Source: Health Times reporter Zhao Weide
According to the "2020 Statistical Communiqué on the Development of Health and Health Undertakings in Mainland China" released by the National Health Commission in 2021, by the end of 2020, there will be 747,000 village doctors and 509,000 administrative villages in the country, with an average of less than 2 village doctors per village. According to the statistics of the health times reporter in the past 5 years, the number of village doctors has dropped sharply at an average rate of nearly 50,000 per year.
Hebei, Shanxi and other places have issued documents to solve the problem of guaranteeing the treatment of village doctors, but there are still problems such as heavy tasks, low income, and no guarantee for the elderly. Experts suggest that rural doctors who have obtained the qualification of practicing (assistant) physicians should be included in the unified management of the township health center.
Village doctor Zhang Shangbao treats villagers. Courtesy of respondents
The number of village doctors has dropped sharply by 186,000 in five years
In February, the cold wind in Luliang, Shanxi, was biting, and early in the morning, Zhang Shangbao filled out the health file in the village clinic. Zhang Shangbao, who is in his 60s, reached retirement age last year but did not go through retirement procedures. "More than 600 people in the 5 natural villages nearby are a doctor, no young people are willing to do it, and when I retire, no one will see them." Zhang Shangbao said.
Judging from the "Statistical Bulletin on the Development of Health and Health Undertakings in the Mainland" in the past five years, the number of village doctors has decreased sharply by an average of nearly 50,000 per year: there were 933,000 village doctors in the country in 2016, 901,000 in 2017, 845,000 in 2018, 792,000 in 2019, and 747,000 in 2020.
According to the data of the National Health Commission's "2020 China Health Statistics Yearbook", as of the end of 2018, from the perspective of age structure, more than 63% of village doctors over 45 years old, more than 32% of village doctors over 55 years old, and only 6.9% of village doctors under 34 years old, with prominent aging problems.
A village doctor on his way to a home patrol. Photo by Zhu Xudong, Xinhua News Agency
The reporter's investigation found that many provinces and cities have issued relevant policies to encourage medical students and young doctors in large hospitals to go to the countryside to exercise and fill the gap in the medical system in the village. "But there are very few willing to come to the village, and at most they are intercepted at the township level." A number of village doctors told the Health Times reporter.
In a township in Weifang, Shandong, where Fang Chunmei is located, there were more than 60 village doctors 20 years ago, and now there are less than 20 people left. "The treatment is too low, no young people are willing to do it, and they can't make up for it." Fang Chunmei said.
Xu Chao, a village doctor in Xuzhou, Jiangsu Province, told reporters, "There were originally 4 village doctors in my administrative village, and now two of them are just pseudonyms, in fact, only I and another village doctor do daily work." ”
Village doctors are the main force in various tasks such as health poverty alleviation and epidemic prevention and control in the village. During the peak period of the Spring Festival, Lu Sen, a doctor in Lu'an Village, Anhui Province, in addition to being on duty, also took advantage of the opportunity of the Spring Festival outgoing personnel to return home and complete the health file as soon as possible. "Every year at this time, it is the time when the task is the heaviest, and there are hundreds of people in the village, and I am the only one to do it."
In 2020, Zhang Zidong, a deputy to the People's Congress of Laiwu District and Zhuang Town, Jinan City, Shandong Province, proposed at the local two sessions that there are 31 natural villages in Hezhuang Town, 2 villages without clinics, no young clinicians have joined the ranks of rural doctors in the past decade, and in 5 to 10 years, more than half of the villages will have no clinics.
Geng Funeng, deputy to the National People's Congress and vice president of the Rural Doctor Branch of the Chinese Medical Doctor Association, said in an interview with the Health Times reporter that there are three reasons for the sharp decline of village doctors, one is that the age structure is large, many of them are over 60 years old, the aging phenomenon is common, and some village doctors quit their posts every year because of their age; the second is that the treatment of village doctors is low, there is no establishment in identity, and the lack of security for retirement has caused the loss of some village doctors who are rich and strong; the third is that the work intensity is large and the assessment requirements are high. Graduates of colleges and universities are reluctant to work in village clinics.
The annual income of village doctors is only 10,000 to 20,000 yuan
The reporter interviewed a number of village doctors and learned that at present, the income of village doctors on the mainland is mainly divided into three parts: outpatient fees, basic drug subsidies after the zero price difference of drugs is sold, and basic public health service fees. However, the income standards of village doctors in various places are not the same, and there are very few who have the above three stable incomes every month, and most village clinics have cancelled the outpatient fee, relying only on basic drug subsidies and basic public health service fees, which is more than 20,000 yuan a year.
Han Liguo, a village doctor in Handan, Hebei Province, told reporters, "Regarding the basic drug subsidy, there are more than 800 people in his village, and the minimum payment standard for outpatient reimbursement per person per year is 75 yuan, after the drug is sold, 30% of the drug price is returned to the village clinic. ”
Geng Funeng said that at present, the mainland requires village doctors to provide basic medical services and basic public health services, wait for work 24 hours a day, basically have no rest days, and also undergo strict assessment. The village doctor is responsible for writing prescriptions, responsible for outpatient logs, outpatient medical records, disinfection records, drug records, health records and other records, and is also responsible for maternal and child health care, immunization, health education, various chronic disease management, home visits and other work in the village, with heavy tasks.
However, for some village doctors, even 20,000 yuan of income per year is not enough. Zhang Shangbao, a doctor in Luliang Village, Shanxi, earns only 400 yuan a month, and less than 5,000 yuan a year, making it difficult to maintain his family's livelihood.
Zhang Shangbao, 62, has been a village doctor for 45 years, and in the materially poor Tietou Village, for nearly four decades, he was the only one who gave medical treatment and medicine to the villagers, filling the gap in the village medical system. Zhang Shangbao has two sons, who are in their 30s and are still unmarried. He said frankly, "Now the dowry money is too expensive, I have a salary of 400 yuan per month, there is no outpatient fee, how much medicine is bought from the health center, how much is sold to the villagers, there is no subsidy, the income is too low, and the family cannot save any money." ”
According to the Notice on Doing a Good Job in Basic Public Health Service Projects in 2021 issued by the National Health commission in 2021, it is clear that the per capita basic public health service subsidy standard in 2021 is 79 yuan. Xu Chao told the Health Times reporter, "According to the regulations, the village clinic undertakes 40% of the basic public health services, and then subsidizes the 40% basic public health subsidy of the village doctor." Counting down to serve a villager should be able to get a subsidy of 31.6 yuan, but not so much. ”
Village doctors in many places are difficult to get rid of the embarrassment of half farming and half doctors
According to the Basic Medical Care and Health Promotion Law, which came into effect on June 1, 2020, it is clear that village doctors are not farmers, but medical and health professionals. The reporter's investigation of many places found that at present, village doctors are hired by the township and village, and are included in the unified management of the township health center.
In fact, village doctors who are not included in the formal establishment often practice medicine while farming, and it is difficult to get rid of the embarrassing identity of half-peasant and half-doctor.
The village doctor farmer is hoeing the field in his spare time. Photo by Zhan Yan of Xinhua News Agency
Zhang Shangbao carried medicine boxes back and forth on the seven ditches and eight beams of the Loess Plateau in his spare time, gave medicine to the villagers to see a doctor, and went to the field to work to subsidize the family when the farmers were busy. "The monthly salary of 400 yuan is too low, and you can't support your family without farming." Zhang Shangbao told reporters, "Last year, there was little rain, and several acres of wheat planted were drought-dead and there was no harvest. ”
"I'm actually a farmer, just doing the doctor's job." Fang Chunmei, a village doctor in Weifang, Shandong, told reporters that most of the local village doctors are working part-time, and when they are not busy, they are no different from farmers.
Fang Chunmei, who has been a rural doctor for 30 years, is now most worried about the pension problem after retirement. "We don't have a staff, the health center does not pay the social security of the staff, we pay the rural pension insurance, after retirement can only receive a few hundred yuan a month, now this price, where is enough to live?" Fang Chunmei sighed and said, "After a lifetime of being a doctor, I am still a farmer!" I am now 51 years old, and I have not paid social security for employees for more than 15 years. ”
Xu Chao also has a similar situation, a few years ago he talked about "retirement treatment" with the director of the township health center, and the director said bluntly, "Farmers can't talk about retirement!" ”
In view of this situation, Han Liguo simply paid the pension insurance for flexible employment personnel, which is the pension insurance policy introduced by the state for people who have no fixed job, unemployment or reemployment who belong to flexible employment, with a high contribution ratio and a slightly higher pension after retirement. "At present, the township health center pays part of it, and I personally pay part of it, and I have to pay 7,000 yuan a year." Han Liguo said.
"But the health center counted us as flexible workers, and I don't even know who I am now." Han Liguo said.
Han Liguo's wife is also a rural doctor, she simply paid the pension insurance for flexible employees in full, "because if the health center helps to pay a part, it must be included in their unified management, usually meetings, duty are present, recent epidemic prevention and control, get on duty at the highway intersection, and do a lot of extra work." Han Liguo said.
Without staffing, accidents at work cannot be guaranteed. Li Xiangcheng, a village doctor in Qin County, Shanxi Province, showed the villagers for 43 years of illness, did not charge a medical fee, after a car accident on the way to the clinic, no unit and department recognized his work injury, 34 villagers and netizens raised 60,000 yuan to save his life; Cao Liqin, a sixty-year-old village doctor in Miyun County, Beijing, died in a car accident on the way to buy medicines, and the court also ruled that the competent department did not have an employment relationship.
Fang Chunmei also told reporters, "A few years ago, an old village doctor in his 60s died of kidney cancer, and there was no last subsidy. ”
Lu Sen told reporters, "An appendicitis patient, after giving him an infusion, insisted that I had given him an appendicitis, and did not pay for the drug." In this case, the health center will not take care of it, and can only recognize itself. ”
Experts recommend that it be included in the unified management of the establishment of township health centers
According to the 2015 Implementation Opinions of the General Office of the State Council on Further Strengthening the Construction of the Rural Doctor Team, order-oriented training for rural doctors was implemented, the free training of rural order-oriented medical students was strengthened, and the 3-year free training of middle and higher vocational medical students for village clinics was focused on the implementation. Free medical students mainly recruit rural students.
The "Opinions" also pointed out that it is necessary to standardize the on-the-job training of rural doctors. All localities should rely on county-level medical and health institutions or central township health centers with conditions to carry out on-the-job training of rural doctors. Rural doctors receive free training not less than 2 times a year, and the cumulative training time is not less than 2 weeks; all localities can choose to send outstanding rural doctors with the qualifications of practicing physicians or practicing assistant physicians to provincial and municipal hospitals for free training; rural doctors go to county-level medical and health institutions or qualified central township health centers for free training every 3 to 5 years, and the training time is not less than 1 month in principle.
A number of village doctors said in an interview with reporters that there are almost no opportunities for this free training and training, and in the end, they still have to learn technology at their own expense. Han Liguo is a national practicing physician and pharmacist, who has been rated as an excellent medical worker many times, and for him, he is also a professional technique for improving pain at his own expense.
Pan Feng, a deputy to the Guizhou Provincial People's Congress and a rural doctor in Lugoutang Village, Puping Town, Anlong County, Guizhou Province, has put forward suggestions for improving the treatment of rural doctors and stabilizing the contingent of village doctors during the two sessions in Guizhou Province for many years. Pan Feng told the Health Times reporter that to stabilize the team of township doctors, the first is to establish a long-term and stable rural doctor training mechanism, regularly train and enrich village-level health service talents; the second is to increase the subsidies of existing rural doctors, it is recommended to refer to the village group cadre standards every month, and refer to the method of enterprise employees to pay pension insurance to solve the existing village doctors' pension care, and can also take the method of combining individuals, health centers and financial subsidies to gradually solve; third, the government should adopt the way of purchasing services. Regular training of professional skills and business parties for village doctors in the jurisdiction.
Fang Hai, a professor at Peking University's China Center for Health Development Research, expressed concern. The current system may be difficult to maintain the operation of village doctors, and young village doctors should be regular employees (physicians) of township health centers with medical specialties or bachelor's degrees. In this way, they can be stationed in the village and rotated for several years.
Professor Tao Hongbing, a pilot evaluation expert for the comprehensive reform of county-level public hospitals in the State Council Medical Reform Office and vice president of the School of Medicine and Health Management of Tongji Medical College of Huazhong University of Science and Technology, told the Health Times reporter, "The village clinic is the bottom of the grass-roots medical system in the mainland, they are familiar with the living habits of hundreds of millions of farmers, and they can provide targeted health services such as chronic diseases, but village doctors in many places are facing the embarrassing identity of "half rural and half doctor", with low income and severe reduction.
In this regard, Tao Hongbing suggested that first of all, we must stabilize the team of village doctors, and the local government should issue regulations to promote qualified village doctors to be included in the unified establishment and management of township health centers, so that a good career development platform can be established and the village doctor team can have expectations. Secondly, local governments can establish a mechanism with local colleges and universities to train college students to train college students to solve the problem of village doctors not being connected. Then a performance appraisal mechanism is set up for village doctors, giving village doctors policy-oriented business income, so that village doctors have better prospects for development.
Li Qiu, deputy to the National People's Congress and president of the Children's Hospital Affiliated to Chongqing Medical University, mentioned, "Most higher-level hospitals have certain restrictions on the basic conditions for village doctors' further training, and it is recommended that local secondary schools and colleges and universities establish a targeted training system, work in the village for several years after graduation, and at the same time smooth the channels for further training for this part of the qualified village doctors, and those who perform well can work in higher-level hospitals." ”
Fang Hai suggested that rural doctors can try to implement the family doctor contract service model to increase income. The family doctor contract service is to enable the general practitioner to establish a long-term and stable service relationship with the contracted family in the form of a contract, mainly providing basic medical services and basic public health services, including medical treatment, medication, referral appointments, home care, etc. The proportion of incentive performance revenue can be increased in contracted services and its distribution can be linked to the quality of service. This maximizes utility, improves service quality and increases revenue. (At the request of the interviewees, some village doctors are pseudonyms)