On March 11, the Chinese Center for Disease Control and Prevention’s COVID-19 release reported an over 80 percent decline in national daily fever-clinic visits, suggesting the massive wave of infections since last December has come to an end.
While the report sends quite positive signs of improvement regarding China’s COVID-19 conditions, it also highlights an earlier-than-expected outbreak of COVID-19 in rural regions. Rural daily clinic visits peaked on December 23, just one day after the urban peak. This was one month before the official anticipation, which estimated the rural outbreak would arrive around the Lunar New Year, after millions of migrant workers carried the virus to their villages through their holiday travels.
Besides indicating an earlier-than-usual New Year migration this year, perhaps caused by COVID-related market depression, the unexpected rural outbreak also suggests that China’s abrupt zero-COVID U-turn may not have given China’s poorly resourced rural primary healthcare system enough time to prepare for the worst outbreak. The sudden COVID-19 outbreak exposed several notable deficiencies in China’s rural primary healthcare system.
A Tiered, Two-Track Healthcare System
Currently, healthcare provision in rural China follows a three-tiered structure. Most villages have a village clinic; this is the first level of healthcare for rural residents treating minor illnesses. Severe patients would be referred to the next level, the township health center, with more professional staff providing healthcare and supervising the services provided by village clinics. The final level is the county hospital, a more comprehensive medical center with specialized physicians and sufficient medical technologies. Similarly, healthcare in urban areas also follows a three-tier hierarchy, consisting of community health centers, district hospitals, and municipal/provincial hospitals.
However, the gatekeeping regulations are not compulsory. Both rural and urban patients are free to choose higher-level healthcare providers, but for rural people, traveling usually takes more time and money. Unless they are seriously ill, only 2.7 percent of rural patients would bypass the rural healthcare system to visit a municipal or provincial hospital.
Village clinics constitute the foundation of China’s rural healthcare system. During this COVID-19 outbreak, the Chinese health authorities expected these fundamental care units to play a key role in tending to the needs of mild cases, as services provided by them are crucial for minimizing the severity rate and death rate. There were thus high hopes that village clinics would take some pressure off higher-level health institutions, places for treating high-risk patients.
A Broken Drug Distribution Channel
However, village clinics are limited in their ability to perform this “gatekeeping” role due to a series of challenges. A particular issue during this COVID-19 wave was the failure of the current system to deliver drugs to village clinics. Due to China’s previous strict targeted-quarantine measures, primary healthcare institutions were prohibited from treating patients with COVID-19 symptoms. Consequently, most village clinics did not have sufficient stocks of relevant drugs. Yet when surging numbers of patients soon exhausted rural medicine stores, village clinics could find no way to replenish their stock due to their disadvantaged status in the health system.
As the smallest unit of care provision, village clinics could order medicine either from the higher-level institution – the township health center – or directly from the market via pharmaceutical firms, drug distributors, etc. This system works well when there is an adequate medicine supply. But either way, village clinics are at the very end of the drug distribution network. When relevant drugs were in short supply all over the country, drug firms and distributors would prioritize larger buyers; township health centers were also unable to support them as they were short of drugs as well. Whether through public or private purchasing, village clinics cannot access necessary drugs if other places and institutions have mopped up the supply.
This situation was particularly challenging for clinics in remote villages, places that are poorly connected by transport and logistics systems. In these areas, inequalities produced by the tiered organization of healthcare services were further complicated by the regional development gap, which made it more difficult for village clinics to get medical supplies, further aggravating the vulnerability of the population in these areas.
Inadequate Healthcare Professionals
Alongside structural issues in drug provision, there is the additional problem of a shortage of village healthcare professionals. Overall, the numbers of healthcare professionals per thousand rural residents are significantly less than in urban areas (see Figure 1 below). Limited rewards in addition to urban-rural inequalities make rural primary healthcare work a non-desirable profession, and the number of them is constantly declining.
By the end of 2021, 1,363,000 professionals were working at village clinics, 80,000 less than in 2020. Over 50 percent of the doctors at village clinics are what have been called “barefoot doctors” – peasants who received basic medical training to work as a part-time health workers. On average, each village only had around two doctors (including licensed physicians and village barefoot doctors) providing community-based services. While the current system appeared fine in normal times, it was far from adequate to support an aging rural population through an Omicron outbreak.
In fact, the outbreak just lays bare the system’s inherent fragility and unsustainability. During the outbreak, doctors at village clinics had to further overload themselves to cope with surging numbers of patients. China Health Yearbook 2022 shows that in 2021, the national average number of patients that a doctor received per day is 7.3. But news investigations have revealed that during the toughest time, the workload of village doctors across Shanxi, Anhui, Hebei, Shandong, Henan, and Yunnan provinces were all tens of times larger than this number. This negatively impacted the quality and timeliness of their services and increased the risk of worsening of patients’ conditions due to delays in giving care.
Equally worrying is the health condition of the doctors themselves, particularly considering that a considerable number of village health professionals are not young. In 2021, 69.5 percent of village clinic staffers were above 45; more than 20 percent of them were older than 60 (see Figure 3). Some elderly doctors themselves belonged to high-risk populations, and they were unable to provide effective care due to old age and poor health status. Once the only doctor(s) in a village got ill, the whole village’s health would be at risk, and more patients would flood to higher-level care providers.
Therefore, it is highly risky to count on a seriously understaffed and aged primary care system to attend to the health demands of a vulnerable rural population and “gatekeep” for more quality medical resources in cities.
Limited Treating and Caring Ability
Further, village clinics lacked experience treating COVID-19 patients and are often poorly equipped, which limited the system’s ability to effectively care for and refer patients. Remember, over half of the doctors at village clinics are barefoot doctors. For the past three years, their main duty was to manage COVID-19 testing and case tracking. Though some township health centers organized several training sessions about COVID-19, the training was vague and health personnel lacked the opportunity to participate in patient diagnosis and treatment.
Low self-confidence combined with shortages of medical supplies pushed some village doctors to refer all patients with fever to higher-level health institutions. This further aggregated the burden on already overloaded health centers and county hospitals.
In addition, most village clinics only have basic medical devices. Hardly any village clinic has an oxygen generator. Before the outbreak, they did not have oximeters either, which is crucial for identifying seriously ill patients and monitoring the progression of the disease. The lack of equipment increased the risks of giving an ineffective diagnosis, particularly considering that COVID-19 can cause “silent hypoxia” in many patients. Therefore, it was difficult for ill-equipped village clinics to effectively identify high-risk cases.
A more worrying problem is medication overuse. Some village doctors broadly applied a “Village Doctors’ Four-piece Set” treatment, which combines antibiotics, antiviral drugs, dexamethasone, and antipyretics, to treat all patients. However, antibiotics cannot treat a disease caused by a virus. Likewise, using dexamethasone in non-severe patients only causes damage to bones. Village doctors overprescribed these medications mainly to prevent the occurrence of bacterial lung infections and severe COVID-19 symptoms to avoid the risks of treatment. But this reflects the common problem village clinics faced with accurately assessing patients due to a lack of medical data.
It further highlights the necessity of having an effective mechanism to oversee and regulate village doctors’ practices in times of crisis. Unfortunately, during this round of the outbreak, such a mechanism was not yet in place.
This round of COVID-19 infections has ended, but the structural and systematic problems that village primary healthcare workers face remain. Rural China has struggled through this wave – but only thanks to excessive exploitation of the labor of village healthcare workers and cooperation from the rural people. But will China always be this lucky?
Before the next public health crisis strikes, it is imperative for China to strengthen its fundamental healthcare facilities. The condition in village primary healthcare is more precarious due to the lack of medications, equipment, and well-trained healthcare workers. If COVID-19 can facilitate meaningful changes in these areas, some of the pain it has inflicted will not be in vain.