Changes in the Job Satisfaction of Village Clinic Doctors Since the New Health Care System Reform: A Comparison Based on Three Surveys in Shandong, China


 Background: In 2009, the Chinese government launched a new health care system reform. One of the important aims of the reform was to improve the capacity of primary health institutions. Village clinic doctors are part of the health service force rooted in rural China and the basis of the three-tiered health service system. The job satisfaction of village clinic doctors has an important impact on the stability and sustainable development of the three-tiered health service system. This study aimed to analyse the changes in village clinic doctors' job satisfaction after the implementation of the new health care system reform.Methods:All the data came from three surveys of village clinic doctors in Shandong Province conducted in 2012, 2015 and 2018. In 2012, an originally designed questionnaire was used to conduct a baseline survey of 405 village clinic doctors from 27 townships in 9 counties (the response rate was 92.9%). In 2015 and 2018, 519 and 223 village clinic doctors in the same counties were surveyed with the same questionnaire (the response rates were 94.3% and 92.9%, respectively). Descriptive analysis, χ2 test and ANOVA were used to analyse the level of and changes in village clinic doctors' job satisfaction.Results: The mean scores of village clinic doctors' total job satisfaction were 2.664 ± 1.069, 3.121 ± 0.931 and 2.676 ± 1.044 in 2012, 2015 and 2018, respectively, with a significant difference (F = 28.732, P < 0.001). The mean scores of the medical practice environment and the job itself showed a continuous downward trend. The change trends of the mean scores for job reward, internal work environment and organizational management were consistent with the trend for total job satisfaction.Conclusion: After the implementation of the NHCSR, the job satisfaction of village clinic doctors showed a trend of first rising and then falling. To improve primary health care service capacity, the Chinese government has implemented a series of new reform policies. With their ongoing implementation, village clinic doctors' job satisfaction should be the subject of more systematic and detailed research.

primary medical institutions. A high level of JS among VCDs is conducive not only to supporting the stability and sustainable development of the health service system but also to providing better medical services for rural patients [7]- [8] .
Inadequate health resources and health service capacity at the primary level (especially in rural areas) have been problems in China's health system, directly leading to and aggravating the di culty and expense of medical treatment. To effectively solve these problems, the Chinese government launched the new health care system reform (NHCSR)in 2009, which adheres to the basic principles of "ensuring the basics, strengthening the locals and constructing the mechanisms". During the rst phase of the reform (2009)(2010)(2011), the focus of the reform was on constructing a basic medical service system, basic public health service system, basic medical insurance and essential medicine system to strengthen the capacity of primary health services [9] . In 2015, the State Council put forward the implementation of the grading healthcare system [10] , aiming to improve the quality of primary health services and attract patients to primary health institutions to promote the formation of a reasonable order of diagnosis and treatment. In 2018, the Central Committee of the Communist Party of China put forward the "Rural Revitalization Strategy" [11] , which calls for "healthy rural" construction and proposes higher requirements for village-level health services. Undoubtedly, VCDs have been the focus of the NHCSR. However, statistics showed that [12] from 2009 to 2013, the annual number of visits to village clinics increased from 1.552 billion to 2.012 billion. However, by 2018, the annual number of visits to village clinics had dropped to 1.67 billion, and the proportion of visits to clinics had dropped to 20.1% from 27.51% (2013-year).
Since the NHCSR was implemented, VCDs have received increasing attention among health management researchers. Previous studies [13]- [19] covered aspects such as VCDs' service capacity, team building, education and training, income treatment, professional mentality, incentive and restraint mechanisms, recognition and evaluation of the NHCSR. Regarding VCDs' JS, Zhang Qi et al. studied the current level of the JS of VCDs in western China, and the results showed that 44.6% of VCDs expressed dissatisfaction with their work. [20] Zhang Xiaoyan et al. described the current situation of VCDs' JS in Jiangxi Province, and the results showed that 87.28% of VCDs expressed dissatisfaction. [21] Ding Haiyun et al. described the current JS of VCDs in Nanjing, and the results showed that 46.5% of VCDs were dissatis ed with their job. [22] Sun Qiaoqiao et al. described the income satisfaction of VCDs, and the results showed that 29.9% of VCDs were not satis ed with the current monthly average income level. [23] Chen Ruixia et al. studied the training satisfaction of VCDs, and the results showed that 86.47% of VCDs were satis ed with the current professional training. [24] Yang Miao analysed gender differences in the JS of VCDs in western China. The results showed that the JS of male VCDs was 3.16 ± 0.74 and that of female VCDs was 3.22 ± 0.66. [25] Most previous studies were cross-sectional studies conducted at a certain moment in time. Although most of the studies discuss the impact of the NHCSR on VCDs' JS, they cannot directly re ect the changes in the JS of VCDs since the implementation of the NHCSR. With the data of three surveys on VCDs conducted in Shandong Province in 2012, 2015 and 2018, this study analysed the changes in the JS of VCDs since the NHCSR and discussed the possible reasons for these changes from the perspective of the NHCSR. The results of this study provide a basis and reference for improving the JS and stability of VCDs.

Sampling
Shandong Province is a province in eastern China. In 2019, Shandong Province had 16 prefecture-level cities (an administrative level below the province and above the county; there were 17 prefecture-level cities in and before 2018), a population of 100.70 million (including a rural population of 38.76 million) and a per capita GDP of 70,653 yuan and belonged to the economically developed regions of China. In 2018, there were 53,246 village clinics and 96,253 VCDs in Shandong Province. On average, there were 1.8 VCDs in each village clinic. All the data in this study came from three surveys of VCDs held in Shandong Province in 2012, 2015 and 2018, with 405, 519 and 223 valid questionnaires and response rates of 92.9%, 94.3% and 92.9%, respectively. In 2012, we conducted a baseline survey using a multistage sampling method. First, according to the economic level, three prefecture-level cities, Jinan, Linyi and Dezhou, were selected from 17 prefecture-level cities in Shandong Province, which represent economically developed areas, moderately developed areas and underdeveloped areas, respectively. Then, three counties with different economic levels were randomly selected from each prefecture-level city, three townships were randomly selected from each county, and one village clinic doctor was randomly selected from each village clinic in the three townships to ll in the questionnaire in the township health centre. The participants were randomly selected using the envelope method. In 2015 and 2018, follow-up surveys were conducted, but thanks to urbanization and regional health development in recent years, some village clinics were abolished or merged and could not be traced. Coupled with the demission of VCDs, [26]- [27] the number of VCDs decreased, resulting in a larger reduction in the sample size in 2018. To ensure that the privacy of the respondents' information was effectively protected, the survey was carried out anonymously by a self-administered questionnaire. All the respondents were fully informed of the value and signi cance of the survey to improve the response rate. All investigators were trained intensively before the investigation to ensure survey quality.

Measurement instruments
The Chinese Physicians' Job Satisfaction Questionnaire compiled by Yin WQ et al. was used to measure the JS of VCDs.
[28]- [29] It included satisfaction with the job itself (such as job signi cance, professional interest and job value), satisfaction with job rewards (such as income level, rationality of income distribution, opportunities for further study and promotion of professional titles), satisfaction with the internal working environment (such as o ce environment, equipment resources, colleague relationships), satisfaction with the medical practice environment (such as doctor-patient relationships, social recognition), and satisfaction with organizational management (such as management system, leadership behaviour, identi cation with the organization). All the items were rated with a ve-point Likert scale, ranging from 1 (very dissatis ed) to 5 (very satis ed). The medical practice environment is a negative item, so it is reverse scored. This questionnaire has been used in many studies and has been veri ed to have good reliability and validity. [30]- [32] Statistical analysis First, descriptive analysis was conducted on the demographic characteristics and JS of VCDs. Then, χ 2 test, one-way ANOVA and post hoc least-signi cant difference (LSD) were adopted to compare the differences in JS among groups. The signi cance level of all tests was set at P<0.05 (two-tailed).

Demographic Characteristics
The demographic characteristics of the participants in the three surveys in 2012, 2015 and 2018 are shown in Table 1 35.9% in 2018. In the three surveys, most VCDs were married, accounting for 96%, 95.9% and 98.2%. In terms of education distribution, doctors with secondary school education accounted for 75.5%, 75.2% and 73.4%, respectively. In terms of professional quali cations, the largest proportion of VCDs had the professional quali cations of village doctors (a quali cation formulated by the Chinese health administrative departments for medical personnel working in village clinics, which requires lower competence than that of licensed assistant doctors and whose scope of practice is general medicine), accounting for 55.6% and 87.1%, and 72.3%. In the three surveys, more than 85% of the VCDs were located in village clinics that participated in the integrated management led by township health centres.
By χ 2 test, differences in the gender composition, age composition, marital status, and education distribution of VCDs among the three surveys were not statistically signi cant. Differences in the quali cations and integration care participation of VCDs across the three surveys were statistically signi cant. The proportion of VCDs with medical practitioners and assistant medical practitioners showed rst a declining and then an increasing trend from 2012 to 2018. The proportion of VCDs with medical practitioners was highest in 2012, with 30.7%. The proportion of VCDs participating in integrated care showed an upward tendency. In the survey in 2018, almost all VCDs (97.8%) participated in integrated care. in 2018), and integrated care (3.2% in 2012 and 0.7% in 2015).

Job Satisfaction Comparison
The results of VCDs' JS across the 3 surveys are shown in Table 2. First, we consider the change in the job itself satisfaction score. According to the results of one-way ANOVA, the mean score of VCDs' job itself satisfaction showed a downward trend (F = 113.696, P < 0.001

Discussion
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 rst 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 rst 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. [33] 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 nding of Li Jing et al. [34] The improvement in the buildings and health facilities of village clinics signi cantly 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 nding of Xu Qionghua et al. [35] 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 ve 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 rst rise The year 2015 marked the close of the 12th Five-Year Plan for China's National Economic and Social Development (2011)(2012)(2013)(2014)(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 nancial subsidies for VCDs. Moreover, the management system and security policies of primary health gradually improved.
[36] [37] 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 nancial 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.
[38]- [39] 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. [40]- [41] 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 nancial subsidies has continuously improved, the actual nancial subsidies of VCDs have not increased signi cantly. 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. [40]- [41] 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, [20] 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; [42] 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 di cult 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. [43] 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 fth 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 speci cations and assessment systems has caused confusion among VCDs. [44] 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. [45] 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 nancial subsidies, which inhibits the enthusiasm of VCDs to some extent. [46] Satisfaction with the medical practice environment and the job itself showed a trend of continuous decline There are ve 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 con rmed by the studies of Hesketh Therese, Wu Dan et al. [47][48] 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. [49] Third, doctors face competition from private clinics and the attraction of doctors from county-level medical institutions. [50]- [51] 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 di cult for VCDs to obtain the same promotion opportunities regarding professional title as other medical staff. [52] 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 insu cient. 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. [53] 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 [54]- [55] but greatly restricts the autonomy of drug prescription by VCDs and weakens the medical service capacity of village clinics to some extent. [51] As a result, VCDs nd it increasingly di cult to meet the requirements of their jobs. The results of the survey in 2012 showed that the VCDs were most dissatis ed with job rewards, while according to the surveys of 2015 and 2018, they were most dissatis ed 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 ndings of Gan Yong et al. for general practitioners. [56] This is the rst 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 in uencing 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 di cult to carry out a large sample follow-up survey. In uenced by the sample size, the results of this study may offer limited representativeness regarding the JS of VCDs in China.

Conclusion
After the implementation of the NHCSR, the JS of VCDs showed a trend of rst rising and then falling. Speci cally, satisfaction with the medical practice environment and the job itself showed a continuous downward trend. The change trends of satisfaction with job reward, internal work environment and organizational management were consistent with the trend of total JS. At the beginning of the NHCSR, VCDs were mainly dissatis ed with job rewards, while in the middle and late stages of the NHCSR, the subject of their dissatisfaction shifted to the medical practice environment. In recent years, the Chinese government has launched a series of reform policies focusing on the construction of a regional medical consortium and the reform of a medical insurance payment system, together with the development and promotion of internet medical technology. All of these factors provide new impetus and hope for VCDs. Therefore, more systematic and detailed research should be carried out to accurately observe the impact of the NHCSR on the JS of VCDs. Ethical approval and consent to participate No ethical approval required for this study. All participants read a statement that explained the purpose of the survey. Written informed consent was obtained from all participants in this study.