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Jan.
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2 [][][][][][][][] [][][][][][][][] Illustrations by Malcolm Garris/Corel |
In November of 1995,
Doctors without Borders came to Yunnan Province to work
on relief efforts after an earthquake. During an
assessment of the province, we discovered that many
people providing health care in rural areas had little
formal training or limited access to medical equipment.
The organization distributed basic medical equipment to
100 village clinics in two counties in November 1996. The next month, Doctors without Borders set out to train village doctors. Since January, when I arrived in China, I have been evaluating and improving the curriculum for this training program. To do this, I have spent time learning about the job of village doctors and the history of China's health system. During the 1970s, the country had a large group of health care providers called "barefoot doctors" working in rural areas. They were responsible for providing primary health care, and promoting public health campaigns. The communes where the doctors lived, and worked, financially supported them. This system was very successful; even the most rural and poor people received health care. But with the dissolution of the communes in the early 1980 — and a switch to private ownership of village clinics — the barefoot doctor system fell apart. Now, village doctors are supported primarily on a fee-for-service basis and by profits from the sales of medications. Although richer provinces are able to pay doctors’ salaries, many provinces are too poor and can pay doctors only a small fee for some preventive services. In Yunnan Province, the county governments pay a small amount each month to some village doctors who are involved in Maternal Child Health and vaccination programs. One county pays $3 a month to doctors; another $7. Many doctors choose to work out of their homes rather than a clinic so that they can tend to their farms when there are no patients. The village doctors provide basic health care including assisting with births, treating minor illnesses, and providing emergency first aid and immunizations. Although they are expected to teach villagers health education, most doctors spend little time doing this. Doctors are not compensated for teaching, and they cannot afford to spend time away from their farms and their practice. The income of village doctors, and some hospitals, is to a large part based on the sale of medicine. The doctors charge a very small fee for their service, usually between 7 and 10 cents, with the rest of their income coming from drug sales. Doctors often over prescribe medicines and intravenous infusions. Part of the problem is the inadequate training of the village doctors. For example, most village doctors do not take patient histories or keep patient records. I have spoken to some village doctors who have had only a few weeks of training, while others have never had any formal training. Instead, they may have learned from another village doctor or they may have studied on their own. Also, villagers expect to receive an injection when they go to the doctor; often they don't feel they have received adequate treatment unless they do get an injection. If patients don’t get what they expect, they may lose confidence in the doctor and never return. And the doctor would loose part of his income. |
