Health systems across the world face a shortage of skilled health workers in rural and remote areas, which hampers progress towards global health-care goals and contributes to inequalities in health outcomes [1–5]. In Beijing, the capital city of China, urban/rural disparities remain strong. Beijing suffers from a shortage of health workers, with only two doctors per 1000 inhabitants in 2006 in rural areas where more than 16.95 million people reside .
As a large agricultural country, China has a population of 1.34 billion with 674 million rural residents . China established the Household Registration System in 1949, which divided the populace into rural residents and urban residents. The State Council released regulations on the official definitions of cities and towns. It stipulated that at least half the population of a rural township had to be in ‘agricultural’ work . Beijing comprises 16 administrative sub-divisions, which are county-level units governed directly by the municipality. Of these, three districts are classified as urban districts as all the residents in the three districts are registered as being non-agricultural. More than half of the people living in the other 13 districts are registered as an agriculture population, and these administrative districts are divided into townships and villages.
There remains an urban–rural dual economic system in China. Whether measured in terms of income, literacy, or access to health services, a large gap is present between rural and urban areas. It was reported that the per capita income of an urban resident was 2.6 times higher than that of a rural resident in China. Typically, urban residents enjoy a better quality of education than rural residents. Furthermore, there is a skewed distribution of health-care services in favor of the urban sector [9–11]. According to the law on Licensed Doctors in China, ‘The Doctors’ refers to medical workers who have obtained licenses as qualified doctors and are registered and employed in medical services, disease prevention or health-care institutions. Anyone who has passed the examinations for the qualifications of a licensed doctor is certified as such. Whoever meets one of the following requirements may take the examinations for qualification as a licensed doctor: having graduated from a university faculty of medicineor having reached the level of a graduate from a faculty of medicine of a university or a polytechnic . In urban areas, most doctors have completed a 5-year bachelor degree program in clinical medicine and obtained licenses as qualified doctors. They become either a family physician or a medical specialist. However, most rural doctors who serve the agricultural community are practicing without a license as a qualified doctor. After being registered at the county’s health bureau, rural doctors may practice at rural health-care clinics. Unlike their urban counterparts, rural doctors are not paid from public funds and are not eligible for social insurance. Their career prospects and training opportunities are poor .
Rural doctors have played a significant role in preventing people from becoming impoverished. In the mid 1950s, a collectivism-based rural health insurance system was established, called the Co-operative Medical System (CMS), which covered the cost of medical and obstetric care . With the transition from a collective economy to a market system at the end of 1970s, the CMS collapsed, leaving around 90% of the rural population uninsured in the 1990s. Lack of health insurance increased the proportion of rural households living below the poverty line by 44% . Rural doctors provided a series of health services to the local residents, including preventive services, maternal and child health services, and emergency medical aid. Despite a low level of service in terms of technique and medical instruments, the primary health-care services provided by rural doctors effectively reduced costs and provided timely treatment for the rural residents .
Researchers at the World Health Organization and other organizations have reported several specific recommendations to increase the availability of health workers in remote areas. These include financial incentive programs, training programs and improvement of working conditions [17–20]. In China, government strategies have been developed to decrease the inequity in health care between urban and rural areas, and these were expected to help improve the recruitment of rural doctors . In 2003, the State Council and the Central Committee of the Communist Party of China initiated the policy of the New Cooperative Medical Scheme (NCMS) . This is a health insurance scheme for rural residents, which is designed to reduce the financial burden of illness on the rural population. In addition, a fixed special government allowance for rural doctors has been introduced in many regions. Since 2006, the Chinese government has initiated large-scale training programs aimed at improving the knowledge and skills of rural doctors.
The coverage of the new strategies had expanded to 2451 counties by the end of 2007, accounting for 86% of all rural counties in China. A recent study found that the implementation of the NCMS significantly increased the use of preventive care . There was an improvement in the working environment of rural doctors in Beijing. Beijing Municipal People’s Government provides an 800-yuan ($130) monthly allowance to each rural doctor. In 2006, a medical training program was initiated by the Beijing Municipal Health Bureau to improve the basic clinical skills and recruitment of rural doctors. A 6 million yuan ($1.0 million) special fund was spent on the training in Beijing. Ten thousand rural doctors participated in the training from 2006 to 2009. However, the impact of the strategies on recruitment of rural doctors is still limited. Although the report released by the Chinese Ministry of Health showed the number of rural doctors increased by 6.5% between 2003 and 2008, from 868000 to 938000, the overall level of human resources suggests a critical shortage in rural areas in China. China’s urban doctor-patient ratio was 2.8 doctors per 1000 residents in 2011. In rural areas, the ratio was 0.95 doctors per 1000 residents .
The problem of health workforce adequacy is operationally and conceptually complex. Intensive and sustained effort is needed to rectify the multidimensional nature of the recruitment of rural doctors. However, there has been very limited research to determine the major requirements of rural doctors in China. The objective of this study was to identify interventions proposed by the government that would lead to improved recruitment from the perspective of rural doctors in Beijing.