China Center for Health Development Studies, Peking University, Beijing, China.
London School of Hygiene and Tropical Medicine, London, England.
Int J Equity Health. 2017 Jul 1;16(1):9. doi: 10.1186/s12939-016-0505-7.
Since 1968, China has trained about 1.5 million barefoot doctors in a few years' time to provide basic health services to 0.8 billion rural population. China's Ministry of Health stopped using the term of barefoot doctor in 1985, and changed policy to develop village doctors. Since then, village doctors have kept on playing an irreplaceable role in China's rural health, even though the number of village doctors has fluctuated over the years and they face serious challenges. United Nations declared Sustainable Development Goals in 2015 to achieve universal health coverage by 2030. Under this context, development of Community Health workers (CHWs) has become an emerging policy priority in many resource-poor developing countries. China's experiences and lessons learnt in developing and maintaining village doctors may be useful for these developing countries.
This paper aims to synthesis lessons learnt from the Chinese CHW experiences. It summarizes China's experiences in exploring and using strategic partnership between the community and the formal health system to develop CHWs in the two stages, the barefoot doctor stage (1968 -1985) and the village doctor stage (1985-now). Chinese and English literature were searched from PubMed, CNKI and Wanfang. The information extracted from the selected articles were synthesized according to the four partnership strategies for communities and health system to support CHW development, namely 1) joint ownership and design of CHW programmes; 2) collaborative supervision and constructive feedback; 3) a balanced package of incentives, both financial and non-financial; and 4) a practical monitoring system incorporating data from the health system and community.
The study found that the townships and villages provided an institutional basis for barefoot doctor policy, while the formal health system, including urban hospitals, county health schools, township health centers, and mobile medical teams provided training to the barefoot doctors. But After 1985, the formal health system played a more dominant role in the CHW system including both selection and training of village doctors. China applied various mechanisms to compensate village doctors in different stages. During 1960s and 1970s, the main income source of barefoot doctors was from their villages' collective economy. After 1985 when the rural collective economy collapsed and barefoot doctors were transformed to village doctors, they depended on user fees, especially from drug sale revenues. In the new century, especially after the new round of health system reform in 2009, government subsidy has become an increasing source of village doctors' income.
The barefoot doctor policy has played a significant role in providing basic human resources for health and basic health services to rural populations when rural area had great shortages of health resources. The key experiences for this great achievement are the intersection between the community and the formal health system, and sustained and stable financial compensation to the community health workers.
自 1968 年以来，中国在短短几年内培训了约 150 万名赤脚医生，为 8 亿农村人口提供基本医疗服务。1985 年，中国卫生部停止使用赤脚医生一词，转而推行发展乡村医生政策。此后，乡村医生在中国农村卫生保健方面一直发挥着不可替代的作用，尽管乡村医生的数量多年来一直在波动，他们面临着严峻的挑战。联合国于 2015 年宣布了可持续发展目标，旨在到 2030 年实现全民健康覆盖。在此背景下，发展社区卫生工作者（CHWs）已成为许多资源匮乏的发展中国家的新兴政策重点。中国在发展和维护乡村医生方面的经验和教训，可能对这些发展中国家有用。
本文旨在综合中国 CHW 经验教训。它总结了中国在探索和利用社区与正规卫生系统之间的战略伙伴关系，分两个阶段发展 CHW 的经验，即赤脚医生阶段（1968-1985 年）和乡村医生阶段（1985 年至今）。从 PubMed、CNKI 和万方数据库中检索中文和英文文献。从选定的文章中提取信息，根据支持 CHW 发展的社区和卫生系统四个伙伴关系策略进行综合，即 1）共同拥有和设计 CHW 方案；2）协作监督和建设性反馈；3）平衡的财务和非财务激励措施包；以及 4）将卫生系统和社区数据纳入其中的实用监测系统。
研究发现，乡镇和村庄为赤脚医生政策提供了制度基础，而正规卫生系统，包括城市医院、县卫生学校、乡镇卫生院和流动医疗队，为赤脚医生提供培训。但 1985 年以后，正规卫生系统在乡村医生制度中扮演了更为主导的角色，包括乡村医生的选拔和培训。中国在不同阶段应用了各种机制来补偿乡村医生。20 世纪 60 年代和 70 年代，赤脚医生的主要收入来源是他们所在村庄的集体经济。1985 年农村集体经济崩溃，赤脚医生转变为乡村医生后，他们主要依靠医疗服务费，尤其是药品销售收入。新世纪，尤其是 2009 年新一轮卫生体制改革以来，政府补贴已成为乡村医生收入的重要来源。
赤脚医生政策在农村地区卫生资源严重短缺的情况下，为农村人口提供了基本人力资源和基本卫生服务，发挥了重要作用。这一巨大成就的关键经验是社区与正规卫生系统的交叉，以及对社区卫生工作者的持续稳定的经济补偿。
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