PhD Seminar: When Primary Care Collapses: Rural Economic Reform and Rising Mortality in China

When Primary Care Collapses: Rural Economic Reform and Rising Mortality in China

China’s agricultural decollectivization, carried out between 1979 and 1984, replaced commune-based farming with household production and substantially raised productivity. Yet dismantling the communes also eroded the collective financing and organizational structures that sustained rural health care and education. This paper examines the consequences of this institutional transformation for rural health. Using a newly digitized county-by-year dataset that links mortality, disease incidence, and local health provision, we estimate staggered difference-in-differences and trend-break models. We find that county mortality rates increased by roughly 1.6 percent following the reform, implying approximately 90,000 excess deaths annually nationwide. The mortality increase is concentrated in counties with the largest declines in village-doctor availability (the so-called “barefoot doctors”), and is accompanied by significant post-reform reversals in the long-run decline of several vaccine-preventable infectious diseases. These patterns are not explained by changes in government health expenditures, while post-reform income growth only modestly mitigates the mortality effect. Taken together, the results show that rural market-oriented reforms carried substantial and long-lasting health costs by weakening local primary care capacity.