Village doctor as street-level bureaucrat and the impact on health care services in rural China

Abstract

The changes in the health care system have been remarkable over the past decades, along with the rapid economic development of China. The overall living standard of rural residents has generally improved; however, health expenses still make up a large part of their annual expenditure. During the new reform period, the importance of the village doctor has been emphasized by many scholars, and yet there are few studies conducted from the perspective of interactions between health administration, village doctor and rural resident to discover the invisible factors that influence the delivery of the health care service. Thus, this study aims to explore the street-level bureaucracy within the rural health care sector and its impact on rural residents. Guided by the Street-level Bureaucracy Theory and its application in public agency research, this study explores street-level bureaucracy in the grassroots health care sector in terms of health care regulation and provision before and after the recent series of health care reforms, and evaluates its impact on rural residents by analyzing health equity in terms of health care access, and the actual working and living conditions of the village doctor were identified. Apart from the official statistical data from document analysis and internet resources, the voices and advice of village doctors and rural residents in Jiangsu Province were also obtained from in-depth interviews, which provided the qualitative information for this study. There are four findings. First, as a typical street-level bureaucrat in the grassroots sector, the working condition of the village doctor has become more stable and their discretionary control has been enhanced greatly after the reforms, due to the implementation of specific rules and regulations and the changes in payment methods; Second, despite the fact that many regulations have been put into effect, compared to the supervision of the health administration, the payment method plays a significant role in the promotion of service equity; Third, village doctors regard their social reputation as important as their income, for they live in a small community network. Although the role of village doctor has been emphasized in the new reform, improvements in health equity are still not obvious and have had limited effect; Fourth, the function of the village doctor is not fully utilized, even though the coverage of current health insurance in rural areas has been tremendously expanded in the past decade. Accordingly, policy implications regarding the understanding of the work and social environment of village doctors in rural areas, especially on the future exploration of their function related to further reforms, are identified in the final chapter. Additionally, the theoretical and practical significances of this study have also been presented.