With the implementation of a healthy rural strategy and a graded health care system, VCDs have been given new and higher requirements. Analysing the JS of VCDs not only is an urgent requirement to improve the capacity of primary health institutions and stabilize the three-tiered health service system but also plays an important role in implementing the principle of "strengthening the locals" in the NHCSR.
The total JS of VCDs showed a downward trend after the first rise
The results of the survey in 2012 showed that the mean scores of satisfactions with the medical practice environment and internal work environment were high, reaching 3.249 ± 0.876 and 3.071 ± 0.722, respectively. To a certain extent, this showed that the NHCSR had achieved remarkable results at the beginning. In 2009, China started the NHCSR based on the basic principles of "ensuring the basics, strengthening the locals, constructing the mechanisms", and 2009–2011 was the first stage of the reform. During this period, the Chinese government issued a series of policies aimed at strengthening the construction of primary health institutions and improving primary health facilities.  Therefore, the mean score of satisfaction with the internal work environment was higher than the scores of other aspects (except medical practice environment). This was consistent with the finding of Li Jing et al.  The improvement in the buildings and health facilities of village clinics significantly improved the recognition of village clinics among rural residents. Moreover, a series of policies to support the development of primary health institutions was implemented. As a result, the mean score of satisfaction with the medical practice environment was higher than the scores of other aspects. This was also consistent with the finding of Xu Qionghua et al.  The results of the survey in 2015 showed that the mean score of the total JS of VCDs was higher than that in 2012. This was mainly attributed to the improvement in VCDs' satisfaction with job rewards and organizational management. The results of the survey in 2018 showed that the mean score of the total JS of VCDs was lower than the score in 2015. The scores for four of the five dimensions of JS decreased. One possible reason was that VCDs' expectations for their work increased, such that the JS level decreased. This phenomenon is still worthy of the attention of health management researchers and policymakers.
Satisfaction with job rewards, internal work environment and organizational management showed a downward trend after the first rise
The year 2015 marked the close of the 12th Five-Year Plan for China's National Economic and Social Development (2011–2015). Over these years, government investment in primary health institutions, such as village clinics, continued to increase, leading to the optimization of the buildings and health facilities of village clinics and increasing the financial subsidies for VCDs. Moreover, the management system and security policies of primary health gradually improved.  Therefore, the scores of the satisfaction with the three indicators improved compared with the results of the survey in 2012. However, there are many reasons for the decline in the scores for the three indicators in 2018. First, the increase in financial subsidies for VCDs has been slow. After the implementation of the NHCSR, subsidies for the essential medicine system and basic public health services became the main sources of income for VCDs. The subsidy of the essential medicine system is the "recurrent balance of revenue and expenditure subsidy" issued by the government for government-run village clinics that implemented the essential medicine system. The amount of compensation is related to the size of the population served by the VCDs, not the actual balance of income and expenditure of village clinics. Moreover, the level of compensation is low. – The subsidy of basic public health services is granted by the government to VCDs who provide basic public health services. It increased from 15 yuan per service population in 2011 (of which 40% were allocated to VCDs) to 69 yuan in 2019. – Beginning in 2014, this policy required that all the new compensation funds in rural areas be used in village clinics, which means that the current level is approximately 47 yuan per service population. The subsidy level is directly related to the population served by VCDs and affected by the hollowing of rural areas. In recent years, although the standard of financial subsidies has continuously improved, the actual financial subsidies of VCDs have not increased significantly. Second, the pressure brought by increased workload has been much higher than the sense of gain brought by the increased income for VCDs. For example, before the NHCSR, VCDs only undertook tasks related to basic medical services. However, after the implementation of the NHCSR, basic public health services were added, and the service content increased from 9 to 12 main functions. – In addition, the increase in workload extended the part-time working hours of VCDs. Previous studies have shown that most VCDs work part-time in agricultural production, commercial activities or temporary employment,  in addition to providing health services, to effectively provide for their families. However, with the increasing workload, VCDs have had to spend more time working to provide health services, resulting in the continuous reduction in income from their other part-time jobs. Third, there is no sustainable long-term investment mechanism for the construction of village clinics and health facilities;  instead, the government has most often provided one-time investment in infrastructure construction, purchasing and maintenance of health facilities of village clinics. The health facilities that received investment in the initial stage of the NHCSR have gradually aged, which makes it difficult for doctors to meet the needs of rural patients. Therefore, the limitations of health facilities are another important factor restricting VCDs from providing medical services. Fourth, the operating funds of village clinics are not guaranteed. This leads to a poor medical environment in village clinics.  Because all the subsidies are related to the service population, without connection to the actual burden of operating a given village clinic, VCDs have to minimize expenditure to control the operating costs of the clinic. This inevitably has a negative impact on the medical environment of the village clinics. A fifth problem regards the continuous adjustment of basic public health services. The project has played a vital role in promoting health. However, the continuous adjustment of technical specifications and assessment systems has caused confusion among VCDs.  Sixth, the incentive mechanism is not perfect. On the one hand, the level of matching between incentive measures and the incentive preference of village doctors is low. Problems that concern VCDs, such as professional risks, welfare and personal income, have not been effectively solved.  On the other hand, the connection between personal efforts and work performance is not strong enough. There is an egalitarian tendency in the granting of financial subsidies, which inhibits the enthusiasm of VCDs to some extent. 
Satisfaction with the medical practice environment and the job itself showed a trend of continuous decline
There are five possible reasons for the decline in satisfaction with these aspects. First, the frequent doctor-patient disputes in China in recent years have placed great psychological pressure on VCDs, which has been confirmed by the studies of Hesketh Therese, Wu Dan et al.  Second, the protection mechanism for medical disputes of VCDs is imperfect. VCDs in most areas do not have medical dispute liability sharing insurance. Moreover, some VCDs who purchase medical dispute liability sharing insurance cannot be protected by the insurance because of a series of problems, such as high restrictions and little compensation.  Third, doctors face competition from private clinics and the attraction of doctors from county-level medical institutions. – Fourth, the career prospects of VCDs are not optimistic. On the one hand, the status of most VCDs is still "semi-agricultural and semi-medical". It is difficult for VCDs to obtain the same promotion opportunities regarding professional title as other medical staff.  On the other hand, because they have experience mainly with single diseases and simple conditions, young and middle-aged VCDs' professional ability improvement is slow, so they have a low sense of achievement and personal value. Fifth, VCDs’ work autonomy is insufficient. The main manifestation of this is the limitation of drug use. Since the implementation of the NHCSR, all government-run primary health institutions have had to implement the essential medicine system. This policy limits VCDs to prescribing only essential medicines.  Moreover, with the advancement of the NHCSR, the implementation and supervision of this policy is becoming increasingly stringent. This regulation effectively controls the abuse of antibiotics and injections in rural areas – but greatly restricts the autonomy of drug prescription by VCDs and weakens the medical service capacity of village clinics to some extent.  As a result, VCDs find it increasingly difficult to meet the requirements of their jobs. The results of the survey in 2012 showed that the VCDs were most dissatisfied with job rewards, while according to the surveys of 2015 and 2018, they were most dissatisfied with the medical practice environment, and their satisfaction was lower in 2018 than in 2015. This indicated that the deteriorating medical practice environment had an increasingly serious impact on the JS of VCDs. This is basically consistent with the findings of Gan Yong et al. for general practitioners. 
This is the first study to monitor the JS of VCDs over time since the implementation of the NHCSR in China. Some limitations of the study should be noted. First, a self-report questionnaire was used to collect information. Social desirability effect caused by observation bias was therefore unavoidable. Second, because influencing factors were not investigated, the reasons for the changes in VCDs' JS may not be limited to those mentioned in this paper. Third, because the places where the VCDs practised were relatively scattered and there were only 1–2 doctors in most village clinics, it was difficult to carry out a large sample follow-up survey. Influenced by the sample size, the results of this study may offer limited representativeness regarding the JS of VCDs in China.