1 Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, H3S 1Z1, Canada.
2 John Molson School of Business, Concordia University, Montreal, H3H 0A1, Canada.
3 Department of Philosophy, School of Humanities, Southeast University, Nanjing, 211189, China.
4 Yitang East Village Clinic, Gaomi, 261511, China.
5 China Centre for Health Development Studies, Peking University, Beijing, 100191, China.
6 Department of Global Health, School of Health, Georgetown University, Washington, DC, 20057, USA.
7 China Centre for Health Development Studies, Peking University, Beijing, 100191, China. Electronic address: xiaoyunliu@pku.edu.cn.

Introduction: Effective health governance is essential for ensuring accessible, equitable, efficient, and high-quality healthcare services. Yet it is often overlooked or oversimplified in health services studies in rural China. We examine the unique role of village doctors in shaping public health governance in rural China.

Methods: A two-phase ethnographic study was conducted in Gaomi, Shandong, from February to May 2023. Phase one involved a one-month in-field rapid assessment of the local health system. Phase two included two months of fieldwork, with participant observation and informal interviews with patients, clinicians, and officials.

Results: Village doctors acted as "quasi-officials," mediating between state authority and local community life. Their practices are shaped by state directives, local moral norms, and market pressures, producing adaptive governance within a "third sphere", which translates national policies into locally workable arrangements. Three overlapping roles for the village doctors emerged: state agent (implementing policies), health care giver (balancing ethics with community embeddedness), and entrepreneur (navigating entrepreneurial pressures). Although these roles can lead to conflicts and create a precarious professional scenario, village doctors exercise strategic agency, negotiating competing responsibilities to sustain their legitimacy and livelihood.

Conclusion: Public health practices in rural China emerge within a "third sphere," where state, market, and community intersect. Village doctors negotiate multiple, often conflicting roles, balancing professional ethics, community obligations, and entrepreneurial pressures. This study challenges simplistic binaries of state versus society, revealing public health governance as a dynamic interplay between structural forces and localized practices.