Clinics in Gansu: How to Stay on as a Village Doctor
by Beate Engelen
Becoming a village doctor had never been one of Chang Xi’s childhood dreams. There was no calling and no aging parent to urge him. “I did it,” he explained, “because I didn’t want to be farming all my life or become a migrant worker.” Chang Xi, a young ambitious man in his early thirties from a small village in Gansu Province near Wuwei, could well have chosen some other occupation to escape a life of harsh physical labor but he picked medicine.
Young people of his age belong to the so-called “post-80s generation” of China. They grew up when the Chinese countryside experienced a major shift in production and living standards from 1979. The people of this generation have fewer siblings and their lives are not so much influenced by political campaigns, food shortages and communal production but rather by a more liberal economic system and a promise that things will become better – even in the countryside. Chang happily took up the challenge to work himself out of a farmer’s life.
First, he managed to secure one of Amity’s scholarships for medical training that enabled him to study at a local health college. When an old village doctor, ready to retire, offered the young graduate to take over his clinic, Chang agreed. Together with his wife, a nurse he had met at college, Chang set up business. During the first three years, everything seemed to work out fine.
When patients stay away
Problems began when modernization arrived at the village and a better road was built. “Our clinic was located at some distance from the new road in a dip,” says Chang, “people didn’t want to take the extra turn.” As Chang and his wife worked hard to keep the clinic running, the number of patients dwindled. The better road, of all things, had cut them off from being able to make a living.
The reason for this sounds like a paradox: The wealthier patients were driving the young village doctor out of business. But the explanation is simple. Living standards around Wuwei had been improving slightly over the years. As more and more farmers earned their incomes as migrant workers, some of the more fortunate ones bought motorcycles. If a clinic looks run down or is inconveniently located, motorized patients ignore it and go on to the next one, which looks nicer or is easier to reach, even if a little further away. As a result, off-road village doctors lose their financially sound patients.
In a way, this looks like healthy competition – but if village clinics close, all the other patients, those who cannot afford a motorcycle, go without any healthcare.
Yet, it is vital for rural communities that all residents enjoy good, hygienic and easy to access medical services. More than anybody else, in fact, it is the people in the countryside who are in dire need of better healthcare. There are huge inequalities between rural and urban areas. The 37 million people living in Guizhou, one of the poorer western provinces with a big rural population, can expect to live 13 years less than residents of Shanghai, according to official reports. One reason is the lack of proper healthcare.
Moreover, rural areas sustain a much higher proportion of ill-health than the cities because of migrant labor. Villagers who move to the cities as migrants tend to be young and strong, leaving behind the children, members of the older generation and the sick. Migrants stay in the cities as long as they are healthy and strong, only to return when their strength and health deteriorates. They are thus exporting health and re-importing ill-health into their home villages.
Even though village doctors like Chang are no doctors in the proper sense of the word but really paramedics or health workers, they are none the less badly needed to treat minor ailments like the flu or stomach aches, to help with emergencies, vaccinate people, watch out for signs of an epidemic and give advice to pregnant women. In order to be able to stay in the game, some village doctors need outside support.
Where is the money?
To help Chang stay on as village doctor and provide basic healthcare for all the villagers, Amity supported his plans to build a new clinic on a patch of land next to the main road granted by the government, which costs RMB 80,000 (US$ 12,000). Around 10% of the cost was covered by Amity but the biggest chunk of the investment Chang needed to raise himself. The banks would only lend him one fifth of the amount he needed. “The rest I borrowed from family members and friends at high interest rates,” says Chang. Interest rates of 25% are not unusual in such private transactions. Moreover, Chang never knows where and when his creditors want their money back: “They come any time and ask me to pay them on the spot.” Chang has sometimes trouble sleeping at night because of his debts. What he needs is a stable income.
The financial situation of village doctors has slightly improved in recent years. The local government in Wuwei has experimented with innovative healthcare schemes that have shown some good results. Under a basic health insurance scheme, the authorities pay a fixed annual sum of RMB 1200 (US$ 176) to every village clinic. Doctors can now count on this small but stable income. This is not sufficient, though, to keep a clinic running.
Village doctors usually make money by selling medicine and treating patients. But money tends to be in short supply. Many patients are too poor to afford even a package of pain killers. Dearth of cash in the countryside cripples business of all kinds and doctors have not choice but to adapt. Chang’s colleague, Yan Ruinian, who runs a clinic in a neighboring village, has specialized on Chinese medicine, because this is what people can afford. Instead of pills and drops, he prescribes herbal concoctions or a blend of mushrooms, collected in the wild and dried by his wife. This, at least, provides him with a monthly salary of RMB 600.
Still, getting any money from patients remains a problem. It is nothing unusual that patients try to avoid paying for medicine and services on the spot. Instead, they prefer to sign an IOU, paying later when money is at hand. In the past, many village doctors had no choice but to become migrant workers themselves because their patients couldn’t pay. Chang has but one chance a year to call in his money. Before Spring Festival, employers hand out the annual salary to their workers. Then, for once, it is payday for the village doctor. At least around 70% of his patients repay their loans at that time. But Chang has still to stop by their houses personally to settle the matter.
Village doctors in Wuwei operate on very narrow profit margins. Chang and Yan – like all the other village doctors – continue to do farm work on top of their medical duties to feed their families and send their children to school.
Since village doctors are on duty at least 12 to 18 hours a day – not counting the emergency cases – they have little time left for further training. Even though it is increasingly recognized that village doctors need more training, courses come at too high a price for them. “I cannot close my clinic for several weeks to attend a training course,” says Chang. The financial loss would be to high. To compensate for missed opportunities to learn about medical innovations, some village doctors collect cut-outs of local newspaper articles on medical issues. This is the best they can do.
Staying on
Still, village doctors struggle hard to stay on. So far, Chang’s investment has been a success. Today, his new 90-square-meter clinic is in good shape. A chatty group of patients and their kin occupy the treatment room, an airy space with two clean beds, IV drip stands, bright windows and carefully chosen pictures on the wall. A wood-stove in the middle of the room oozes warmth and a living-room atmosphere. On one of the beds, a 50-year-old woman farmer receives an IV in order to get rid of a tenacious case of the flu. She and her husband have come down from another village by motorcycle despite the biting November cold to visit Chang Xi’s clinic. “The price is fair and the service is excellent,” they say. They would rather be here than at another clinic.
While Chang’s wife is changing the IV drips, swiftly and carefully, Chang pokes the fire. He wants his patients to feel at home. He and his wife have a good reputation in the area. “People respect me,” says Chang, “I can sense it when I am on family visits.” It looks as if Chang will stay on despite all the troubles.
