Factors associated with the decline of the Cooperative Medical System and barefoot doctors in rural China.

The Cooperative Medical System (CMS) and its barefoot doctors have been in decline in rural China for nearly a decade. In order to explore the reasons for this, in 1987 we carried out a survey of villagers, barefoot doctors, and local administrators in Fengxian, Shanggoa, and Loaan counties, where incomes are good, fair, and low, respectively. The state of the CMS in these counties was contrasted and the situations which prevailed in 1978, 1982, and 1985, when the system was, respectively, at its peak, had begun to decline, and had declined markedly, were compared. A random sample of villages was selected and all the barefoot doctors and administrators as well as a random sample of households were surveyed. The results indicate that health status (as measured by infant mortality, immunization coverage, and rate of infectious diseases) has decreased in areas where the CMS has declined, while per capita incomes increased. Concomitantly, villager's expenditures on health care have increased. Barefoot doctors and their patients were, however, reasonably happy with the system, and in its absence the doctors are no longer able to obtain ongoing training. The CMS was fiscally sound, and did not decline to the same extent in all areas--it continues to thrive in Fengxian, which is relatively affluent. It is concluded that the system probably declined because many local administrators perceived that it no longer enjoyed the backing of the central government.