Barefoot doctor

Barefoot doctors are farmers who received minimal basic medical and paramedical training and worked in rural villages in the People's Republic of China. Their purpose was to bring health care to rural areas where urban-trained doctors would not settle. They promoted basic hygiene, preventive health care, and family planning and treated common illnesses. The name comes from southern farmers, who would often work barefoot in the rice paddies.

In the 1930s, the Rural Reconstruction Movement had pioneered village health workers trained in basic health as part of a coordinated system, and there had been provincial experiments after 1949, but after Mao Zedong's healthcare speech in 1965 the concept was developed and institutionalized. In his speech, Mao Zedong criticized the urban bias of the medical system of the time, and called for a system with greater focus on the well being of the rural population. China's health policy changed quickly after this speech and in 1968, the barefoot doctors program became integrated into national policy. These programs were called "rural cooperative medical systems" (RCMS) and strove to include community participation with the rural provision of health services. Barefoot doctors became a part of the Cultural Revolution, which also radically diminished the influence of the Weishengbu, China's health ministry, which was dominated by Western-trained doctors.

Training
The barefoot doctors usually graduated from secondary school and then received about six months of training at a county or community hospital, though training length varied from a few months to one and a half years. Training was focused on epidemic disease prevention, curing simple ailments that were common in the specific area, and were trained to use Western medicines and techniques. An important part of the Cultural Revolution was the movement of sending intellectuals, and in this case doctors, to serve in the countryside (Chinese: 下鄉 pinyin:xìa xiāng). They would live in an area for half a year to a year and continue the education of the barefoot doctors. About a fifth of the barefoot doctors later entered medical school.

Work
Barefoot doctors acted as a primary health-care provider at the grass-roots level. They were given a set of medicines, both Western and Chinese, that they would dispense. Often they grew their own herbs in the backyard. As Mao had called for, they tried to integrate both Western and Chinese medicine, like acupuncture and moxibustion. An important feature was that they were still involved in farm work, often spending as much as 50% of their time on this - this meant that the rural farmers perceived them as peers and respected their advice more. They were integrated into a system where they could refer seriously ill people to township and county hospitals.

Barefoot doctors provided mostly primary health care services, and focused on prevention rather than treatment. They provided immunizations, delivery for pregnant women, and improvement of sanitation. The income of the barefoot doctors was calculated as if it were agricultural work; they were paid roughly half of what a classically trained doctor made. This funding came from collective welfare funds as well as from local farmer contributions (from 0.5% to 2% of their annual incomes). This program was successful in part because the doctors were selected and paid by their own villages. By the 1960s, there were RCMS programs in 90% of China's rural villages.

The work of the barefoot doctors effectively reduced health care costs in the People’s Republic of China, and provided primary care treatment to the rural farming population. The World Health Organization regarded RCMS as a “successful example of solving shortages or medical services in rural areas”. Because of barefoot doctors providing primary health care so that basic health care is an affordable cost and give China’s entrance into the United Nations (UN) and WHO. Moreover, this also represents that some certain diseases in poor countries can be solved but just need adequate technological solution.

End of barefoot doctors in China
Two-thirds of the village doctors currently practicing in rural China began their training as barefoot doctors. This includes Chen Zhu, China’s current Minister of Health, who practiced as a barefoot doctor for five years before going on to receive additional training.

The barefoot doctor system was abolished in 1981 with the end of the commune system of agricultural cooperatives. The new economic policy in China promoted a shift from collectivism to individual production by the family unit. This shift caused a privatization of the medical system, which could not sustain the barefoot doctors. The barefoot doctors were given the option to take a national exam, if they passed they became village doctors, if not they would be village health aides. Village doctors began charging patients for their services, and because of the new economic incentives, they began to shift their focus to treatment of chronic conditions rather than preventative care.

By 1984, village RCMS coverage had dropped from 90% to 4.8%. In 1989 the Chinese government tried to restore a cooperative health care system in the rural provinces by launching a nationwide primary health care program. This effort increased coverage up to 10% by 1993. In 1994 the government established “The Program”, which was an effort to reestablish primary health care coverage for the rural population.

In 2003 the Chinese government proposed a new cooperative medical system that is operated and funded by the government. This program is run more like an insurance program. It pays 10 Renminbi per year for each person covered by the program, and by ensuring coverage for serious diseases. This new program relies heavily on lessons learned from the times of the barefoot doctors, but faces many challenges in providing sufficient, cost-effective care for China’s rural populations.

Historical legacy
The system of barefoot doctors was among the most important inspirations for the WHO conference in Alma Ata, Kazakhstan in 1978 where the Alma Ata Declaration was signed unanimously. This was hailed as a revolutionary breakthrough in international health ideology - it called for local communities participating in deciding health care priorities, called for an emphasis on primary health care and preventive medicine, and most importantly sought to link medicine with trade, economics, industry, rural politics and other political and social areas.

International development with NGOs
In 1977, Jean-Pierre Willem created an international humanitarian apolitical NGO of doctors called Medecins Aux Pieds Nus in France. Volunteers work in Burundi, Colombia and Southeast Asia with local healers to develop "medical garden" for herbalism and make essential oils for gemmotherapy. In 1999, Jean-Claude Rodet became the first president of Medecins Aux Pieds Nus Canada working with Mark Smith in United States. This NGO leads ethnobiological missions based on "proximity, prevention and humility"