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Since a 1981 review of health status and health services in Shanghai County, there have been considerable social and economic changes in the People's Republic of China. A major question currently is the impact of the new economic "responsibility system," which was introduced in 1982, on the cooperative health structure and the "barefoot doctors" (BFDs). Investigators in other areas of China have reported the collapse of the cooperative systems and a shift in the role of the BFDs as a result of incentives for them to spend more time in agricultural production. In Shanghai County, however, BFDs continue essentially full time as before, salaried by the brigade, with fee-for-service charges prohibited. Recent evidence from Shanghai County shows that the health care system and those who direct it can remain flexible and respond positively to changes in the social, economic, and political structures.