At nine o'clock in the evening, Li Xin, who works as a village doctor in a small county town in Hebei Province, is about to end a busy day's work.
After breathing, he released the circle of friends: "Today, the national nucleic acid sampling is over, three villages, one word: acid!"
Li Xin's five flavors and miscellaneous chen are all condensed in this "sour" word.
From the "barefoot doctor" preferred by villagers to see a doctor, to now more basic public health work. With such a change of identity, Li Xin has not been able to adapt to this day.
He laughed at himself and said that although he was in a small county town on the "eighteenth line", his working hours were no less than the "996" of the Internet factory, and it could even be said to be "007".
After graduating from the Health School in 2003, Li Xin rejected some olive branches thrown by hospitals and chose to become a rural doctor. At that time, no one wanted to come to this small village with a population of less than a thousand people, because there were fewer villagers and less public health subsidies. The public health allowance is calculated on a per capita basis, and the more populous the village, the higher the subsidy received by the village doctor.
Grassroots public health subsidies are the most important source of income for village doctors. According to national standards, village doctors undertake 40% of the public health tasks and receive 40% of the public health subsidies, but in fact, the work done by village doctors in many places is far more than 40%, so the call to increase the proportion of public health subsidies for village doctors is growing.
Many rural doctors have cultivated land, and Li Xin is no exception. Their family has an acre and a quarter of land, and in addition to doing the village doctor, he also has to take care of the harvest in the field. The village doctor's work is relatively busy, so the annual land income is not high, less than two thousand yuan.
Since practicing medicine for 19 years, Li Xin's life has been tight, often after buying the medicines needed in the health room, paying tuition for his daughter, and not having much money in his hands.
Li Xin's account book is also a bunch of bad debts, and even the arrears of more than ten years ago have not been recovered. (Previously, villagers liked to pay on credit first, wait until the end of the year or to a certain amount, and then settle the settlement uniformly.) ）
The leaders of several local county-level hospitals had approached Li Xin and hoped that he could work in the hospital or contract a department in the hospital, but Li Xin refused.
Li Xin and his wife have both obtained a bachelor's degree from the self-examination, as well as a pharmacist's certificate, a practicing physician's certificate, and a general practitioner's certificate, and he knows that whether it is to open a pharmacy in the county town or go to the hospital, it is better than being a village doctor. But he also knew that the villagers of these villages could not do without him.
Household nucleic acid under daily epidemic prevention
As a rural doctor, a large part of Li Xin's work was decided by the National Basic Public Health Service Project (hereinafter referred to as the Basic Public Health System), which was implemented nationwide in 2009.
The content of the basic public health system has been increased several times, and the current unified service items implemented nationwide mainly include: resident health record management, vaccination, health management of patients with chronic diseases (including health management of patients with hypertension and type 2 diabetes), reporting and handling of infectious diseases and public health emergencies, and providing contraceptives free of charge.
The implementation rate of some basic public health service projects according to the 2017 National Basic Public Health Service Specifications (Source: Medical Management)
However, in the context of the resurgence of the epidemic, most of the energy of rural doctors has been occupied by nucleic acid sampling, door-to-door temperature measurement, distribution of medicines, and filling out forms at home.
The workload is large and cumbersome, taking the work of filling out forms in the household as an example, rural doctors need to go door to door to register, and all villagers can register to get a full amount of "public health subsidies". But even so, public health subsidies are sometimes difficult to disburse, and even deducted in individual places.
What made Li Xin feel the biggest was the collection of nucleic acid at night, and the nucleic acid test that could have been completed in a few minutes would take almost an hour more at this time.
It is precisely because rural doctors like Li Xin have supported the "first line of defense" for the normalization of rural epidemic prevention and control.
The level of public health has improved, but villagers have to go far to see a doctor
The improvement of the health level of grass-roots residents on the mainland is inseparable from the efforts of rural doctors.
But rural doctors spend most of their time doing public health, so who should villagers look for? After all, the village clinic was the "120" at the doorstep of the villagers, and even pregnant women gave birth to births by village doctors.
Yuan Rongdi, a village doctor from the Huilong Village Clinic in Baihetan Town, Qiaojia County, Zhaotong City, Yunnan Province, has been a doctor for nearly 40 years, and now that she has passed retirement age, she still guards the health of about 2,000 villagers in Huilong Village.
According to her recollection, many children in the village came into this world through her hands. But now, she will no longer help the mother deliver the baby, "the child needs a birth certificate to go to the household registration, but the village doctor can not issue a newborn birth certificate, so now the mothers go to the county hospital to complete the birth." 」
Gu Yue, a villager from a rural area in Hebei, also told the health community that in the past, everyone saw a doctor in the village clinic, but later some sick village doctors could not see it, and everyone gradually began to go to the town or county hospital to see. Now, rural doctors are more likely to measure blood pressure, take preventive injections, grab medicines, and see some simple diseases.
Gu Yue's wife suffers from diabetes, metformin, gliclazide, glipizide and other commonly used drugs for diabetes need to be taken every day, in addition, insulin is also taken every day. A 3 ml: 300 units insulin glargine injection produced by Sanofi, 20 units at a time, can only last for half a month.
However, these drugs are not in the national basic drug list, so the village clinic cannot be prescribed. Gu Yue, who was rare in ancient times, had to take a car for more than an hour every month to the county hospital to prescribe medicine for his wife.
Village Clinic (Source: Figureworm Creative)
The diagnosis and treatment function of the village clinic is weakened?
In August 2020, the Hebei Provincial Health Commission announced the "Hebei Provincial Village Clinic Public Medical Service Specification". It is clearly emphasized that the village clinic is mainly responsible for providing basic medical services and public health services for rural residents.
In addition to the emergency surgical hemostasis and small wound treatment that must be carried out to save the patient's life, the village clinic shall not provide the following services in principle:
(a) surgical, hospitalization and childbirth services;
(2) Medical services that are incompatible with their functions and qualifications;
(3) Other medical services that the administrative departments for health at or above the county (city, district) level clearly stipulate must not be engaged in.
The policy intent is clear. In the prescription of chronic diseases, safety is the first priority, but the reality is that there are only a limited number of doctors with practicing physician qualifications in rural areas, and the safety of medicines for villagers is not guaranteed.
According to the "2020 Statistical Communiqué on the Development of Mainland Health and Health Undertakings", by the end of 2020, a total of 609,000 village clinics will be set up in 509,000 administrative villages across the country. The number of employees in the village clinic reached 1.442 million. Among them, there are 465,000 practicing (assistant) physicians, 185,000 registered nurses, and 791,000 rural doctors and hygienists. The average number of people in the village clinic is 2.37.
The health community noted that compared with the previous year, the number of village clinics decreased by 7,266 and the total number of personnel decreased by about 4,000, of which 50,000 were rural doctors and hygienists, but the number of practicing (assistant) physicians increased by 30,000 and the number of registered nurses increased by 17,000.
As we all know, in the vast rural areas, many patients with chronic diseases prefer to go to the village clinic to see a doctor, not only because they are close to home, but also because the village doctor is more familiar with their physical condition.
In view of this, on August 12, 2021, the National Health Commission and the National Medical Insurance Bureau jointly issued the "Long-term Prescription Management Specification (Trial)", which proposed to encourage long-term prescriptions issued by primary medical and health institutions in response to the long-term medication needs of patients with chronic diseases. However, the Code particularly emphasizes that the first long-term prescription should be issued by a physician with an intermediate title in a medical institution at or above the second level, or a physician with an intermediate title in a primary medical and health institution.
Because the Code requires more in the first issue of long-term prescriptions, the right to prescribe drugs has been restricted by some rural doctors.
Will rural doctors all turn to basic public health services?
Under the promotion of hierarchical diagnosis and treatment, the diagnosis and treatment authority of rural doctors has been compressed, and the focus of work has been tilted towards health education and prevention. Does this change mean that the profession of rural doctors will all shift to basic public health services in the future?
Some insiders said that with the in-depth promotion of graded diagnosis and treatment, in the future, the village level will focus on public health and the township level will focus on medical treatment.
Liu Lihong, a rural doctor from the Dahe Village Clinic in Fuyu Town, Susong County, Anqing City, believes that rural doctors must do a good job in basic medical care and basic public health services in the future, and both should take into account.
She believes that the medical needs of rural residents are still inseparable from rural doctors, especially many rural left-behind populations are mainly old, weak, sick and disabled, and they need rural doctors. For most of the common diseases, rural doctors can also solve, "the most important thing is that basic medical care itself is a powerful hand for public health."
But at present, for doing public health services, rural doctors have a bitter heart:
Large workload and shortage of manpower;
The content is cumbersome and requires frequent door-to-door registration and filling out forms;
Highly informatized, it is difficult for older rural doctors to operate;
Public health subsidies are small or even difficult to obtain.
Liu Lihong believes that public health needs an incentive mechanism to do a good job. Rural doctors lack the enthusiasm of public health, so they cannot really devote themselves to this work, so that the sense of gain of residents for so many years is not strong, which can be said to be contrary to the original intention.
Yan Guojin, chief physician of the Dongtai Municipal Center for Disease Control and Prevention, believes that it is more feasible to do medical treatment and public health care separately, and to build village clinics by classification.
Judging from his long-term observation of the grassroots, there are some problems in basic medical care:
First, there are few rural doctors in the village clinic, some are only 1, and some do not have female village doctors;
Second, the types of doctors in the village clinic are not fully equipped, some are studying Western medicine, not learning Chinese medicine, some only have the certificate of rural doctors, or even just hygienists;
Third, the overall level of diagnosis and treatment of the village clinic is poor, and the villagers are reluctant to patronize it, so the villagers have to go to other village clinics nearby or go to the township health center for treatment;
Fourth, no matter how poor the conditions are in the village clinic, there is a lack of basic diagnostic and treatment equipment, and rural doctors often prescribe drugs without diagnostic equipment, "hanging water", there are many hidden dangers in medical safety, and the medical accidents caused by this aspect have been reported frequently.
In view of the above phenomenon, some places have made efforts to build higher standards of joint village demonstration clinics on the basis of standardized clinics in villages and villages.
Based on this, Yan Guojin believes that it is advisable to reasonably set up three types of health rooms according to the comprehensive consideration and analysis of regional location, the number of rural doctors, and the ability to diagnose and treat:
Comprehensive joint village demonstration clinic (service coverage radiates 2 to 3 natural villages or administrative villages around the periphery, reaching the standard of being able to independently carry out "3+1" inspections);
Standardized clinics (providing common basic medical care and basic public health services for residents of the village);
Public health type village clinic (the basic medical service capacity is weak, mainly to undertake basic public health services, with conventional basic drug supply, thermometer, stethoscope, sphygmomanometer as the main basic diagnosis and treatment services).
How can the treatment of rural doctors be improved?
In the past two years, in order to strengthen the prevention and control of the community epidemic, 24 provinces across the country have promoted the construction of public health committees in village (resident) committees to varying degrees, of which Beijing, Guangdong, Anhui, Gansu and other provinces (cities) have been fully promoted within the province (city), but there was a lack of guidance documents at the national level before.
On the last day of 2021, the Ministry of Civil Affairs, the National Health Commission, the State Administration of Traditional Chinese Medicine, and the National Bureau of Disease Control jointly issued the Guiding Opinions on Strengthening the Construction of Public Health Committees of Village (Resident) Committees (hereinafter referred to as the Guiding Opinions).
The "Guiding Opinions" proposes to strive to achieve full coverage of the public health committee mechanism (nationwide) in about two years. The director of the public health committee is generally a member of the village (resident) committee, and may also be the deputy director of the village (resident) committee; its deputy director may be concurrently served by the staff of the village (community) health service agency. Widely absorb township health centers, village clinics, street (community) health service centers (stations), and medical personnel, health instructors, family health workers and retired medical personnel in community old-age service institutions as members of the public health committee.
In Liu Lihong's view, the document stipulates that the village (community) public health committees that receive clear financial support should be treated higher than the current village doctors. What rural doctors should do is seize the opportunity: at the grassroots level, they are professionals, they have been with the local residents for a long time, and they are very familiar with public health work, so if the village doctors usually accumulate a solid mass base, they may be considered as deputy directors of the public health committee first.
In addition, in terms of ensuring and improving the treatment of rural doctors, at the end of 2021, the state issued 58.855 billion yuan of public health funds, which were pre-allocated to village clinics in advance. The document clearly states that the direct funds issued in advance are marked as "01 central direct funds", which runs through the entire process of fund allocation, disbursement and use, ensuring the transparent, timely and full distribution of public health fund subsidy funds throughout the process, and eliminating the possibility of deduction.
Public health subsidies are the most important source of income for village doctors. According to the explicit provisions of the former Ministry of Health, 70% of the current year's funds should be pre-allocated before the start of the annual basic public health service work for rural residents. In public health services, village clinics take on 40 per cent of the tasks. This also means that 40% of the grass-roots public health subsidies should be allocated to the village clinic.
The basic public health subsidy has achieved "ten consecutive increases" after "another 5 yuan" in 2022.
Changes in public health funding standards between 2009 and 2022 (Source: WeChat public account "Rural White Coat")
The public health allowance is more laborious and more expensive, and the upper limit is generally 40% of the standard public health funding. With the increasing call to increase the proportion of public health subsidies for village doctors, various localities have begun to explore, such as Henan Province, Xinjiang Tacheng District, Buxel County, Guizhou Sandu County increased to 50%.
From 40% to 50%, what does it mean for village doctors? In March 2022, the state clarified in the government work report that the per capita financial subsidy standard for basic public health services was increased to 84 yuan.
Taking Li Xin as an example, if you manage a village with a population of 900, according to the 50% subsidy standard, the annual public health expenditure will reach 37,800 yuan, an average of 3,150 yuan per month.
After the village doctor undertakes 10% more basic public health service items, for each person who manages, he will have an additional income of 8.4 yuan, and 900 people is 7560 yuan (annual).
However, this is an ideal situation, and some village doctors are worried that there are areas that need to be improved in the assessment and allocation of public health at the village level:
According to the regulations, at the beginning of each year, the county should pre-allocate the rural public health budget funds to the township health center and the village clinic on a quarterly basis according to the proportion of 70%, and at the end of the year, according to the assessment of the relevant departments, the remaining 30% of the service funds will be issued. The health center shall be issued in a timely manner according to the assessment of the village doctor.
But why is it that the township health center is both an athlete and a referee, and the tasks undertaken by village doctors far exceed 40%, but how many public health subsidies should be received every quarter and every year are often not disclosed in time?
After all, only by actually distributing funds to village doctors can the "ten consecutive increases" of public health subsidies be said to be implemented.
(At the request of the interviewee, Li Xin and Gu Yue are pseudonyms in the text)
Health Community Exhibits
Written by | Wang Dandan