Background
The population of China is aging rapidly due to the cumulative effects of the consistently low fatality rate [
1], the one-child policy [
2], and the increasing life expectancy [
1]. The proportion of the elderly population (aged over 65 years) of China is projected to reach 23% to 30% by 2050, as estimated by the United Nations [
1,
3]. At the same time, China is urbanizing at a rapid rate due to the rural-to-urban migration occurring since the post-1978 economic reform. The urban population rose from 191 million in 1980 to 622 million in 2009, and the urban population further overtook the rural population in 2011 (51% vs. 49%) [
4]. As more than 85% of the migrates are younger than 40 years old [
5], migration has greatly accelerated the population aging in the rural areas – by 2050, the population aging in rural areas is estimated to be more severe than that in urban areas when taking the rural-to-urban migrates into consideration (23% vs. 21%) [
6].
The interaction between population aging and fast urbanization exerts increased pressure on the health system in rural China. Firstly, due to the health migrate phenomenon, people migrating to urban districts are relatively healthier than those who do not [
7]. Therefore, the remaining rural residents, mainly the elderly and the very young, have greater healthcare demands than the migrating population. Secondly, when migrating workers fall ill or become injured, they always return to their hometown to receive healthcare services, probably due to the fragment of the health insurance system and the high out-of-pocket expenditure in urban hospitals [
4,
8]. Thus, the healthcare demands of rural China have not decreased in parallel with the decrease in the rural population; on the contrary, such a transition requires rural health facilities to provide more and better healthcare to the remaining rural residents.
Along with population aging, the last 30 years have also seen an epidemiology transition partly because of the rapid lifestyle changes occurring within this period. In 2005, chronic diseases accounted for 80% of deaths and 70% of the disability-adjusted life-years in China [
9]. In rural China, the three main causes of death (i.e., malignancy, cardiac diseases, and cerebrovascular diseases) accounted for over 60% of all deaths in 2011. Thus, chronic diseases have overcome communicable diseases to become the major disease burden in China [
10]. Specifically, the prevalence of hypertension in rural adults was 31.3%, slightly higher than that in urban adults (29.2%) [
11]. For diabetes, the prevalence in rural areas was lower than that in urban areas (10.3% vs. 14.3). However, the prevalence of pre-diabetes in rural residents was higher than that in urban residents (50.9% vs. 48.4%), whereas less diabetes cases were diagnosed in rural areas compared to urban areas (2.5% vs. 5.6%) [
12]. Thus, if no effective intervention is implemented in rural districts, the prevalence of diabetes in rural areas might overtake that of urban areas in the near future [
13].
To meet these challenges, the rural health system needs to be more effective and efficient, and the human resources for health should be improved not only in quantity, but also with regards to equitable distribution, competency, quality, motivation, productivity, and performance [
14]. The health system in rural China has a three-tiered structure: county hospitals, township health centers (THCs), and village clinics [
15]. The county hospitals and THCs are usually of public ownership and managed by local health bureaus. For physicians working at the THCs and hospitals, they must pass the national Licensed Doctors Examination or the Licensed Assistant Doctors Examination after at least three years’ medical education at a medical college. As they are publicly employed, they have an institute-based income and public pension provided by the government. Furthermore, doctors from the public hospitals and THCs must retire and receive a pension at the age of 60 for males and 55 for females.
The establishment of village clinics differs from that of THCs and public hospitals. Before 1980, the village clinics were supported by the village collective economy. After the collapse of the collective economy following the economic reforms, some village clinics were supported by the village committees or township governments, while others were supported by the village doctors themselves, who became private practitioners and made money mainly through the selling of drugs [
16,
17]. Recently, the Chinese government has begun to once again fund the construction of village clinics, aiming to establish a standard clinic in each village. Moreover, the village doctors were previously not included in the public pension system, since they were registered as farmers rather than public employees. Therefore, the pension they would receive from the New Rural Social Pension Insurance System, a new universal pension scheme for all rural elderly in effect since 2009, amounted to 55 RMB per month [
18]. Recently, some counties, such as Changshu and Yongchuan, have launched a special pension for their retired village doctors [
16].
Medical education in China has also changed considerably during the past decades [
19]. Before 1980, the main purpose of the medical education system was to provide sufficient health professionals to the rural villages in order to tackle the wide urban-rural disparity. After 1980, China prioritized the steady development of its medical universities to provide sufficient and qualified doctors to the health system overall [
19]. In 1998, China expanded its tertiary education system after a major expansion of comprehensive universities, which led to the rapid growth of health professionals [
20]. However, the human resources for health were not distributed according to the needs in rural and urban areas – doctor density in the urban areas was more than twice that in the rural areas [
20]. In the villages, about one million village doctors still played an important role in providing healthcare to rural residents. The minimum requirement for medical practice at the village clinics was to have passed the local examination held by the county health bureau and to obtain the Village Doctor Certification, while some village doctors could also pass the National Licensed (Assistant) Doctors Examination and become a licensed (assistant) doctor. By 2010, only a minority (14.2%) of the village doctors had passed the national examination [
21].
A proportion of the village doctors remain from the barefoot doctors, who have been practicing medicine for over 40 years in rural China; these doctors will inevitably retire within the next few decades [
16,
17]. Earlier studies on barefoot doctors did not take the aging factor into consideration [
22‐
28]. The age structure of the village doctors has changed considerably over time, and has begun to skew towards the aging side in recent years. Several recent studies have shown that more than 30% of the village doctors in the sample areas (both developed and under-developed districts) were 50 years old or older in 2009, and few village doctors were younger than 30 years old [
29‐
34]. However, these studies had some limitations. First, their sampling methods were various, including multistage sampling [
29,
31], convenience sampling [
35], multistage random cluster sampling [
30], and cluster sampling [
33]. Furthermore, several studies did not report the sample population and the response rate [
29,
30,
32], and the quality control was unclear [
29‐
33], leading to inconvincible results. Additionally, all these studies were descriptive, only reporting the average age or the percentage of each age group, while the causes and implications of the aging of village doctors were not deeply discussed.
Recently, there have been several new policy progresses regarding the village doctors, mainly including improving the quality, strengthening the management, and prioritizing public health services [
36]. First, to improve the quality of the provision of village doctors, their on-the-job training has become a requirement by the central government. Second, the government began to monitor the village clinics with a more rigorous standard, especially for the certification of village doctors, the use of drugs, and the reimbursement procedure. Third, since the health reform in 2009, the Ministry of Health (MOH) has requested the village doctors to provide both medical and public health services to the rural residents [
21]. As a matter of fact, there was still no consistent or sufficient public funding for the operation of the village clinics, although the village doctors could receive some compensation through various channels [
16].
Therefore, more systematic analyses regarding the aging of the village doctors are required in order to benefit the rural health system in China, since village doctors provided 1.59 billion outpatient services for rural residents in 2011 [
13]. If the aging challenge is not addressed, it will probably result in a human resource for health crisis in rural China in the near future. This study aimed to reveal the age structure of the village doctors and to explore the causes and the relationship between aging and education levels, practicing methods, outpatient numbers, medical income, and expected pension. The outpatient numbers per month, implying the average quantity of outpatients treated by a single village doctor, were included into the analysis to gauge the workload and the capacity of the village doctors. As the income and the retirement pension were considered to be the most important factors of the recruitment and retention of village doctors in Beijing [
34], we further conducted quantitative analysis on them. Therefore, this study tried to present a panorama of the aging of the village doctors in China.
Competing interests
We declare that we have no conflicts of interest.
Authors’ contributions
DT, ZQ, XZ, ZS, and HX participated in the research design and project implementation. HX and WZ participated in the data collection and data analysis. HX wrote the original text. LG participated in the manuscript discussion and revision. All of the authors read and approved the final manuscript.