Over the past decade, China has implemented reforms designed to expand access to health care in rural areas. Little objective evidence exists, however, on the quality of that care. This study reports results from a standardized patient study designed to assess the quality of care delivered by village clinicians in rural China. To measure quality, we recruited individuals from the local community to serve as undercover patients and trained them to present consistent symptoms of two common illnesses (dysentery and angina). Based on 82 covert interactions between the standardized patients and local clinicians, we find that the quality of care is low as measured by adherence to clinical checklists and the rates of correct diagnoses and treatments. Further analysis suggests that quality is most strongly correlated with provider qualifications. Our results highlight the need for policy action to address the low quality of care delivered by grassroots providers.

BackgroundScylla paramamosain (Crustacea: Decapoda: Portunidae: Syclla De Hann) is a commercially important mud crab distributed along the coast of southern China and other Indo-Pacific countries (Lin Z, Hao M, Zhu D, et al, Comp Biochem Physiol B Biochem Mol Biol 208-209:29–37, 2017; Walton ME, Vay LL, Lebata JH, et al, Estuar Coast Shelf Sci 66(3–4):493–500, 2006; Wang Z, Sun B, Zhu F, Fish Shellfish Immunol 67:612–9, 2017). While S. paramamosain is a euryhaline species, a sudden drop in salinity induces a negative impact on growth, molting, and reproduction, and may even cause death. The mechanism of osmotic regulation of marine crustaceans has been recently under investigation. However, the mechanism of adapting to a sudden drop in salinity has not been reported.MethodsIn this study, transcriptomics analysis was conducted on the gills of S. paramamosain to test its adaptive capabilities over 120 h with a sudden drop in salinity from 23 ‰ to 3 ‰.ResultsAt the level of transcription, 135 DEGs (108 up-regulated and 27 down-regulated) annotated by NCBI non-redundant (nr) protein database were screened. GO analysis showed that the catalytic activity category showed the most participating genes in the 24 s-tier GO terms, indicating that intracellular metabolic activities in S. paramamosain were enhanced. Of the 164 mapped KEGG pathways, seven of the top 20 pathways were closely related to regulation of the Na+ / K+ -ATPase. Seven additional amino acid metabolism-related pathways were also found, along with other important signaling pathways.ConclusionIon transport and amino acid metabolism were key factors in regulating the salinity adaptation of S. paramamosain in addition to several important signaling pathways.Electronic supplementary materialThe online version of this article (10.1186/s12864-018-4803-x) contains supplementary material, which is available to authorized users.

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