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However, beginning with [[Chinese economic reform|economic reforms]] in 1978, health standards in China began to diverge significantly between urban and rural areas and coastal and interior provinces.
The barefoot doctor system was put in free fall in 1981, as the "commune" system was shut down.<ref name=":18">{{cite journal |vauthors=Dong Z, Phillips MR |title=Evolution of China's health-care system |language=English |journal=Lancet |volume=372 |issue=9651 |pages=1715–6 |date=November 2008 |pmid=18930524 |doi=10.1016/S0140-6736(08)61351-3 |s2cid=44564705}}</ref><ref name="mcconnell">{{cite journal | last = McConnell | first = John | title = Barefoot No More | journal = The Lancet | year = 1993 | volume = 341 | issue = 8855 | page = 1275 | doi = 10.1016/0140-6736(93)91175-l | s2cid = 54379134}}</ref> By 1984, only 4.8% of villages had cooperative healthcare coverage, a sharp drop from the 90% coverage aof decadethe agomid-1970s.<ref name="carrin">{{cite journal | vauthors = Carrin G, Ron A, Hui Y, Hong W, Tuohong Z, Licheng Z, Shuo Z, Yide Y, Jiaying C, Qicheng J, Zhaoyang Z, Jun Y, Xuesheng L | display-authors = 6 | title = The reform of the rural cooperative medical system in the People's Republic of China: interim experience in 14 pilot counties | journal = Social Science & Medicine | volume = 48 | issue = 7 | pages = 961–72 | date = April 1999 | pmid = 10192562 | doi = 10.1016/S0277-9536(98)00396-7}}</ref> The barefoot doctor model officially ended during the Chinese Medical Reformation of 1985, when the term 'barefoot doctor' was removed from the healthcare system and replaced with the term and concept of 'village doctors'.<ref name=":17">{{cite journal | vauthors = Hu D, Zhu W, Fu Y, Zhang M, Zhao Y, Hanson K, Martinez-Alvarez M, Liu X | display-authors = 6 | title = Development of village doctors in China: financial compensation and health system support | journal = International Journal for Equity in Health | volume = 16 | issue = 1 | pages = 9 | date = July 2017 | pmid = 28666444 | pmc = 5493879 | doi = 10.1186/s12939-016-0505-7 | doi-access = free }}</ref><ref name=":19">{{cite journal |vauthors=Lee Y, Kim H |title=The Turning Point of China's Rural Public Health during the Cultural Revolution Period: Barefoot Doctors: A Narrative |journal=Iranian Journal of Public Health |volume=47 |issue=Suppl 1 |pages=1–8 |date=July 2018 |pmid=30186806 |pmc=6124148}}</ref> Though most village doctors are former barefoot doctors, they started charging for their services as private entities.<ref name="watts">{{cite journal | vauthors = Watts J | title = Chen Zhu: from barefoot doctor to China's Minister of Health | journal = Lancet | volume = 372 | issue = 9648 | pages = 1455 | date = October 2008 | pmid = 18930519 | doi = 10.1016/S0140-6736(08)61561-5 | pmc = 7159084}}</ref>
Urban residents also faced healthcare privatization as they were laid off from state-owned enterprises and lost much of their social security and health benefits. As a result, the majority of urban residents paid almost all health costs out-of-pocket beginning in the 1990s, and most rural residents simply could not afford to pay for healthcare in urban hospitals.<ref name=":22"/>
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