The barefoot doctor : training, role, and future

PHN Technical Notes GEN 19 THE WORLD BANK TIE BAREFOOT DOCTOR:' TRAINING, ROLE, ANTD FUTURE- May, 1984 EftpuiatiL,a, ffevfitih and Nutrition Department * Thispae is one of a series issued by the Population, * *Health and Nutrition Department for the information* * and guidance of Bank staff working in these sectors. * * The views and opinions expressed in this paper do* * not necessarily reflect those of the Bank.*  GEN 19 A B S T R A C T Our analysis of the activities of barefoot doctors (BFDs) showed, for the first time, that less than one-third of a BFD's time is spent on preventive and curative medical activities. The other two-thirds is spent on supportive activities, such as drug preparation and equipment sterilization, and non-heal-th-related activities. The preventive activities that have contributed to the crucial reduction of communicable diseases take only a very small amount of a BFD's time. Our results also show that there should be concern about the BFD's ability to maintain proficiency in clinical skills, especially when a further shift from preventi've to more and more complex curative activities takes place. As a consequence of the global socioeconomic changes, alter the introduction of a responsibility system, one of the patterns we observe is a professionali'zation of BFDs. BFDs with rural doct.or certificates tend to work full time as health workers, see more patients, and use more drugs. The demand for better quality care is increasing. Those BFDs with clintzal slkills that are below standards appear to be weeded out. Preventive services were a major contributing factor to China's success in improving the health status of its population, and the BFDs played a significant role in sustaining these health levels in the rural areas by providing readily accessible pri-mary care at little or no cost. A major question stirs our concern:' given the changes in the socioeconomic structure, can China sustain its own rural health care system with the same degree of success it has had in the past? This paper is Supplementary Paper No. 10 to World Bank Report No. 4669-CHA, "The Health Sector in China". Prepared by Mary E. Young, IH.D., Dr. P.H., Consultant April 1983 (Revised, May 1984)  THE BAREFOOT DOCTOR - TRAINING, ROLE AND FUTURE Contents Page No. Abstract ..................................................... i Contents. ......... ................................................ ii List of Tables ..................................................... iv 1.0 INTRODUCTION 1.1 Objective ................................. .. ... . ...... . 1 1.2 Historical Perspective to 1949 ..........................1 1.3 Local Health Services Oraanization since 1949 .......... 2 2.0 MAKING OF THE B.AREFnOT DOCTOR (BFD) 2.1 Origins ............2.................... 2 2.2 Recruitment ......... I.................. ........... 4 2.3 Training Process ....................................... 4 2.4 Training Related to Functions .......................... 5 2.5 Training Mlaterials and the BFD Maanual .................... 2.6 Continuing Education .................................... 6 2.7 Income. ............................................... 8 2.8 Activities .............................................. 8 2.9 Summary ...................................................... .9 3.0 BFD PRACTICE IN QUE'U COUNTY 3.1 Logistics .............................................. 9 3.2 Qualifications .............................................. 10 3.3 Survey ............................................... .10 3.4 Characteristics ........................ ......... 10 3.5 Training ................................................ 11 3.6 Retraining ............................................. 13 3.7 Income ...................................................... 14 3.8 Practice ............................................... 15 3.9 Referral ................................................ 25 3.10 Supervision................................................. 26 3.11 Job Satisfaction ........................................ 26 4.0 FUTURE OF BAREFOOT DOCTORS 4.1 Modernization ......................................... 27 4.2 Standardization .......................... ......... 27 4.3 Free Enterprise Initiatives ............................ 27  Page No. 5 . 0 CONCLUS IONS .................................... 28 6.0 LIST OF REFERENCES ......................... 30 7.0 APPENDIX TABLES ......................................... 34  - iv - LIST OF TABLES Page No. 1. Vertical and tiorizontal Political Organization in Rural China.... 3 2. Curriculum for Initial Training in Yexian ........................a @ . 7 3. Proportion of Clinical Theory and Practice ......... ......... 7 4. Ratio of Population 'L'O BFDs, 1981.............................. 10 5. Age Distribution of BFDs in lWanghuan and Shuyuan Commmunes in Qufu County, 1981.. ............................................ 11 6. Number of BFDs Trained in Qufu County, 1959-1980 ................. 12 7. Content of Training ............................................... 13 8. Months of Retraining, 1979-1981 .................................. 13 9. Type of Additional Training Desired by BFDs, 1982 .................... 14 10. Comparison of Income: BFD and Population, 1981 ...................... 14 11. Comparison of BFDs' Age, Income, Years of Education, and Years of Practice and Training, by Sex, 1982 ...................e 15 12. Time Distribution of Work per Week as Perceived by BFDs, 1982.... 16 13. Volume of Patients Seen per Day as Perceived by BFDs, 1982....... 16 14. Percentage Distribution of Type of Practice, as Perceived by. BFDs, 1982 ................. ........................ .......... *17 15. Priority in BFDs Practice as Perceived by BFDs, 1982................. 17 16. Percentage Distribution of Chief Complaint, by Sex, 1982 ......... 18 17. Percentagae Distribution of Chief Complaint, by Age Group, 1982... 19 18. Type of. Medications Used by BFDs for Patients with Common Cold and Acute Gastroenteritis, Qufu, October 1982 ............. 20 19. Percent Distribution of Western Drugs Used By BFDs for Common Cold and Acute Gastroenteritis, Qufu, October 1982 .............. 21 20. Percent Time Distribution of Work Sampling Observation of BFDs' Activities, Qufu, 1982.................................... 22 21. Reimbursement of Cost of Care for Referral, 1982 .................. 25 22. Emphasis of Supervision as Perceived by BFDs, 1982 ................ 26 23. Frequency of Supervision Described by BFDs, 1982 ................... 26 24. Area of Change Needed in BFD Program, 19822 ........................ 27 Appendix Tables 1. Coefficients of Regression Equation with Percent Time Spent on Preventive Care from Work Sampling Observations ................. 34 2. Coefficients of Regression Equation with Percent Time Spent on Curative Care from Work Sampling Observations ................... 35 3. Coefficients of Regression Equation with Percent Time Spent on Maintenance from Work Sampling Observations ..................... 36 4. Coefficients of Regression Equation with Volume of Patients ......e 37 5. Coefficients of Regression Equation with Number of Drugs Prescribed per Patient Visit per BFD.............................38  THE BAREFOOT DOCTOR: TRAINING, ROLE, AND FUTURE by Mary E. Young* 1.0 Introduction 1.1 Objective This paper reviews the literature on the barefoot doctor (BFD) movement, describes the September 1982 Survey of BFD.practice in Qufu County in Shangdong Province, and discusses the future of barefoot doctors.. 1.2 Historical Perspective to 1949 Data on the BFDs in China, listed in the bibliography, was obtained from multiple sources, including the Johns Hopkins libraries, the Eastern Asia- Yenjing Library (in Chinese) at Harvard, and extensive interviews with Chinese visiting scholars who trained and worked with barefoot doctors. Until the seventeenth century, traditional medicine was the only form of medicine available to the Chinese. Dating back to 2500 B.C., it was perhaps the world's oldest body of medical knowledge. The first Jesuit missionaries arrived in China at about 1630, but for 200 years achieved only limited penetratioa. Thus, until the nineteenth century there were few Western doctors in the cities, and in rural areas Western medicine was nonexistent. The first school of Western medicine, St. John's University iledical School, was founded by missionaries in Shanghai in 1880. In 1881 the Chinese established a second medical school in Tienjn. Western medicine was systematically introduced in 1917, and the number.of graduates averaged 500 per year. 1 As a consequence of poverty and malnutrition, the population of China befor'e 1949 was burdened by,a high incidence and prevalence of infectious diseases,' such as typhoid fever, cholera, and tuberculosis, and by premature deaths. The crude deatth rate was 30 to 40 per 1,000 population; the infant mortality rate was 200 per 1,000 live births; and life expectancy was 32 years. At that time there was little preventive medicine in China, and there were only some general national or municipal public health services. 3-5 Thus, in 1949 the bulk of medical care for the Chinese people was provided by about 500,000 traditional medicinal practitioners. Physicians trained in Western me icine numbered about 40,000, approximately 1 doctor for every 15,000 people. * This paper was initially prepared as a review of the relevant literature prior to the World Bank's Rural Health and Medical Education Mission to China in September and October, 1982. It was updated based on the author's participation in the mission, particularly in light of data gathered during the mission's field visit to Shangdong Province.  -2- 1. ocal Health Services Organization since 1949 The history of the use of health auxiliary workers in China before barefoot doctors dates back to the mid-1920s. The Ting Hsien Experiment, developed by Dr. John B. Grant, was tht' forerunner of the present-day Chinese rural health network. Village health workers were trainLd to work with the peasants on immunization, registration of births and deaths, health education, and the treatment of minor ailments. A physician was available at a district health stition for referrals and for training of the village health workers. 8 Only after the liberation in 1949 was this experience used because priority was given to establishing rapidly mass campaigns for a health care system that could cover the entire population and to focus resources to support preventive services, to subsidize the cost of drugs, and to train health auxiliaries such as the BFDs. Since 1949, medical care has increasingly been provided publicly in organized primary care services rather than privately. 9 Each county has a three-tiered health system (see Table 1). At each level, control of personnel and programs is under the revolutionary committee of that administrative unit. Planning and policy decisions are transmitted down through the central and provincial hierarchy, but implementation is decentralized and is a local responsibility. Brigade cooperative health stations started in 1969. They are firqvmced by dues from the brigade members and fees for user services, medicinal herbs sold for profit, and a subsidy from the brigade welfare fund. The government subsidizes this cooperative medical service by setting the cost of Western drugs artificially low, providing free vaccines and contraceptives, and subsidizing most of the initial and continuing cost of training BFDs. The commune health center is financed by commune funds, county and provincial subsidies, user fees, and contributions. The staff supervises the BFDs, organizes continuing in-service training for them, provides outpatient and obstetrical services, and performs minor operations. The county hospital provides technical support, supervises the lower-level health care units, and receives referrals from the brigade or aommune. It is funded from county funds and the state's regular budget. 1 11 The county health bureau, responsible for preventive activities, also directly supervises the BFDs. 2.0 Making of the Barefoot Doctor (BFD) 2.1 Origins There exists an extensive literature by both Chinese and Western authors on the origin, selection, educational background, income, and tasks of the BFDs. As Pickowicz states, "BFDs are neither 'barefoot' nor 'doctors'; they are really paramedical personnel." 2  -3- Table 1: Vertical and Horizontal Political Organization in Rural China Administrative Population Executive Branch Chinese Unit Responsible Level Size of Government Communist for Health Party Unit Service Delivery Nation State council Secretariat Ministry of Health 1,008,175,000 of central committee Province 3,000,000- Provincial Provincial Provincial health (or autonomous 130,000,000 governmernt party department region or committee (supervisory), municipality) hospitals, epidemic prevention and TICH stations Cotunty 400,000- County County County health 600,000 government party bureau committee (supervisory), hospitals, epidemic prevention station, MCH station Commune 15,000- Commune Commune Commune 50,000 management party health committee committee center Production 1,000- Brigade Brigade Cooperative brigade 3,000 leadership party medical group branch station Production 250- Team Party Part-time team 800 leader cadres health aide  -4- The first group of BFDs was trained in 1958 by a mobile team of physicians in Chiangchen Commune on the outskirts of Shanghai. By June 1960 over 3,900 such health workers in the 2,500 production brigades of the 10 counties in Shanghai municipality had been trained. Between 1961 to 1965 the training'was stopped because of a change in political direction condemning the role of the health workers, and the 3,900 health workers in Shanghai County were reduced to about 300. Training resumed in the months preceding the Cultural Revolution and began in earnest following Mao's "June 26 Directive" in 1965, which stated, "In medical and health work, put the stress on the rural areas." In 1966 the Cultural Revolution broke out and brought with it the true BFD, who was an agricultural worker trained as a paramedic. Their numbers increased markedly during the Cultural Revolution and reached about 1.6 million in 1975. By 1980 the number had fallen to approximately 1.5 million (an 8 percent annual attrition rate) 13'and in 1981 to about 1.4 million. Wihen they first appeared with their medical kits in the rice fields near Shanghai, the new health workers often went barefoot in the fields, hence their peasant patients called them barefoot doctors. Today, this term is used throulahout China, but the BFD .is considered by his community and apparently thinks of himself as a peasant who performs some medical duties rather than as a health worker who performs some agricultural work. 1 There are exceptions, however; the BFDs in Shanghai,County are full time health workers. 2.2 Recruitment There is no standardized criteria for selection of BFDs. They are recruited from among the peasants. The recommendations for selection come from the production brigade and are based on enthusiasm and political and ideological attitudes. 15 19 Most candidates have a primary or junior high school education. They are young, averaging 23 years old, but some are in their 60s. 20 Approximately 30 percent are female. 2.3 Training Process There is no single uniform model in training BFDs because of the highly decentralized government and local autonomy. Each region has developed its own training program and has set its own pace to meet local needs according to available resources. 21 Wang has described three patterns of training. 22 The content of training constitutes a progression from continuous preventive to curative medicine. In the beginning a minimum level of expertise was needed. The BFDs learned the basics in providing environmental sanitation services, immunization, and family planning. As the people's standard of living improved, the BFDs adapted to the new need for more curative care through continuing education. The training is an ongoing process 23-26 and much of it is informal. 27, 28 The length of initial training received varies, averaging three to six months, 29-3 with a range of one month to about one year. They are trained in a number of places, some locally at the commune hospital, others by mobile service teams of urban medical workers who travel from county  5- to county for the purpose of training BFDs. Yet other potential BFDs leave the commune to study at county hospitals. Over the past few years, as the number of BFDs trained per period of time diminished, training has become less formal. Counties which have ongoing BFD training schools can still afford to train the newly selected BFDs from the brigades; for example, since 1974 Yexian offers one year of initial training for all entering BFDs. But those who do not have formal training centers, train BFDs on the job. By following the senior BFD and by first making home visits, delivering medication, and doing surveillance work, the BFD trainee gradually learns the skills in curative medicine. Thus, a new BFD is likely to concentrate on prevention and to learn clinical skills through actual practice on the job. The additional retraining varies in format, including training in groups or individual sessions by qualified doctors, one day a week, one day a month, or several months at the commune hospitals. The underlying principle of the training is to integrate theory with practice.3 2.4 Training Related to Functions BFDs' functions, in practice, vary in accordance with .their training backgroundd These functions can be divided inio four categories: prevention, diagnosis, treatment, and nursing. Emphasis is placed on the common and frequently occuring diseases in China's rural areas. Both lWestern and traditio3nal Chinese medicine are combined with the use of local medicinal herbs. . Horn has described the content of the initial training in 1965: "They studied anatomy, physiology, bacteriology and pathology, clinical medicine and hygiene. They learnt to identify gerns in contaminated waters, recognize the eggs of worm parasites in excreta, give injections, diagnose common disease and detect signs of serious illness. 36 Each student is issued a well-illustrated book especially written for peasant doctors; the training manuals are prepared by teaching staff at urban medical schools or hospitals who have travelled in rural areas with mobile health care teams. They are especially written to suit students with little education. 2.5 Training Materials and the BFD Manual The Barefoot Doctor's Manual, required to be carried by almost every BFD in China, was edited by the Revolutionary Committee of Chiang Chen Commune Hospital, and completed in January 1970. The book was published in June 1970 by the People's Medical Publisher in Beijing. There are two veSions, one for use in Northern China and the other for use in Southern China. The book treats its subjects in the following proportions: 45 percent on identification and use of medicinal herbs; 40 percent on diagnosis and treatment of common disease, including infectious diseases, parasites, obstetrical and gynecological and pediatrics diseases, first aid, and surgical conditions; 10 percent on therapeutics, including treatment with Chinese herbs, folk treatments, and new therapeutic techniques; 3 percent on diagnosis techniques; 1 percent on environmental sanitation such as water and excreta management, pest control, and occupational hazard prevention; and 1 percent on  -6- birth control techniques. Tables 2 and 3 show the curriculum at Yexian Training Center. 2.6 Continuing Education Continuing education of BFDs has expanded since 1973, with more specialized courses given in primary health care at commune or county hospitals. The Barefoot Doctor Journal, a monthly periodical that is easily accessible to BFDs, began its first cigulation in March 1973. Analysis of issues from March 1973 to August 1980 indicated 48 percent of the contents are on curative medicine (including disease diagnosis, treatment in internal medicine, pediatrics, and surgery); 10 percent on methods of improving environmental sanitation; 7 percent on prevention of communicable disease; 7 percent on pharmacology with use of herbs and W4estern medicine; and 5 percent on family planning. The remaining material discussed cases and questions from the barefoot doctors and explained terminology. The contents of both the BFD Manual and the BFD Journal reveal greater emphasis on curative than on preventive care of frequently encountered diseases and injuries, but prevention of these diseases is also discussed. During the mid-1970s there was criticism of the training, competence, and practice of the BFDs. Examples of their mistakes appeared. in the Chinese press, suggesting that some BFDs went beyond the limits of their technical knowledge and skills. A more neutral view, as expressed by Vice Premier Deng Xiaoping, suggested that the BFDs needed,to gradually upgrade their knowledge. In the late 1970s, in keeping with the drive to improve technical quality, local health departments at the county level began to provide periodic short training courses. The BFD Journal had several editorials describing what so provinces had been doing for contin.,Ling education to upgrade the BFDs. In 1979 in Peking and Shanghai, examinations began to be administered to weed out BFDs with unacceptably low levels of knowledge. The examination covers management of patients with illnesses such as rickets, acute gastroenteritis, and appendicitis, and preventive practices such as immunization and achieving safe water supplies. Traditional Chinese and Western medicine are included with questions on phy?-iology and pathology and on traditional theories of diagnosis and treatment. The Beijing Bureau of Public Health provides material to help the BFD prepare for the examination. Failing the examination, however, does not Qbange their practice, since another chance is given for those who fail. 4 This ongoing attempt to combine the techniques of modern Western medicine with those of traditional ghinese medicine, as described by Pickowicz, Rosenthal, and Lampton, 4547 is a political decision for the Chinese government. Facing shortages and unequal distribution of health personnel, the government gave political support to traditional Chinese medicine. In this way it counterattacked the resistance, dominance, and power of the Westernized medical profession.  ! -7- Table 2: Curriculum for Initial Training in Yexian Total Content Hours Lecture Practice Rural health 50 30 20 Basics Traditional Chinese medicine 90 80 10 Western medicine 144 104 40 Treatment of Frequent Disease Traditional Chinese medicine 104 96 8 Wqestern medicine 260 222 38 Basics of Diagnosis and Treatment 60 35 25 Frequent used drugs Traditional Chinese medicine 60 48 12 Wiestern medicine 80 66 14 Total 848 681 167 Table 3: Proportion of Clinical Theory and Practice Content Hours- Percent Percent Basic Theory Traditional Chinese medicine 150 12 57 Western medicine 334 26 Clinical Theory Traditional Chinese medicine 104 8 43 Western medicine 260 20 Practice 448 34 Total 1,296 100 100  -8- 2.7 Income The income of a BFD depends on the economic level of the brigade and is determined in the same way as that of other peasants in the commune. It is based on the number of "work points" generated by doing "medical work" instead of "agricultural work" during the same period. The number of work points assigned to individuals depends on their equivalent agricultural production based on a scale of one to ten. BFDs are usually awarded between eight and nine points per day for their work, depe diTj on their age and sex (older and female BFDs receive fewer work points). Until 1979, as an agricultural and health worker, a BFD earned.a salary that exceeded that of a ngrmal peasant but was lower than that of a doctor working in the commune. 5 However, the introduction of the responsibility system in the rural sector in 1979 emphasized the opportunity for everyone, including BFDs, to gain increasing agricultural income from private plots and increasing production. Consequently, a peasant's potential income increased while the BFD's income, still based on work points, fell behind. The responsibility system has thus raised t.he "opportunity cost" of work as a BFD and will encourage attrition and emiphasize agricultural ra-ther than health work.. There are now chanaes in the method of remunerating BFDs and in upgrading them to. the position of "rural doctor" to reflect the higher level of training and income. 5 Rural doctors' now receive a subsidy in addition to their salary; the amount varies depending on the economic status of the region. As part of the national policy, slightly higher subsidies are given to health workers in remote areas and minority regions (for instance, in the mountains of Ningxia Autonomous Region). 2.8 Activities The activities of a BFD vary from area to area, commune to commune and even brigade to brigade within a commune. 56- In general, BFDs are responsible for environmental sanitation, health education (use of birth control methods, prenatal education, and infant care education)., immunization, medical care (first aid, treatment of common illness, and prenatal care), referral, and also for serving as a "patient agvocate" when escorting patients to commune or county h6spitals for treatment. Female BFDs provide some family planning services (for example, urging the use of birth control methods) and most of the maternal child care services. Other services, including family planning, are shared among BFDs regardless of sex. The Report of a BFD Investigation from Shanghai stated that BFDs can prescribe nearly 100 medicinal preparacions and diagnose and treat around a hundred;common ailments of frequent occurrence in the countryside. 62 In 1980 Gong and C:hao logged the activities of 57 BFDs and showed that 50 percent of a BFD's time was allocated to outpatient consultation, 12 percent to preventive activities (family planning, maternal child care, health education, and other preventive w.rk), and 20 percent to home visiting. 63 The rest of the time was spent supplying drugs, performing administrative activities, and attending meetings. At the time of year that the study was performed, a BFD saw an average of 10 to 11 patients per day in the brigade health station. P* :  -9- In the field of environmental sanitation, BFDs train health aides to perform various sanitation tasks such as collection, treatment, storage, and use of human feces as fertilizers. They supervise these trainees by inspecting them regularly on site. BFDs are also responsible for directing pest control campaigns, and they regularly-visit homes of commune members to spray insecticides. BFDs give immunizations against diphtheria, pertussis, tetanus, poliomyelitis, meningococcal meningitis, measles, and Japanese B encephalitis. With the promotion of the "one child per family" policy, babies are increasingly being delivered in the commune or county hospital rather than in the patient's home. However, the BFDs still provide prenatal care. For women who have been previously pregnant, monthly prenatal examination starts between the fifth month and the seventh month and is performed twice in the eighth month and weekly during the ninth month. The examinations begin earlier and are more frequent for first pregnancies. Exdminations include blood pressure determination, urinalysis, auscultation of the fetal heart beat, and determination of the fetal position. 2.9 Summary BFDs are chosen by the people in their community. They have incomplete secondary educations and extremely short periods of initial training, with emphasis on practical work rather than on theory. They combine medical duties with agricultural work and are paid on a scale equivalent to their productivity as a peasant, although they now also earn fees for services. They provide a wide range of both preventive and curative health services and receive continuing training either from doctors who visit thenm periodically or from attending courses in the commune or county hospitals. Factors contributing to the BFD movement have been the flexibility in prerequisites, training curricula and functi6os, deprofessionalization, and decentralization of the health care system. 3.0 BFD Practice in Qufu County 3.1 Logistics Qufu County is one of the 106 counties in Shangdong Province. The county is located in the Jining Prefecture, 105 kilometers south of the provincial capital of Jinan, and about 500 kilometers south of Beijing. The county is divided into 12 communes and 1 township. It had 470 brigades and 517,035 inhabitants as of 1981. in 1981, there were 1,123 BFDs in Qufu County (2.3 per 1,000 inhabitants), which was higher than the national and Shangdong provincial averages (see Table 4) but comparable to the BFD population ratio in Shanghai County (2.1 per 1,000 inhabitants). 65  -10- Table 4: Ratio of Population to BFDs, 1981 China Shangdong Qufu Population (millions) 1,014.4 74.0 0.52 Number of BFDs 1,396,452 144,788 1,123 Population per BFD 714 478 460 Source: Ministry of Public Health and Qufu County Health Bureau, October 1982. 3.2 Qualifications Since 1979 the professional knowledge and skills of the BFDs throughout China have been reexamined, and a new title, "Rural Doctor," has been given to those who passed the examinations. Some have also been certified without the examination if they met any of the following criteria: 1) BFD since 1966; *2) more than one year of training in a prov'ricial or higher-level hospital; 3) mid-level medical school. certification. In Qufu County, 935 out of the 1,123 BFDs took the Rural Doctor Certification Examination in 1981; 730 (75 percent) passed and were certified. However, by 1982 the examination had not yet been standardized throughout the country. Rural doctors have at least elementary and junior high school education and the equivalent of two to three years of medical training. 3.3 Survey In September 1982 a special survey was made in collaboration with the World Bank team; it involved interviews with 133 BFDs, 102 (76 percent) males and 31 (23.3 percent) females in 2 of the 12 communes in Qufu County. BFDs were questioned about their age, education, training, income, previous work experience, plans to continue in that role, time spent per week in the major activities, satisfaction with training, and suggested changes for the BFD program. 3.4 Characteristics The mean BFD age was 33 years (range 19 to 72 vears). The average age for a male BFD was 33 years, and the average for a female BFD was 32 years (see Table 5).  Table 5: Age Distribution of BFDs in Wanzhuan and Shuyuan Commurnes in Qufu County, 1981 Age Number of BFDs Percent Less than 20 2 2 20-29 46 34 30-39 62 47 40-49 18 14 50+ 5 4 Total 133 100 Prior to BFD training, the average level of education was 9 years (range 4 to 14 years). BFDs worked 11 years on average (range 1 to 42 years: the BFD who worked for 42 years was a traditional practitioner who considered his BFD practice as a continuation of his prior medical practice). Not surprisingly, age and years as a BFD have a strong correlation (20.8). Before becoming BFDs, 55 percent were farmers, 7 percent were teachers, 4 percent were government workers, and 13 percent were factory and other workers; 21 percent of the BFDs were in their first job. The average distance between the brigade health station and commune healih center in these two communes was 6 li (range 1 to 14 li: 2 li equal 1 km). 3.5 Training a. Location Both the county and the commune participated in providing the initial training and the retraining of the BFDs. ideally, as described by the county health officer in Qufu, BFDs receive initial training in the commune and retraining at the county level. From the survey, 71 percent received their training in the communes, 14 percent in the county hospital or county training school, and 15 percent were taught on the job. Eighty-seven percent received retraining in the commune health center, 6 percent in the county hospital, and 7 percent in other locations. There is great variability in the content and quality of training because training is provided by different teachers and often from different curriculums.  - 12 - b. Duration The average length of initial training was 18 months, and 87 percent receive'd.it part time; but the actual training time by hours was not known. Table 6 shows the time period in which the initial training took place. A different period of training may reflect varying e"mphasis on certain activities, for example, attention to family planning varied from a pol.icy of no birth control during the Cultural Revolution to restriction of births since 1977. Thus, different cohorts of BFDs reflect the political changes during the last three decades. Table 6: Number of BFDs,Trained in Qufu County, 1959-1980. Period Initiation of Training Completion prior to 1959 5 3 1960-65 19 9 1966-69 28 35 1970-75 47 36 1976-79 16 27 1980+ 14 18 Total 131 130 c. Content At least 90 percent of the BFDs received training in basic medical studies and clinical medicine. The emphasis was on curative care, regardless of the time period during which the initial training was given (see Table 7). The content of training given to the BFDs was not essentially different from the present curriculum as seen in the Yexian Secondary Training Scho.ol (their theory course was 57 percent basic medical study and 43 percent clinical medicine). Teaching in preventive medicine (family planning, communicable disease control, and environmental sanitation) did not seem to have constituted as high a proportion of the training as expected. However, content analysis of the actual curriculum is needed to determine whether some preventive medicine is taught as part of clinical medicine.  - 13 - Table 7: Content of Training Subject Percent* Maternal child health 53 Family planning 11 Basic medical study 95 Communicable disease 74 Environment sanitation 35 Internal medicine 90 Surgery 78 Traditional Chinese medicine 56 * Percent of 133 BFDs surveyed who reported training received in this area. 3.6 Retraining The average duration of retraining over the three-year period 1979- 1981 was three months annually (see Table 8). Ninety-six percent of the BFDs received retrai ning at least once in 1981, prior to the Rural Doctor Certification -Examination. The total time spent away from agricultural production is substantial; but such training is mostly scheduled during the agriculturally light seasons. Table 8: Months of Retraining, 1979-1981 Standard Year Mean 'laximum Minimum Deviation 1979 3.7 12 0 3.52 1980 3.2 12 0 4.11 1981 3.8 12 0 2.24 BFDs were asked to identify whether they considered their training on various functions adequate; 66 percent considered the training inadequate for their present work. Table 9 shows that they felt a need for additional training in curative skills, both in Western and traditional medicine. BFDs did not express a need for further training in preventive topics such as family planning, environmental sanitation, or health education.  - 14 Table 9: Type of Additional Training Desired by BFDs, 1982 Number of BFDs Skills in: responded yes Health care 2 Maternal child health 17 Environment sanitation 2 Administration 1 Family planning 3 Traditional medicine 36 Western medicine 67 Communicable disease 5 Preliminary analysis showed no correlation between the length or content of training and the distribution of a BFD's practice in curative or preventive services. This raises questions as to whether the substantial investment of time and money in training was fruitful when the curriculum did not appear to meet the felt needs of the BFDs for their present practice. 3.7 Income A BFD's per capita income is lower than that of an agricultural labor force worker (see Table 10). The yearly income of male BFDs (Y345) is higher than that of female BFDs (Y322). Table 10: Comparison of Income: BFD and Population, 1981 Yuan Yuan Yuan Mean Minimum Maximum BFD total 348 108 1044 sideline 96 0 800 Population per capita 240 80 308 sideline 49 3 98 Agricultural labor force 529 241 695 Most BFDs were remunerated on the work point system in 1982 and received about 80 percent of the maximum possible work points at the time of the study. In addition, they could earn money through sideline activities and could receive a small subsidy if certified as rural doctors. This has changed since the introduction of the responsibility system; in many counties the BFDs are now earning their income through fees for services.  -15 3.8 Practice Table 11 compares BEDs' years of practice by age, sex, income, years of education, and training. Table 11: Comparison of BFDs' Age, Income, Years of Education, Years of Practice and Training, by Sex, 1982 Standard Mean Maximum Minimum Deviation Age M 33 72 19 8.6 F 33 41 19 6.0 Income (Yuan) U 355 1044 i08 135.4 F 322 905 174 127.7 Years of education M 9 14 4 2.9 F 8 14 6 2.0 Years as BFD X 12 42 2 7.2 F 10 20 1 4.8 Duration of training a M 19 60 1 11.6 (months) F 16 36 3 8.2 a This is total duration, not net time equivalent of training.. BFDs describe their weekly work schedule as follows: an average total of 82 hours, of which 32 hours is spent seeing'patients, 33 hours on farming and other activities, and 10 hours on preventive services and environmental sanitation (see Table 12). Contrary to previous descriptions in the literature, the inspection of water and sewage is performed mainly by brigade staff not by BFDs.  16 - Table 12: Time Distribution of Work per Wleek as Perceived by BFDs, 1982 Hours Standard Activities Mean Minimum Maximum Deviation Total 82 67 102 6.8 See patient 32 10 60 7.2 Preventive 6 0 35 4.6 Prepratory maintenance 6 0 30 4.3 Environment sanitation 4 1 14 1.8 Farming 20 4 36 6.4 Other 13 0 24 5.4 BFDs reported that July, August and September were the busy months; gastro-intestinal and respiratory illnesses were described as the most frequent complaints. BFDs saw an average of five patients per day (see Table 13).and used mainly Wqestern medicine (see Table 14), Table 13: Volume of Patients Seen per Day as Perceived by BFDs, 1982 Standard Patients Seen Mean Maximum Minimum Deviation Average 5 10 1 1.8 Maximum number of oatients 25 30 4 l1,4 Minimum number of patients 2 6 0 1.3  - 17 - Table 14: Percentage Distribution of Type of Practice. as Perceived by BFDs, 1982 Standard Type of Practice Mean Maximum Minimum Deviation Traditional medicine 15 85 0 18.8 Traditional surgery 2 30 0 4.1 Acupuncture 7 30 0 6.5 Acupressure 2 20 0 3.4 Western medicine 74 100 9 24.6 There seemed to be no relationship between the proportion of BFDs' time spent in providing patient care and such characteristics as age, sex, income, years of education, or content of their initial training. However, older BFDs tended to practice more trad.Litional Chinese medicine. Most BFDs placed curative service as the priority in their practice (see Table 15). Table 15: Priority in BFD's Practice as Perceived by BFDs, 1982 Priority Number Percent Curative 120 90 MIaternal child health 38 28 Health education 64 48 Family planning 35 26 Communicable disease 48 36 Environment sanitation 45 34 Food hygiene 32 24 Tuberculosis 2 2 Retraining 15 11 The survey reports of a BFD's practice mentioned above were compared with the analysis of the BFD's dail.y patient log, which recorded age, chief complaint, diagnosis, and treatment for each patient. This comparison provided a cross-sectional description of a BFD's practice, summarized in Tables 16 and 17.  -18- Table 16: Percentage Dis.tributions of Chief Complaint,'by Sex, 1982 .a Total Male a Female Complaint No. % No. % No. % Common cold 355 17.5 214 17.4 141 17.6 Bronchitis, pneumonia; asthma, 228 11.2 142 11.6 86 10.7 Enteritis 349 17.2 226 18.4 123 15.3 Other gastrointestinal and parasitic disease 290 14.3 175 14.2 115 14.3 Arthritis, back pain, neurasthenia 128 6.3 81 6.6 47 5.9 Tonsilitis, otitis, pharyngitis, adenitis 65 3.2 -33 2.7 32 4.0 Eye disease 9 0.4 5 0.4 4 0.5 Renal and urinary disease 49 2.4 28 2.3 .21 2.6 Dental, periodontic disease 41 2.0 22 1.8 19 2.4 External injury, burn, wound infection 241 11.9 174 14.2 67 8.3 Hypertension, heart disease 35 1.7 18 1.5 17 2.1 Skin disease 116 5.7 69 5.6 47 5.9 Anemia. 34 1.7 9 0.7 25 3.1 Gynecological disease 28 1.4 0 28 3.5 Headache 22 1.1 7 0.6 15 1.9 Communicable disease of childhood 10 0.5 6 0.5 4 0.5 Poisoning 2 0.1 1 0.1 1 0.1 Psychiatric 4 0.2 4 0.5 Fever 23 1.1 17 1.4 6 0.7 Other 3 0.1 3 0.2 Total 2032 100.0 1229 100.0 803 100.0 a Respondents were 60 percent male, 40 percent female.  - 19 - Table 17: Percentage Distribution of Chief Complaint by Age Group, 1982 <1 1-5 6-14 15-49 50+ Complaint No. % No. % No. % No. % No. % Common cold 5 9.4 82 25.5 51 21.2 177 16.7 40 11.3 Bronchitis, pneumonia, asthma 12 22.6 51 15.8 21 8.7 80 7.5 64 18.0 Enteritis 10 18.9 45 14.0 35 14.5 205 19.3 54 15.2 Other gastroenteritis and parasitic disease 16 30.2 65 20.2 22 9.1 136 32.8 51 14.4 Arthritis, back pain, * neurasthenia 0 1 0.3 9 3.7 85 8.0 33 9 ,3 Tonsilitis, otitis; pharyngitis, ad&nitis 1 1.9 8 2.5 19 7.9 33 3.1 4 1.1 Eye disease 0 0 2 0.8 7 0.7 0 Rehal and uri-nary disease 0 1 0.3 6 2.5 29 2.7 13 3.4 Dental, periodontic disease. 0 1 0.3 1 0.4 25 2.4 14 3.9 External injury, burn, wound infection 0. 23 7.1 41 17.0 153 14.4 24 6.8 Hypertension, heart disease 0, 1 0.3 1 0.4 9 0.8 24 6.8 Skin disease 6 11.3 24 7.5 17 7.1 53 5.0 16 14.5 Anemia 0 8 2.5 1 0.4 14 1.3 11 3.1 Gynecological disease 0 0 27 2.5 1 0.3 Headache 0 0 4 1.7 17 1.6 1 0.3 Communicable disease of childhood 1 1.9 3 0.9 5 2.1 0 1 0.3. Poisoning 0 O 0 2 0.2 0 Psychiatric 0 0 0. 2 0.2 0 Fever 2 3.8 9 2.8 6 2.5 5 0.5 2 0.6 Other 0 0 0 2 0.2 2 0.3 Total (2032) 53 322 241 1061 355 In order to study the appropriateness of t:he BFD's practice, we carried out case reviews of all patients with the diagnosis of common cold and acute gas-troenterits. In the 335 cases of common cold, BFDs prescribed an average of 1.6 drugs per patienit: 32 percent of the cases received  - 20 - antibiotics,.52 percent received traditional Chinese medicine, I' and 74 percent received an analgesic or antipyretic. (Each patient may receive a combination of any of the above). Of the 108 patients who received antibiotics, 10 percent received kanamycin, 20 percent received gentamicyn, 44 percent received tetracycline, 20 percent received penicillin, and 6 percent received sulfamethaxazole (see Tables 18 and 19). In standard Western medical practice, antibiotics are seldom used for the common cold because most of them are of viral etiology. Kanamycin and Gentamicyn in particular are never used. There is no justification for their use; these drugs are expensive and can caus. serious side effects such as nephrotoxicity and ototoxicity. Of the 334 cases of acute.gastroenterits, an average of 1.7 drugs per patient was prescribed; 56 percent of the cases received traditional Chinese medicine, and 81 percent received Western medicine. Table 18 presents the different types of medications used, and Table 19 gives the breakdown of the antibiotics used. Of the 191 patients who received antibiotics, 80 percent rec.eived either gentamicyn or kanamycin. Again, there is no justification for aminioglycosides or for routine use of antibiotics for acute gastroenteritis unless there is clinical evidence suggesting the presence of bacterial etiology such as shigella,.salmonella, or enteropathogenic E.col.i. because laboratory diagnosis in the rural areas is not feasible, Even so; the aminoglycosides would not be the drugs of first choice.. Some reasons for the overp-rescription and misuse of drugs are the .patient's demand for them becauise of the notion that "a gcood doctor is one who prescribes medicines" and the low cost and high availability of drugs--China: has placed high priority on making medicines available at the lowest level of the health care system (each brigade health station carries about 200 items of Table 18: Type of Medications Used by BFDs for Patients with Common Cold and Acute Gastroenterits, Qufu, October, 1982 Common Cold Acute Gastroenteritis Number of Drugs prescribed 531 571 Drugs per case 1.6 1.7 Traditional drugs 176 215 Wiestern medicine 355 356 Antibiotics 108 191 Other 247 165 Number of Cases Received Traditional medicine 176 186 Western medicine 268 270 1/ Analysis of the appropriateness of traditional Chinese medicine is not feasible because little is known about their function and efficacy, and especially since each concoction has multiple  - 21 - Table 19: Percent Distribution of Western Drugs Used by BFDs for Acute Gastroenteritis and Common Cold, Qufu, October 19812 Acute Gastroenteritis Common Cold Antibiotics 191 (54%) 108 Kaopectate 4 (1%) 247 Aspirin 6 (2%) Atropine 92 (26%) Probanthine 29 (8%) -Antacid 15 (4%) 50% Glucose/KCL 9 (2%) VIT B;C 10 (3%) Total Western MIedicine Used 356 355 Antibiotics of WIhich: Karnamycin 68 (36%) 11 (10%) Gentamicyin 84 (44%) 22.(20%) Erythromycin 8 (4%) Tetracycline 8 (4%) 48 (44%) Sulfa \ 8 (4%) 6 (6%) Streptomycin 3 (2%) Penicill.tr-I\;. t%) -< 21 (20%) Total ; ,.'i, : i 108 different traditiofial and We este-% mernicines, ranging from herbs to aspirin to major trany4uiLlizerE). Over-; escr:LioLon may also be the result of inadequate traininp in nthe use of the drugs and t Vr +ailabi`ity to poorly trained health ^worke r' The issue c' -nsuring app.opriate us'ec'n f driygs needs to be addressed a-t the ministry level.. Policies-..rst -. at up for standardizing practice, for e7xcample, settin.-g ` .otoco