During the 1950s, the system of barefoot doctors and the Cooperative Medical Scheme (CMS) financed health care was conducted in China to look after the health of the rural population. This “barefoot doctor” service was initiated by the peasants on a collective and mutual aid basis [1
]. After farmers received another medical short-term training (3, 6 or 12
months), they returned to their villages and took on the role of barefoot doctor. Despite simple techniques and inadequate medical equipments at the primary level of health service, the system of barefoot doctor and CMS programme substantially decreased medical costs and provided timely treatment to the rural population [2
]. Following the economic reform in the early 1980s, the CMS collapsed and was changed to a fee-for-service system of medical care in rural areas. Coverage of the CMS fell from 90% in the 1960s to 5% in 1985 [3
]. At that time, barefoot doctors lost institutional and financial support. The Ministry of Health changed the title of “barefoot doctor” to “village doctor” for those who passed an examination. Those who could not pass turned to other professions [4
]. These private village doctors had to focus on treatment of patients to gain financial profit. The level of public health activities in the village decreased. Currently, a farmer who wants to be a village doctor must have at least completed 5
years primary education, and attended and passed the examination of the 1–2
year medical training course at the township or county hospital. Then he/she can be fitted into a vacant position for a village doctor. General education level of village doctor is secondary school and medical health school. Village doctors provide preventive services, maternal and child health services, and simple outpatient care to village residents. Amidst the world trend of health finance reform in 2003, the Chinese government started the New Rural Cooperative Medical Scheme (NRCMS) to reduce the financial burden on rural residents. It is a combined government-run, voluntary, community-based and cost-sharing medical insurance programme. This system requires members of the participating household to pay some part of the premium, including a contribution of 10 RMB, with a local government subsidy of 20 RMB per capita per year [5
]. In 2010, NRCMS covered more than 90% of the rural population [6
]. However, because of the poor quality of new village doctors who provide primary health care in the village, people are still facing many problems at the grass roots level in China.
Worldwide, almost 10 million children die every year before their fifth birthday [7
Seven in ten of these deaths are caused by acute respiratory infections (mostly pneumonia), diarrhea, measles, malaria, malnutrition or a combination of these conditions [8
]. To solve this problem, in the early 1990s the World Health Organization (WHO) and United Nations International Children’s Emergency Fund came up with the Integrated Management of Childhood Illness (IMCI) strategy. The purpose of this programme is to improve the case management in an integrated fashion in order to tackle the most common childhood illnesses [9
]. Immediately after the introduction of the programme, multi-country evaluations in Uganda, Tanzania, Bangladesh, Brazil and Peru were conducted. It was shown that IMCI could improve the health service quality, and reduce childhood mortality and health care costs. Subsequently, the IMCI programme has been introduced in over 113 countries with varying levels of understanding [10
Rural China shares the same pattern of childhood diseases listed in IMCI. Pneumonia is still the leading cause of under-five mortality. IMCI was introduced to China in 1998 and since then has been launched as a pilot project in 46 counties of 11 provinces. However, only about 2% of the rural areas have been included [11
]. The slow and limited progress of IMCI for more than one decade reflects the low level of commitment by the central and local governments. Over one million village doctors scattered throughout the whole country are still untrained on this important technique.
Yunnan Province is situated in southwest China, bordering Myanmar, Laos and Vietnam and has a population of 45 million. It is one of the poorest and the most remote provinces of China. More than 75% reside in rural areas. In 2001, the provincial average GNP per capita in 2001 was 4,872 RMB (US$609). Approximately 5.6 million people live with an average income per year below the national poverty line of 300 RMB (US$36.1) [12
Living in a mountainous area, rural residents have limited access to health facilities due to the long distances involved in traveling. The high cost of the health care is also a barrier. The mortality rate of children aged under-5-years in border areas (18.6%) was over 5 times higher than that in non-border areas (3.5%) [13
In 2010, the government of Yunnan planned to launch IMCI training in all rural areas. The highest priority was placed on border areas. This study was conducted prior to the training. It aimed to assess health systems and the clinical competency of village doctors on childhood illness. Information obtained from the study would be used in detailed planning of the training and further improvement of the health system.