Jianhua said in a low voice. This is because he refused to give villagers the time to go to the medical insurance reimbursement system under the pretext that the system is broken.

He also found that as long as the villagers' medical insurance money is not moved, the township hospital in charge of supervision has no incentive to investigate him.

He also evaded the "zero mark-up" requirement for essential medicines, bought the medicines from pharmacies, and sold them to patients at an increased price.

He himself knew that this was "a violation of regulations."

  But he has his own set of justifications: the reimbursement procedure is too complicated and he will not use it; the types of "basic medicines" are limited and the prices are sometimes more expensive; patients believe in his medical skills and have no complaints about self-financed medical treatment; if villagers want to spend their own medical insurance accounts The money in it can go to the town hospital for medical treatment.

  In a village in eastern Sichuan, Wang Jianhua evaded the reimbursement system, making it impossible to implement medical insurance benefits for patients.

Village doctors in other places choose to falsify medical records for reimbursement, which is to defraud medical insurance funds.

Recently, in Cuikou Village, Laihe Town, Shan County, Heze County, Shandong Province, the village clinic registered 2,908 "stroke patients", which exceeded the number of permanent residents in the jurisdiction. More than 37,000 medical records were suspected of being falsely reported, and the medical insurance fund was collected. , It also affected the villagers’ commercial insurance. After the incident was exposed, the village doctor Zhu Moju was detained on suspicion of fraud.

  Fifty or sixty years ago, the barefoot doctors who "sponsored agriculture and medicine" were an important medical force in rural China.

But in the 1980s, rural doctors became self-employed self-employed, medical services became "commodities," and the bottom farmers looked down on diseases.

Entering the new century, the "new rural cooperative medical care" has been implemented, and farmers have access to medical care. In further reforms, the main business of rural doctors has begun to shift to public health services.

  Observing from the experience of Wang Jianhua, who has practiced medicine for 35 years, there is still a gap between the actual situation of the grassroots and the goal of "strengthening the grassroots" of policy makers.

Xu Yucai, who served as the deputy director of the Shanyang County Health and Health Bureau in Shaanxi Province, compared the village doctor to the "capillaries" in the human body.

"If a person’s large blood vessels are broken, symptoms will appear very quickly, and the human body will immediately perceive it and see a doctor quickly. However, if the capillaries are malfunctioning, they may not show symptoms until they eventually break down in a large area. It is also more troublesome to treat. So the more basic problems, the more difficult it is to treat the problems of capillary end."

Changes in the role of village doctors

  Wang Jianhua's clinic is not big, it is on the first floor of the self-built house, and there are two staff members—their husband and wife.

He has a license for practicing physician qualifications, which is higher than that of a wife who is registered as a "village doctor".

The couple cleaned up the self-built small building. Even in the middle of the night, if an old man had chest pain or a child had a high fever, he would jump out of bed and turn on the lights in the consulting room.

  Everything is just as his father did.

Their parents are "barefoot doctors."

Wang Jianhua's father graduated from Xinjiang Railway Health School in 1950. Later, he gave up his assignment and returned to his hometown in Sichuan to practice medicine. He became the first batch of "barefoot doctors" in China, and he continued to work at the grassroots level until he was in his 70s.

  At the beginning of the founding of New China, in rural areas, natural villages set up clinics with health workers.

At that time, the positioning of rural doctors was to "not divorce from production" while performing medical and public health functions.

At that time, doctors and hospitals were mostly concentrated in the cities. Although the rural population made up the majority, they lacked doctors and medicines. This attracted the attention of the top leaders of the country at that time.

On June 26, 1965, Mao Zedong issued the "June 26 Directive", "The focus of medical and health work should be placed in the countryside!" "Cultivate a large number of doctors who are'affordable in rural areas' to treat farmers. service."

  According to public information, since 1966, some production brigades began to experiment with "cooperative medical care". Each member paid 1 yuan each year to form a fund pool. Each member only spent 5 cents on diagnosis and treatment fees in the brigade clinic. Initial medical protection.

Barefoot doctors are in full bloom throughout the country. According to statistics, by 1977, the number of barefoot doctors in the country had reached 1.5 million.

  Wang Jianhua said that when his father was young, his reputation as a village doctor was very high.

"At that time, village doctors were able to deal with many diseases, because the conditions of the town and county hospitals at that time were not much better, so village doctors were very popular." In addition to treating illnesses, the barefoot doctors at the time also walked the streets with their medicine boxes on their backs. Chuanxiang, "delivering medicine to the mouth", distributing anti-malarial drugs, polio pills and other medicines, injecting vaccines, planting "vaccinia", helping the villagers "eliminate the four evils", and putting a lot of energy into rural public health undertakings , Also played a practical effect.

  In the mid-to-late 1980s, the people's commune system withdrew from the stage of history, and the cooperative medical model of the people's commune was also suspended.

In 1985, the "barefoot doctor" was renamed "village doctor". From this year on, barefoot doctors who passed the examination and were equivalent to the technical secondary school level will receive the "village doctor certificate."

Since then, "village doctors" have become self-employed, clinics have become profit-making institutions, and the cost of medical treatment for farmers has also increased.

"When the ambulance rang, a pig was raised for nothing; I lived in the hospital last time and worked for nothing a year." At the end of the last century, these sayings were widely popular in rural areas.

  Ye Zhimin, a professor of public health at Harvard University in the United States, has been studying China's medical policy for a long time, and has carried out research projects in China since the end of the last century.

She told China News Weekly that from the end of the 1980s to the beginning of the new century, rural doctors were almost self-employed. “At that time, many village doctors did a good job, but that they had good economic conditions. Can make money."

  That may be the most "vigorous" era for rural doctors.

Ye Zhimin recalled that more than 20 years ago, she found in a village in Shandong that the village doctor was the richest in the whole village.

"But is the medical service he provides the best? That's not necessarily." She pointed out that in the era when village doctors became self-employed, the problem of "over-medical treatment" was serious, and not much public health work was done with low subsidies. .

"At that time, being a village doctor was to see a doctor, but the ability to see a doctor was not high. No matter what kind of disease you were, you were prescribed a lot of medicine."

  The new medical reform in 2009 put forward the principles of "guarantee basics, strengthen the grassroots, and build mechanisms" to solve the problem of "difficult and expensive medical treatment" for the common people.

An important measure to "strengthen the grassroots" is to rebuild the rural three-level health network, including county-level medical and health institutions, township health centers, and village clinics. The village clinics are the bottom of this network. Village doctors want to realize farmers The "gatekeeper" of "the little sick can't leave the village".

  Wang Jianhua has a mobile phone that never mutes and accepts consultation from villagers at any time.

The township hospital is more than 5 kilometers away from the village, and Wang Jianhua's clinic takes care of the villagers' minor illnesses.

  However, since the new medical reform, Miao Yanqing, deputy director of the Rural Health Research Office of the Health Development Research Center of the National Health Commission, has pointed out that although the "strengthening the grassroots" has achieved some construction results, the service capabilities of the grassroots medical institutions have not improved, but have improved. Has declined to varying degrees.

  The first is the serious aging of village doctors.

According to the results of a questionnaire survey of 1,828 village doctors conducted by the Village Doctor Project of the Shanghai Fosun Public Welfare Foundation in 2021, more than 70% of village doctors are over 40 years old.

At the beginning of this year, Nanmeng Town, Gaocheng District, Shijiazhuang City, Hebei Province, which was closed due to the epidemic earlier this year, had 120 medical staff, and the youngest village doctor was 50 years old.

  According to the "Statistical Bulletin of the Development of my country's Health Services", the number of health clinics nationwide has declined year by year in recent years, from 639,000 in 2016 to 609,000 in 2020.

Among the practitioners in village clinics, the number of people certified as "village doctors and hygienists" has been declining, from 1 million in 2016 to 792,000 in 2020; but the number of "practicing (assistant) physicians" during the same period It has been increasing year by year, from 320,000 to 465,000.

  Xu Yucai, who has been dealing with the grassroots for a long time, explained that in the reform of rural institutions, small villages with a small number of people merged into large administrative villages, so the total number of villages decreased. In principle, each administrative village retains one clinic, and the number of clinics is also reduced.

The increase in the number of licensed (assistant) physicians has benefited from the liberalization of the "National Examination" suitable for village doctors-the qualification examination for rural general practitioner assistant physicians.

  The "village doctors and hygienists" in the statistics are those who have not passed the "national examination". Among them, the "rural doctors" are those who have passed the county-level examination and registration, and the "hygienists" are those who have not passed the country doctors' examination. Many of these people may be elderly village doctors.

Xu Yucai said that those who have obtained the qualifications of practicing (assistant) physicians may just "attach" their work units to the village clinics, while people work in other places.

  The proportion of farmers seeking medical care in the clinic has also been declining.

Xu Yucai compared the data in the "Statistical Bulletin on the Development of my country's Health Care Services" between 2010 and 2020: The number of village clinics in 2020 was 1.43 billion visits, although the impact of the epidemic was 170 million fewer than the previous year.

"But in fact, the number of consultations in the village clinics has been declining after reaching a peak of 2.01 billion visits in 2013. Compared with the peak, the number of consultations has dropped by 19.4%, and compared with 2010, the number of consultations has dropped by 13.9%."

  Xu Yucai also discovered that the amount of consultations and hospitalizations lost by village doctors may have gone to higher-level hospitals.

In the ten years from 2010 to 2020, while the number of village doctors' diagnosis and treatment is declining, the number of visits and admissions in county-level (including county-level cities) hospitals has increased by 68.1% and 83.4%; while the number of visits in township hospitals has increased by 26.4 %, the number of admissions decreased by 6.8%.

His observation is consistent with Wang Jianhua's experience.

Diagnosis and treatment capacity is weakened

  Wang Jianhua remembers that around 2009, the number of people visiting his village clinic began to decrease.

This is because, according to the new reimbursement system at that time, “reimbursements can be made for hospitalization, and many villagers are going up, and the hospitals in the town and county are much better.”

  In October 2002, the "Decision of the Central Committee of the Communist Party of China and the State Council on Further Strengthening of Rural Health Work" pointed out: "Gradually establish a new type of rural cooperative medical system focusing on the overall planning of major diseases" (hereinafter referred to as "new rural cooperative medical care").

The new rural cooperative medical system began to be piloted in 2003 and will basically cover rural areas across the country by 2010.

  At the initial stage of the implementation of the "New Rural Cooperative Medical System", only hospitalization expenses were reimbursed, but outpatient expenses were not reimbursed.

Huang Erdan, a researcher at the Health Development Research Center of the National Health Commission, told China News Weekly that such a design conforms to the insurance principle of “social mutual aid”.

"It must be insured against serious illnesses. According to international standards, the fewer people who spend more money, the higher the efficiency of insurance. If minor illnesses are also reimbursed, it will be evened out, which is equivalent to paying everyone's money. It makes no sense to go back."

  But the problem is that soon afterwards, some hospitals expanded their hospital indications, encouraging patients to stay in hospital or "housing in bed," and "patients and doctors colluded."

Huang Erdan summarized this as, "The New Rural Cooperative Medical System has activated the township health centers and county hospitals as a whole."

  At the same time, it is not easy to raise funds for the new rural cooperative medical system because it only covers serious illnesses.

"The farmer does not have the concept of mutual aid. He will only feel that it is not necessary to pay every year. Moreover, it is very difficult to charge in rural areas. Many people do not have a bank account. Sometimes the cost of collecting tens of dollars is far greater than tens of dollars. "Huang Erdan said that in order to encourage farmers to participate in cooperative medical care, some of the money was later used for outpatient reimbursement.

Around 2008, the New Rural Cooperative Outpatient Co-ordination began to be gradually implemented throughout the country, and health institutions in villages and towns were able to reimburse part of the outpatient expenses.

  Ye Zhimin also pointed out that in the early stage of the new rural cooperative medical system, because outpatient expenses were not reimbursed, villagers were encouraged to go to township health centers and county hospitals for hospitalization, and village clinics that could only see outpatient clinics began to be ignored.

  In addition, with the development of the economy, super-large hospitals in cities began to rise, and medical resources and patients flowed from the grassroots to large hospitals. This trend continues to this day.

Ye Zhimin pointed out that China's current medical system is still dominated by large hospitals, strong in the top three hospitals, and the grassroots is still weak.

Rural doctors are the entrance to the medical system for rural patients, but the reality is that patients skip the multi-level medical institutions and go straight to the big hospitals.

  "So the inability to retain people in rural areas is not just a problem in one aspect. If you want to improve the situation, you need to establish a mechanism, not a unilateral policy." Ye Zhimin said.

  But soon, the village doctors discovered that not only had they not established a new mechanism to keep the patients at the grassroots level, there were even stricter constraints waiting for them.

Wang Jianhua now uses an outpatient prescription software that he bought online to prescribe drugs when he receives a doctor. The data is not shared with any higher-level medical institutions or regulatory authorities. The annual fee is 20 yuan.

Whenever a patient took out a medical insurance card, hoping to "reimburse", he lied that "the system was broken" and asked the other party to pay for it.

His approach does not comply with the current regulations.

  In 2009, as an important measure of the new medical reform, the "essential drug catalog system", which is mainly applicable to primary medical institutions, was implemented. Village clinics were no longer allowed to purchase drugs from pharmaceutical factories and could only purchase drugs from township hospitals. Essential drugs purchased centrally are sold to patients at a "zero markup rate."

Before this, village doctors' income almost depended on selling medicines to earn the price difference.

This action is tantamount to directly discarding the "rice bowl" of the village doctor.

After losing the profit of the medicine, most of the village doctor's income depends on government subsidies.

  Huang Erdan said that the original intention of implementing the "basic medicine" system is to promote graded diagnosis and treatment and standardize the use of medicines.

The concept of "basic medicine" originated from the basic medical kits provided by international organizations to aid Africa, which contained free medicines for common diseases. Grassroots distribution, if the village doctors are raised, the grassroots will be close to free medical care."

  However, village doctors did not realize the good intentions of this design, and their direct feeling was that their right to prescribe was restricted.

Liu Zhigang, a village doctor in the Northeast, said, “The entire medication spectrum has changed. Some common diseases have disappeared from the list, and many of the drugs in the catalog are not familiar to us, and they don’t correspond to my usual medication habits. I felt stretched.” However, the two “basic medicines” he listed are not in the catalog, but the two medicines that village doctors love to use: Pudilan and Yankening, both belong to the category of Chinese patent medicines that often cause great controversy. .

  If the village doctors cannot understand the original intention of the basic medicine system due to their own level, it is not a big problem. What patients cannot accept is that Liu Zhigang found that the price of some basic medicines purchased from the health center is more In the past, the prices purchased from pharmaceutical factories were much higher; even after some medicines were reimbursed by medical insurance, the price paid by patients was higher than that of medicines purchased through other channels.

  Drugs are entered into the catalog through a bidding process, sometimes lacking transparency, and there have been major cases of basic drug supplementation corruption.

In June 2010, the Chinese Academy of Social Sciences issued a survey report to evaluate the results of the implementation of the essential medicines list system over the past year.

Zhu Hengpeng, the person in charge of the survey and the deputy director of the Institute of Economics of the Chinese Academy of Social Sciences, said in an interview with the media, "(2010) Field surveys in Zhejiang, Fujian, Beijing, Hunan and Hubei from January to March showed that government bidding for essential drugs The price includes 60% of the rebate and rebate space for hospitals or individual doctors.” “In the provincial centralized bidding and procurement of essential medicines implemented in various provinces this year, a considerable part of the essential medicines won bids were significantly higher than the actual prices of the previous health centers. buying price."

  Ideal is full, the reality is very skinny.

Huang Erdan admitted that the basic medicine system has been implemented in China for more than a decade, and not only has it failed to achieve free medical care, it may be more expensive to sell.

Moreover, since the basic medicine system is mainly aimed at primary medical and health institutions, after a patient sees a doctor in a county hospital, if the county hospital prescribes a non-basic medicine, it will not be available in the township health center or village clinic. In the end, they have to return to the county. The hospital queues up, "it is exactly the opposite of the idea of ​​hierarchical diagnosis and treatment."

  Nowadays, the implementation requirements of the basic medicine catalog system have begun to loosen at the local level. For example, Yunnan, Inner Mongolia, and Guangxi have issued documents that allow grassroots medical institutions to also be equipped with a certain proportion of non-essential medicines.

In the next step of reform supported by Huang Erdan-the implementation of compact county-level medical donors, the drug catalogs of hospitals at all levels are required to open up and break through the restrictions of the basic drug catalogs.

  In recent years, news about the collective resignation of village doctors has repeatedly appeared in the newspapers. The reason for their resignation is mostly due to increasing work pressure but decreasing income.

"We always consider the interests of rural patients and have not fully mobilized the enthusiasm of rural doctors." Huang Erdan pointed out that the new medical reform "cleaned up" the high income of village doctors, which caused a lot of loss of young and capable village doctors. .

  The recent incident of suspected insurance fraud by village doctors in Shanxian County, Shandong Province was also produced in this context.

Xu Yucai said that because the money in the medical insurance account cannot be withdrawn, the masses also lack the motivation to supervise this.

"Someone works outside, and his medical insurance account cannot be spent or inherited. This year, it won’t be invalidated next year, so the people don’t care. Many things will happen frequently and frequently if they lose the supervision of the masses, relying solely on government departments. Sometimes it can’t be supervised. There is a problem of supervision ability.”

  But in the view of Li Ling, a professor at the National Institute of Development Studies at Peking University, this is not just a matter of regulation.

"In recent years, the country’s medical reform has actually invested a huge amount of money at the grassroots level, but it is the problem of insurance fraud. I think not only village doctors, it should be said that hospitals at all levels and various types of insurance are cheating insurance. It is not only private hospitals that are cheating insurance, but public hospitals. Hospitals are also cheating insurance, because fundamentally speaking, as long as there is excessive medical treatment, insurance is cheating." Li Ling pointed out that there are also problems with the current system design.

"You can only get reimbursement after seeing the disease. You will stimulate the doctor to see the doctor hard and expand the number of outpatient clinics. As for the village doctor, if there are few patients, he will have to make up the patient."

The public health function has become a form

  Excessive medical treatment and random prescribing of drugs are wrong, Huang Erdan said, but the general clinical diagnosis and treatment capacity of village doctors is not high, and it is very difficult to improve in a short time.

As the reform progresses, he is also constantly thinking about the positioning of the village doctor, "What is the responsibility of the village doctor? Is it to open a small clinic to sell medicine?"

  The answer Huang Erdan found was that the village doctor should become the farmer's "health gatekeeper."

Village doctors have a unique advantage in the ability of public communication between farmers. Under this premise, the main responsibility of village doctors should be to carry out health management and actively provide health consultation and intervention services.

  "This is not the same concept as sitting in the clinic waiting for others to come to see a doctor." Huang Erdan visited several village clinics and found that many village doctors actually knew the "key groups" under their management, and not only knew their basics. I also know the family situation, which city the family members are in, and even the future plans of the elderly.

However, although the village doctor knows a lot, how to motivate the village doctor to intervene more, make farmers healthier, and thus obtain more income, these "interest mechanisms" have not yet been opened up.

  The positioning of the new medical reform in 2009 for village doctors is to shift from self-financing "self-employment" to relying on government subsidies, and through subsidies this "baton", so that village doctors can focus their work on public health services.

Currently, village doctors can obtain three types of subsidies: subsidies for basic public health services, subsidies for the basic drug system, and subsidies for general diagnosis and treatment expenses.

Among them, the largest amount is the "basic public health service project subsidy", which is similar to earning the government-purchased funds for the services of village and town health institutions, focusing on serving children, pregnant women, the elderly, and patients with chronic diseases. The subsidy standard investment is increasing year by year. An additional 5 yuan per year will be added.

In 2021, the per capita subsidy standard for basic public health services is 79 yuan.

  The task of basic public health services in rural areas is jointly completed by the villages and towns, so the subsidy of 79 yuan is also allocated by the villages and towns for a second time.

Xu Yucai explained that in order for village doctors to get the money, they need to pass the assessment of basic public health service items. The assessment is carried out by the town health center entrusted by the county health bureau.

In his previous work experience, the village doctor can get about 50% of the amount.

  But Wang Jianhua complained that his distribution ratio with the township hospital was 40% and 60%, and he had a small head.

His clinic receives an annual subsidy income of about 20,000 yuan. After deducting miscellaneous expenses such as water and electricity, medical consumables such as test strips for diabetic patients, and office paper, there is still less than 10,000 yuan.

According to China News Weekly, the per capita disposable income of resident urban and rural residents in his county will be more than 25,000 yuan in 2020, and the per capita disposable income of rural resident residents will be more than 18,000 yuan.

Xu Yucai also pointed out that some counties have financial difficulties and sometimes withhold subsidies issued by the state, reducing the income of village doctors.

  Huang Erdan also admitted, "It is said that after subsidizing the village doctors, the income is about the same as before the medical reform, but in fact it is just an average line. In this way, those with ability and income below the average line will desperately come in. The ability and income The people on the top are all gone. They are originally a private economic market, and the government buys them as a whole. The monthly payment is seven or eight thousand yuan, and a village is equipped with 1 to 2 village clinics. This idea is very good. Yes, but there is no vitality."

  At the operational level, public health services are transformed into incomplete forms for village doctors.

"Public health projects work too much. I basically spend time outside every day, meeting to study, going to the countryside to interview chronic diseases, mental illnesses, children, and maternity. There are too many things." Wang Jianhua said, filling out the form took up a lot of time and made a lot of work. The actual work of public health cannot be completed. “Some of the work only stays in paper or electronic forms, and the villagers can’t get real services. Check on it, and only according to the objectives of the assessment rules, you can look up one by one. record."

  Wang Jianhua feels that even if the follow-up is on time, the effect is sometimes not obvious.

In 2019, among the population served by Wang Jianhua, there were 39 hypertension patients and 20 diabetes.

According to regulations, he will follow up patients with chronic diseases once every quarter.

  Wang Jianhua said that at each follow-up, he advised patients with high blood pressure to take medicine and explained to them the dangers of high blood pressure. “I advise them to live a healthy life and instruct them on how to exercise and how to take medicine. The medicine is not positive. Instead, I heard people say that taking a certain medicine is good, so I hurried to buy it."

  For villagers with poor compliance, Wang Jianhua has nothing to do.

"The treatment of hypertension is not in the village clinic. I give the patients a transfer notice and ask them to go to the higher-level hospital for treatment, but if they don't go, I can only constantly check their blood pressure and keep issuing notices." Follow-up, Wang Jianhua is recorded on the form.

  Huang Erdan admitted that many village doctors will take 50% to 70% or more of the time to fill out various forms, "Because only by filling out this form can the assessment pass the assessment and earn income. But the irony is that when people come to see the doctor, he doesn't have any income. time."

  Professor Wei Lai of the School of Management of Zunyi Medical University has visited many places for research and published articles such as "Continuous-Fragment-Integration-The Historical Evolution and Enlightenment of my country's Rural Tertiary Medical and Health Network Service Provision Model", and the effect on basic public health services There are doubts.

He believes that most of the current cases are evaluated according to the process, not the result.

"For example, to assess the follow-up of village doctors, the advantage is that they go every time, but the disadvantage is that the quality is difficult to guarantee."

  In this regard, Huang Erdan pointed out the crux of the problem, “It is the state that gives the village doctors the money to serve the people, and the village doctors don’t take the money. Prove that the village doctors should do their job well? Just fill in the form every day. In the end, there will be a group of'cousins' and'cousins' at the grassroots level. On the contrary, the actual service time of the village doctors has been reduced." Huang Erdan said, this is again A place where there is a huge gap between theory and practice, "but I think this is also a way to go. You don't propose a standard at the beginning, and then you want to refine it later, there is no way."

  Wei Lai pointed out that the increase in tables and data does not mean that it is effective.

"For example, the control rate of chronic diseases assessed by primary public health services is very variable, and it is actually difficult to monitor. Have we controlled it from the end, such as the prevalence rate and the hospitalization rate of the people? Woolen cloth?"

  He also doubts the authenticity of some data. For example, in some places, the health management rate has reached 90%, and the disease control rate has reached more than 80%, which is increasing year by year. "Then why are so many people sick? When you control the intensity, Why is the hospitalization rate also up?"

It’s not that the countryside is regressing, but that the growth is not as fast as the cities.

  However, even if the village doctors fill in the form carefully, they cannot increase their income. On the contrary, with the loss of the rural population, the "heads" managed by the village doctors decrease, and their income is still declining.

According to the seventh national census data released on May 11 this year, China’s rural population in 2020 will decrease by 164 million compared with 10 years ago.

  Wang Jianhua told China News Weekly that although the amount of state subsidies has increased year by year, the "approved number" of the population he is responsible for has decreased each year.

"The registered population I served was originally 1,460 people. At 79 yuan per person, the town health center took 60%, and I took 40%. The income was pretty good, but there were not so many people actually approved each year." In 2019, Wang Jianhua's approval The managed population is 987, and by 2020, it has been reduced to 800.

  Ye Zhimin pointed out that the exodus of the rural population is not because the rural areas themselves are regressing, but the development is not as fast as the cities.

"In the past 10 years, China's rural medical system has been gradually established, but the development of rural areas is still much slower than that of cities. Therefore, the gap between rural and urban areas is getting bigger and bigger, and more and more people are flowing to cities."

  She also pointed out that in other countries in the world, with the advancement of industrialization and urbanization, rural areas are gradually shrinking.

"This is a natural process, and it depends on what policies the government uses to treat the countryside." She mentioned the recent China's rural revitalization opinions, many of which are aimed at improving the living and economic conditions in the countryside so as to retain people.

"It depends on how these policies are being advanced in the future, and what the results are. At present, I think the speed is a bit slow."

  Xu Yucai said that the assessment is generally based on the location of the household registration, and the exodus of a large number of people reduces the actual income of the village doctors, and it is also easy for the village doctors to fabricate false files for the exodus.

Wang Jianhua also mentioned that when a hypertensive patient in his jurisdiction "wasted" to a certain big city, according to local regulations, he needed to live there for more than six months to establish a health record. , I can urge him, but as long as he moves away, he will lose the chain."

  Wei Lai believes that there is actually a certain degree of "depreciation" of the identity of rural doctors.

"In the field of vision of some policymakers, the quality and level of rural doctors are not placed on a higher position. The requirement for rural doctors is to'just ask for something, not for good'."

  "Whether they are urban residents or rural residents, their disease spectrum is actually similar, but the doctors who provide medical services do have different levels. I think this concept is not correct." Wei said.

How to encourage village doctors to play a better role?

  In Tianjin, following the local demolition, in 2018, village doctor Deng Miao became a “temporary worker” in the town’s hospital.

He no longer visits doctors, but engages in public health services full-time.

However, Deng Miao was not satisfied with his "supernumerary" status. Without an establishment, he would "different pay for the same work" as regular employees.

"I heard that in some eastern coastal areas, village doctors like me who have passed the qualifications of rural general practitioner assistant physicians have been recruited."

  Huang Erdan once wrote a report to analyze and solve the problem.

He pointed out in the report that the first thing to do is to clarify the functional positioning of village doctors, to solve their status and treatment issues, "old methods for the elderly, new methods for newcomers", so that the old village doctors who are not very capable of business can retire. The old village doctors with service ability strengthen treatment guarantee and carry out standardized management, while the assessment of young village doctors must be strengthened.

"Some may be included in the management of the establishment of township health centers. Eventually, the village clinics will become the dispatch agencies of the township health centers to solve the problem of the establishment of village doctors." He said.

The second is to improve the level of service capabilities of rural doctors. "Village doctors must at least reach the level of practicing assistant physicians and have basic capabilities in the diagnosis and identification of common diseases."

The third is to innovate the service mode of village doctors, so that village doctors will change from passive to active, and carry out health management, especially for the daily diagnosis of elderly patients with chronic diseases and tumor patients.

  In February 2020, the No. 1 document of the Central Committee of the Communist Party of China and the State Council, “Opinions on Doing a Good Job in the “Three Rural Areas” to Ensure an All-Round Well-off Society” With the establishment resources, the township hospitals can give priority to hiring qualified village doctors.

  But solving the problem of village doctors is not that simple.

"This is a problem caused by the entire system. It can only be said that the governance capacity needs to be modernized, especially the grassroots governance is very important." Xu Yucai said.

  Huang Erdan believes that village doctors should be general practitioners, and their main responsibility is to actively carry out health management. This requires huge incentives, but further research and exploration are needed to motivate village doctors.

"Some people say that if the rural population is declining, village doctors are no longer needed. I think it is very wrong. These village doctors are obviously very useful in solving the villagers’ minor illnesses. You need to see a village doctor for usual headaches and brain fever. , Especially in more remote areas."

  The "medical community" model of county-rural integration is being promoted nationwide.

For example, Li Ling said that in Sha County, Sanming City, Fujian Province, the government packaged the medical insurance fund to the general hospital in advance. According to the "medical community" design, the general hospital includes county hospitals, town health centers, and village clinics. The town’s health center dispatched agency personnel.

"Doctor's annual salary system, annual salary assessment work points system, the healthier the people in the county, the higher their income."

  The Sanming medical reform has indeed effectively reduced the hospital admission rate, but will there be cases where hospitals reject patients in order to earn a balance?

Huang Erdan believes that the medical insurance department will conduct monitoring. "I talked to the Sanming medical insurance management department. They generally control the balance below 20%. Excessive balance is definitely a problem."

  How to monitor these?

"With informatization, it is impossible to do without informatization." Huang Erdan said.

He pointed out that the soundness of informatization can solve the problem of village doctors becoming "cousins" in basic public health services, and can better supervise the operation of the system, but they also face the problem of lack of training after informatization. .

"In fact, the cost of early-stage information technology is not high, and the biggest cost is how to teach village doctors to use software." However, these services cannot form fixed assets and often do not receive support from the financial department.

  He said that the lack of training resulted in the irregular filling of data for primary medical staff. “Sometimes an information system is built, but the data that comes up can’t be used.”

  Huang Erdan emphasized that any reform must be people-oriented.

"The Chinese government has never lacked the courage and determination to reform itself, but only by implementing the original aspirations of reform centered on people's health can the government's reforms be promoted in a coordinated manner." Thinking about how to really lock in the needs of the people, such as how to improve the continuity of the medical service system, without considering specific scenarios, "the whole cycle of disease treatment is fragmented."

It is also difficult for agencies and government departments to reach consensus on specific reform paths.

  Beginning in 1979, when the then Ministry of Health proposed "to use economic means to manage health services," China's medical reforms have turned several times, and they are still deepening.

Huang Erdan believes that China currently has only one round of medical reform, which started in the 1980s and has continued to this day.

"China's medical system is still in the process of shifting from the Soviet public ownership model to the social medical insurance model. The reform has been going on for more than 40 years. It can be seen that the transformation is not easy."

  (At the request of interviewees, Wang Jianhua, Liu Zhigang, and Deng Miao are pseudonyms)

  China News Weekly, Issue 41, 2021

Statement: The publication of the "China News Weekly" manuscript is authorized in writing

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