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The system of barefoot doctors and cooperative medical care was created for the basic medical needs of China’s vast rural population from the 1960s to 1980s, filling a critical role

By Li Mingzi Updated Feb.1

Working as a village doctor for 54 years, Ma Wenfang is used to still being called a “barefoot doctor” by his patients, even though the program was abolished in 1985. 　

The term “barefoot doctor” first appeared in the 1960s, connected to the commune system, a rural Communist administrative unit. In summer 1968, Red Flag magazine, sponsored by the Central Committee of the Communist Party of China, published an article titled “Shanghai Investigation Report on the Direction of the Medical Education Revolution from the Growth of the ‘Barefoot Doctor.’” It begins: “The ‘barefoot doctor’ is an affectionate appellation for people who work as both healthcare worker and agricultural farmer in the suburbs of Shanghai.” 　

The article caught the attention of Chairman Mao Zedong, who later issued written instructions published in State-run newspaper the People’s Daily on September 14. The term “barefoot doctor” was quickly promoted across all media. The image of the barefoot doctor was printed on posters, in comic strips, even on stamps and calendars. It became an archetypal symbol of the era.　

Ma Wenfang, who continues to work as a village doctor in Liuzhuang Village, Tongxu County in Central China’s Henan Province, believes the biggest contribution of barefoot doctors was to provide the most basic healthcare services for farmers. 　

After the 1980s, the people’s commune system collapsed and barefoot doctors disappeared. Yet research for a book titled From Barefoot Doctor to Rural Doctor published by Yunnan People’s Publishing House in 2002 found that the system had persisted in poor rural areas. “Despite the continuous change of medical services in rural areas, most rural doctors are the barefoot doctors of before. Many of them are still working today.” 　

Rural Gap

After the founding of the People’s Republic of China in 1949, health workers and hospitals were disproportionately concentrated in urban areas, while in rural China where most of the nation’s population resided, there was a shortage of clinics and doctors. Health authorities sent mobile medical teams from urban hospitals to provide health services to rural residents. Yet because there are no proper healthcare networks in China’s vast rural areas, the mobile services could not meet the demand. 　

“In the 1950s and 1960s, we had no doctor in our village,” Ma told NewsChina. Large communes had a clinic, but smaller ones generally did not. Ordinary people could not afford medicine, so they used cheap folk remedies like drinking hot water for minor ailments. If they were seriously ill as the disease progressed, they did little more than wait to die, as going to an urban hospital was out of reach. 　

According to statistics, in 1964, 69 percent of senior health workers were in urban areas, where 10 percent of the national population lived, while 31 percent of healthcare workers were in rural areas where more than 90 percent of the population lived. 　

Ma’s mother died of typhoid aged only 32 in the 1960s. His younger brother, just 8 years old, died of the same disease five days later. There were no doctors or medications. After the family tragedy, Ma vowed to become a doctor to help the villagers. 　

To tackle the issue of disparity in healthcare service distribution, the country started to explore a proper rural healthcare system. On June 26, 1965, Chairman Mao issued a directive to shift “the focus of medical and health work to the rural areas,” and “cultivate a large number of doctors who can also serve peasants in the rural regions.” 　

Following this directive, a rural health worker training pilot program was launched in Jiangzhen People’s Commune in Shanghai. Trainees selected from villagers would participate in a four-month training course in basic healthcare services before returning to the commune to act as village doctors. They were called “barefoot doctors,” a name indicating that they also work in their own rice paddy fields when they were not attending patients. The program was later promoted nationwide, offered training of three to six months. By 1966, some communes had started building cooperative healthcare systems, requiring commune members to pay 1 yuan (US$0.41 at the time, worth US$3.52 today) a year to support the clinic.　

In 1977, there were some 1.5 million barefoot doctors across the country. 　

Village doctor Ma Wenfang checks a patient on January 16, 2013

Zhang Qingwen, a village doctor, prescribes medication for patients in Xiushui County, Jiujiang, Jiangxi Province on August 19, 2014

Limited Knowledge

In 1967, Ma Wenfang, who had graduated from junior high school, was selected as a barefoot doctor and sent to train for one year. He learned modern anatomy, physiology and diagnosis, traditional Chinese medicine (TCM) and acupuncture. 　

During the commune period, rural residents did not receive a salary, instead earning work points, a measurement to evaluate an individual’s work contributions. The points were linked to the food individuals could get, which was distributed by the production brigade. 　

Ma said barefoot doctors could earn up to 280 work points a month, much higher than ordinary villagers. Commune members had to pay a small sum toward the medical system, Ma said, which in his village was 0.1 yuan (1.5 cents) every month. The rest was covered by the village collective economy. 　

“Because barefoot doctors have limited professional medical capacity, they could really just treat basic health problems. It can only be said that under the conditions, barefoot doctors provided help to common folk at that time,” Zhang Daqing, head of the Department of Medical History and Philosophy of Medicine at Peking University Health Science Center, told NewsChina. 　

According to the book Creation and Reconstruction – Research on the Rural Cooperative Medical System and Barefoot Doctor Phenomenon during Collectivization Period by Li Decheng, associate professor with Jiangxi Normal University, by the mid-1960s, due to continuous learning, practice and training, barefoot doctors had the skill to treat dozens of common diseases, knew how to use dozens of drugs, as well as other knowledge including acupuncture and TCM. 　

At that time, medicines were in short supply and prices were high. Ma said that if people caught a serious cold, they would spend 0.02 yuan for two aspirin pills, and if that was not enough, they would have a penicillin shot, which had a nationally set price of 0.18 yuan. 　

“It was a planned economy and there was a quota system for the distribution of precious antibiotics like penicillin,” Ma said. “Each village could get at most 10 shots of penicillin a month.” 　

Zhang Daqing believes that barefoot doctors played a positive role in the modernization of drug popularization in rural areas. Ma said barefoot doctors helped solve the dilemma of lack of medicine and doctors in rural areas. But barefoot doctors, unlike the previous traditional and folk medical practices of local healers, were positioned and arranged in an institutionalized political atmosphere. 　

Barefoot doctors also shouldered the responsibility for general hygiene, including ensuring villagers had clean drinking water, a clean rural environment, proper disposal of human feces and pest control. During the 1960s when malaria was endemic, villagers did not know how to prevent it. Ma went to each household to deliver medicine and educate locals on malaria prevention. Ma cajoled every villager to take the medicine and monitored them after. Eradicating malaria in the village took two years. 　

“A barefoot doctor diagnoses and treats simple illnesses, but his main duties are in health education and preventive medicine,” says an article published in the British Medical Journal in 1974 titled “Barefoot Doctors and the Medical Pyramid.” The article continued that it was the barefoot doctor’s job to teach commune members about simple personal hygiene and to make sure that “children and adults are immunized against infectious diseases, and to lead campaigns about birth control and the eradication of pests such as flies and mosquitoes.” 　

Li Decheng thought barefoot doctors and the rural cooperative medical system were products of scarce medical resources and their severe uneven distribution. In his doctoral dissertation titled “Cooperative Medical System and Barefoot Doctors (1955-1983),” he wrote that it was the barefoot doctors who successfully implemented instructions from higher medical administrations, such as ensuring smallpox vaccinations were done and distributing epidemic control drugs in an extraordinarily fast and efficient way. 　

Barefoot doctors walk in a parade in Gaozhou, Guangdong Province in 1969, in response to Mao Zedong’s call to shift “the focus of medical and health work to rural areas.” A large number of doctors were trained and put into the rural area at that time

A doctor gives a patient an inoculation in a village clinic in Wuzhong, Ningxia Hui Autonomous Region in 1998

Village doctors exchange ideas with trainees of a workshop on primary healthcare held by a healthcare cooperation center co-established by the World Health Organization and Jiading County in Shanghai in the 1980s

End of an Era

After 1976, the number of grassroots health workers, including barefoot doctors, decreased at an average rate of 400,000 per year. Health authorities started to regulate healthcare employees and reduce the number of barefoot doctors. As the people’s commune system collapsed along with the collective economy, the rural cooperative medical care system and the barefoot doctor system lost institutional and economic support. By 1983, the number of barefoot doctors had fallen to around 1.2 million. 　

On January 25, 1985, the People’s Daily published an article officially announcing the abolition of the term, marking the end of the barefoot doctor era. Many former barefoot doctors retired, changed profession or started to run private clinics. Others contracted to run the clinics from the communes and became self-employed medical practitioners, although most villagers still referred to them as barefoot doctors. 　

Through continued training and self-improvement, barefoot doctors kept improving their professional skills, so in the 1990s, village doctors were still popular. Ma said that he might see some 150 patients a day at his busiest. “From the late 1980s to the early 1990s, it was a boom time for village doctors,” Ma said, talking about the good income he earned back then. 　

From the mid-1990s, fast development in eastern coastal regions saw many rural dwellers flock to cities. Due to outdated facilities and a shortage of young doctors, village clinics gradually lost their appeal, and rural patients started to travel to larger urban hospitals as their income increased. 　

“The collapse of the cooperative health care system and the transformation of the barefoot doctor role have led to a difficult situation faced by rural primary healthcare. Villagers started to lose basic medical security,” Zhang Daqing said. In 2003, Zhang said, the Chinese government proposed a plan to establish a new rural cooperative medical care system and issued the Regulations on the Management of Rural Doctors to rebuild the rural primary healthcare system.

Yet rural medical services and the skills of rural practitioners still need improvement. Gaps in the service system mean lack of supervision of rural healthcare practices, as well as financial incentives to encourage them to provide a good service.

“The current problem in the rural grassroots medical system can’t simply be solved by restoring the old system of barefoot doctors,” said Zhang Daqing, who pointed out that as society develops, it is natural that people will demand better healthcare services. The government should set up a tiered medical system and channel more high-quality health resources to rural areas. More importantly, there must be clarity in the way the rural health service system is designed for its functions and responsibilities. 　

In 2008, Ma Wenfang was elected as a representative for the National People’s Congress, and he started to conduct research on rural medical services and village doctors. After visiting over 300 villages in seven provinces including Henan, Shandong and Hunan, he found many villages were empty of working age residents leaving only the young and old behind – the “hollowing out” phenomenon. There were only a limited number of rural health workers living on meager salaries in these hollow villages. In some, there were no rural doctors at all. 　

Ma is worried about the situation. “With a monthly salary of around 1,000 yuan (US$156) these days, who’d want to be a rural doctor? What is the future for them? What will we do about rural medical and public health issues?” he asked.　

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