Transformation of the education of health professionals in China: progress and challenges
Jianlin Hou, Catherine Michaud, Zhihui Li, Zhe Dong, Baozhi Sun, Junhua Zhang, Depin Cao, Xuehong Wan, Cheng Zeng, Bo Wei, Lijian Tao, Xiaosong Li, Weimin Wang,Yingqing Lu, Xiulong Xia, Guifang Guo, Zhiyong Zhang, Yunfei Cao, Yuanzhi Guan, Qingyue Meng, Qing Wang, Yuhong Zhao, Huaping Liu, Huiqing Lin, Yang Ke*, Lincoln Chen
In this Review we examine the progress and challenges of China’s ambitious 1998 reform of the world’s largest health professional educational system. The reforms merged training institutions into universities and greatly expanded enrolment of health professionals. Positive achievements include an increa in the number of graduates to address human resources shortages, acceleration of production of diploma nurs to correct skill-mix imbalance, and priority for general practitioner training, especially of rural primary care workers. The developments have been accompanied by concerns: rapid expansion of the number of students without commensurate faculty strengthening, worries about dilution eff ect on quality, outdated curricular content, and ethical professionalism challenged by narrow technical training and growing admissions of students who did not express medicine as their fi rst career choice. In this Review we underscore the importance of rebalance of the roles of health sciences institutions and government in educational policies and im plem entation. The im perative for r
eform is shown by a loom ing crisis of violence against health workers hypothesid as a result of many factors including defi cient educational preparation and harmful profi t-driven clinical practices.
Introduction
China, as the world’s most populous country, has a vast and complex system of health professional education. Insuffi ciently recognid are Chine reforms that might be the world’s most ambitious, largest, and fastest transformation of health professional education in contemporary times. In 1998, the Chine Government announced a national policy to merge many of the free-standing health professional institutions into universities.1,2 This policy resulted in the shift of technical schools into large university systems, following the pattern of health professional education in the USA and other developed countries.
This latest round of changes builds on a century of reforms. n 1912, the Republic of China started a national system that was dramatically expanded and transformed in 1949 by the People’s Republic of China. The model of health professional education adopted that of the former Soviet Union’s, characterid by autonomous medical institutions under the Ministry of Health and focud exclusively on the training of health workers. The training institutions were disrupted during the cul
tural revolution of 1966–76, with some schools closing and others shifting to the briefer training of farmers as barefoot doctors.3–6 The opening of China to the global economy in 1978 enabled health professional institutions to ramp up the training of more highly skilled professionals.7
The education of professionals might be credited with some Chine health success. The mobilisation of basic health workers at the start of the People’s Republic in the 1950s is one of the key factors accompanying the rapid acceleration of China’s average life expectancy. The barefoot doctor movement in the 1960s and 1970s revolutionid thinking about health workers, especially for disadvantaged rural communities.5,8 This round of reform in 1998 comes at a time of robust economic
growth as China attempts to reform education and
health to balance social development with economic
development.7
n this Review we focus on the latest round of
educational reforms. What actually happened to the
mergers, especially health sciences integration into
universities? How did the mergers aff ect the institutional
and instructional design of education? What have been
the positive and negative results? What are the challenges?
I n addressing the questions, our Review adopts the
framework propod by The Lancet Commission on
Education of Health Professionals for the 21st century.9
Referring back to the Flexner report of 1910, the
Commission propos that health professional education
be examined via what is learned (instructional design) and
also where learning takes place (institutional design).10
The two approaches provide a framework to show the
dynamics of health professional education reform.
Lancet 2014; 384: 819–27
Institute of Medical Education,
Peking University, Beijing,
China (J Hou PhD,
Prof Z Dong PhD); China
Medical Board, Cambridge, MA,
USA (C Michaud MD, Z Li MS,
L Chen MD); Center for Medical
Education Rearch, China
谏太宗十思疏教案Medical University, Shenyang,
China (Prof B Sun PhD); Health
Human Resources
Development Center, Ministry
of Health, Beijing,China
(J Zhang PhD); Harbin Medical
University, Harbin, China
(Prof D Cao PhD); West China
School of Medicine and West
China Hospital, Sichuan
University, Chengdu, China
(X Wan PhD); West China School
of Public Health and No. 4 West
China Hospital, Sichuan
University,Chengdu, China
(Prof C Zeng D.Sc, Prof X Li PhD);
Guangxi Food and Drug
Administration, Nanning,
China (Prof B Wei BM); Xiangya
School of Medicine, Changsha,
China (Prof L Tao MD); Peking
University Health Science
Center, China (Prof W Wang MD,
Prof Y Ke MS); Shanghai Medical
College, Fudan University,
Shanghai, China (Prof Y Lu PhD,
Q Wang: MM); Jiujiang
University Medical Center,
Jiujiang, China (Prof X Xia MM); Search strategy and lection criteria
The Initiative reviewed offi cial documents issued by the Ministry of Education (MOE), Ministry of Health (MOH [now the National Health and Family Planning Commission]), and other relevant ministries, published reports, and news reports from both international and domestic sources (in both English and Chine). Also arched were PubMed, Google Scholar, Science Direct (Elvier) Journal, Springer Link, China National Knowledge Infrastructure, and Wan Fang Data for articles published since 1998. The arch was restricted to works published in English or Chine and ud
the arch terms “medical education”, “human resources for health”, “medical education reform”, “clinical medicine”, “public health”, “nursing”, “institutional design”, “instructional design”, “medical education institution”, “enrollment”, “pedagogy”, “merger”, “doctor-patient relationship”, and “professionalism”, combined with the term “China”. We also arched the websites of international development agencies and Chine Government agencies
for related documents and statistics. The date of the last arch was April 10, 2014.
School of Nursing, Peking
University,Beijing, China
(Prof G Guo PhD); Guangxi Medical University, Nanning,
China (Prof Z Zhang MD,
Y Cao MD); Offi ce of Educational Administration, Peking Union Medical College,
Beijing, China (Y Guan MM);
China Center for Health Development Studies, Peking University, Beijing, China (Prof Q Meng PhD); Department of Human Resources, China Medical University, Shenyang, China (Prof Y Zhao, D. Admin);
School of Nursing, Peking Union Medical College, Beijing, China (Prof H Liu PhD); and Ministry of Education, Beijing,
China (H Lin PhD)
Correspondence to: Prof Yang Ke, Peking University
Health Science Center, Beijing
100191, China
keyang@ Data sources and arch strategy
I n this Review, health professional education refers to
many health professions such as clinical medicine,
nursing, public health, pharmacy, and allied professions,
and the term health sciences institutions refers to an
organid cluster of health professional schools. Under
this practice, the term medical education refers only to
the training of clinical physicians.
The overwhelming bulk of the statistical data for China
comes from two previously unrelead datats provided
by China’s Ministry of Education (MOE): number of
health professional graduates by major degree and
schools and number of faculty of health sciences by
professional title and schools (unpublished). Major refers
to disciplines (eg, medicine, nursing, and public health)
and there are more detailed majors for masters and
doctoral students, such as gynaecology, epidemiology,
and health statistics. Each higher education institution
submits yearly statistical forms to local education
authorities and to the MOE. Only aggregate results of
the forms are accessible to the public, mainly through
the MOE website and statistical yearbooks. For this
Review, we obtained the complete datats from the
MOE, which consist of all health professional education
institutions and their students. The total number of
students and faculties in both the aggregate statistics
available to the public and the complete datats are the
same, which underscores the completeness and accuracy
of the MOE datats.
The Chine data were supplemented by data for
other countries from the Organisation for Economic
Co-operation and Development (OECD), and various
countries’ Ministry of Health (MOH), MOE, medical
council, or medical school association.11–16
Many of the analys for this Review come from the
China Medical Education Reform and I nnovation
Initiative that was launched in Beijing in May, 2011. The
I nitiative, a Chine national follow-up to the global
Commission in The Lancet, brought together an informal
鸽子功效expert group of 23 professional leaders from universities
and r earch institutions across the breadth of China.
The expert group met regularly to review health
professional education, analy challenges and
diffi culties, and formulate recommendations for reform.
The nitiative also commissioned nine background
papers including veral questionnaire surveys of
institutions, graduates, and faculty. The studies will be
reported elwhere in a Chine book. Data from one
commissioned study (unpublished), “Eff ect of university
merger on admission of medical undergraduates” by Hou
and colleagues, studied the merger of institutions by
examination of yearly data provided by the MOE on health
sciences faculty mergers. The investigators also reported
on a sample survey stratified by province and type of
institution of full-time medical undergraduate students in
2011, which was done to obtain information about the
effects of different admission patterns in universities.
糖醋丸子怎么做Questions were grouped into six categories: background
information, study, professionalism, asssment of
medical education, fi nancial status, and career preferences.电灯图片
The appendix provides English and Chine versions of
the questionnaire ud. The questionnaire was pre-tested
among students in Peking University Health Sciences
Center; of 4103 student questionnaires distributed to
sampled students, 3132 surveys completed by students
who had not predetermined their career choices were
tabulated for this Review. 67 questionnaires were
incomplete and thus were not included in the analysis.
Every questionnaire was double-entered with EpiData to
理发教学
guarantee accuracy. Nevertheless, the datat will probably
suff er from lection bias becau private medical schools
did not participate in the survey although they were
sampled. Becau public medical schools are dominant in
China’s health professional education, the eff ect of
lection bias is not expected to be large. The questionnaire
survey was part of a situation analysis of China’s health
professional education approved by the MOE.
Health workforce
China is by far the world’s largest producer of health
professionals, albeit China shares with other countries
the common difficulties of shortages, maldistribution,
and imbalanced skill mix. Table 1 shows China’s basic
indicators with annual production of health professionals
and its human resources for health stock in comparison
with lected countries.11–16 Although I ndia has more
medical schools than China (381 vs 268), China has a very
large production of graduates (144 000 per year) in
comparison with I ndia’s 49 000. The USA has half the
number of medical schools and produces only
22 000 graduates every year. China’s health professional
education system is complex and consists of degree
programmes lasting from 3 to 8 years. The explanation
for China’s great production system is its very large class
sizes, averaging 548 graduates per school.
The health workforce in China has 1·9 doctors per
1000 population, which is better than I ndia’s 0·6 per
1000, but lower than the UK’s at 2·8 and the USA’s at
2·4 per 1000. Chine nurs at 1·9 per 1000 are greater
沙棘油的十大功效than India’s 1·0, but only a fi fth the density of nurs in
the UK and USA. The resulting nur-to-doctor ratio in
China is very low, less than 1·0. The overall workforce
density of doctors plus nurs in China is 3·5 per 1000,
about a quarter of that of the UK and USA.
Data inconsistencies, such as very large cohorts of
graduates without commensurate increas of workforce
density, suggest production ineffi ciencies of the Chine
system. There would em to be many graduates who do
not move on to professional practice, accepting
employment in non-medical roles such as jobs in
industry or shifting to other occupations. The data
suggest that eff orts to train large numbers of graduates
might not translate into eff ective workforce
strengthening. Anand and colleagues17 showed that
See Online for appendix
between 2000 and 2005, the total number of medical
graduates from all health educational institutions greatly
exceeded increas in the stock of practising doctors, suggesting that many graduates were not entering into
professional practice after graduation.
China’s workforce also displays disparities between urban and rural areas and high variability in educational
attainment. Doctor density in urban areas, which contains 52% of China’s population, was more than twice that in rural areas, with nur density showing more
than three-times diff erence. Whereas 43% of urban
doctors had college or higher educational degree in 2005,
the comparable proportion in rural areas was only 13%. I n 2005, 3% of nurs in urban areas had a college or
higher education degree, and less than 1% of the nurs
in rural areas hold such a degree.17 I n both urban and rural areas, a large number of nurs only had condary
school or high-school education or less. China also has
1·2 million village doctors, who are not classifi ed as health professionals, since few village doctors have more than high-school training. Many are former barefoot doctors and vocationally trained workers. There have been continuing eff orts to strengthen the village-bad health workers through continuing medical education.
This picture of human resources for health comes from a half-century of an established professional education system that has categorid health professionals into standard categories: doctors, nurs, public health practitioners, dentists, pharmacists, and allied
professionals. Professional education after high school varies enormously both across and within the professions. Medical doctor training has variably taken 3–8 years, with the longest duration usually associated with more competitive schools. Nursing education is customarily diploma level, with brief training periods after high school and very few bachelors or postgraduate degrees. Public health education is mostly undergraduate
education or 5 years after high school, unlike the postgraduate public health degrees of the USA. For the clinical professions, undergraduate classroom work is usually followed by clinical practicum at affi liated hospitals.Figure 1 shows the number of medical, nursing, and public health graduates by degree levels in 2012. China
graduates 67
000 5-year bachelors medical students every year, which is the national standard that China eks to achieve for all medical professionals. However, about an equal number of 63 000 graduates have only 3 years or less
of medical training. About half of the graduates obtain additional higher masters or doctorate degrees. Although
盐水花生about 29
000 obtain nursing bachelor degrees, a robust 156
000 nursing graduates obtained diplomas mostly entailing brief training after high school. This substantial
increa in nursing will help to correct low nur-to-doctor ratios, but how the briefl
y educated graduates will translate into quality of care or improvement of health systems teamwork and delegation of functions is unknown. Public health has fewer graduates: only 5000 bachelor degrees in 2012. Many public health graduates cure jobs in Centers for Dia Control and Prevention (CDC) and governmental health inspection units.Institutional design
Health professional training institutions in China are mostly government owned, with MOE policies guiding both institutional and instructional design. Government
Figure 1: Number of graduates by degree programmes in 2012
policies are comprehensive, ranging from degree-granting status to the specifics of curricular design. Although China’s MOE has been committed to the design and supervision of the curriculum, there is an increa in movement towards decentralid autonomy for health professional schools to experiment with a new curriculum. Different levels of government (central, provincial, prefecture, and county) also have variable roles in ownership, operations, and fi nancing. The political and bureaucratic context in China diff ers from private or public universities in many other countries, with China’s system marked by strong government ownership and guidance.
The major reform of 1998 was aimed to increa the quality of all higher education in China, not only health professional education. To enhance academic quality and bring effi ciency of scale, all health professional schools were encouraged to be integrated with universities. The integration might be viewed esntially as moving from the former Soviet model (independent medical training institutions with emphasis on empirical clinical training) to a developed country model (health professional education in universities and academic discipline bad in the natural sciences). The early model that China adopted had medical training institutions providing technical training under the MOH. The developed country model that was introduced brought health professional education into comprehensive universities as one of the major faculties and under the MOE. The reforms were implemented mostly by administrative action with a powerful eff ect on institutional design and numerical expansion of graduates. Although there was interest in progressive educational improvement, the reforms did not revamp instructional design as much as the organisation of university management. Curricular reform has been a slow and steady continuing process, not sudden or dramatic like the administrative reform. Starting from 1990, 98 health professional training institutions have been organisationally merged into 76 institutions.18 The university ba for health professional school mergers has consisted of general universities, institutes or faculties of science and technology, and other independent institutions. The number of mergers peaked at 20 in the year
2000. Integration was greater among centrally controlled and funded health professional schools than in provincial or prefecture schools. Among clinical medical education programmes, the percentage of integrations into universities was estimated to be 72% for schools linked to the central government, 32% for schools linked to provincial governments, and 14% for schools linked to prefecture governments. Nearly all highly competitive national medical schools were merged into universities. Many provincial and low-level schools were not integrated. Many schools were left standing and some were consolidated by combination of veral smaller schools. One of the aims for mergers was to consolidate academic universities to become strong academic institutions. For example, veral condary schools might have been merged to form a medical college, or colleges were merged to form a university. After the merger to create a higher education institution, the schools can admit undergraduate and diploma students that they were not allowed to before. Thus, a faculty who taught diploma students in the past begins to teach undergraduate students. Whether or not they have the competency is of obvious concern. Furthermore, there might be insuffi cient expansion of educational resources for the revamped institutions to train more advanced students.
The integration of medical schools into universities changed their institutional design, which includes fi nancing, affiliation, and management structure. No administrative model defining the relation betwe
en medical schools and the university has yet fully emerged; two basic models have predominated but there are many variants in between. The fully centralid model integrates all the diff erent health science faculties into the university, with deans of medicine, nursing, public health, etc, individually reporting directly to the university president. The decentralid model brings the health sciences faculty under unifi ed management, usually the medical school, within the university. An intermediate level of integration organis administration and fi nancing somewhere in between the two extremes. There are also pudo decentralid models in which the organisations might appear decentralid on paper but operationally are still centralid.
The administrative models might have had a substantial eff ect on the autonomy of medical schools in terms of student admission, staffi ng, teaching, scientifi c rearch, financing, and international cooperation (table 2). Universities that created health sciences centres keeping all health science faculties together, retain substantial administrative power. Education of the health professionals, including interprofessional education, can be pursued more effectively becau of administrative cohesion of the veral professional schools. By contrast, the centralid organisations might have more potential for multidisciplinary rearch and education between the
health sciences and other disciplines in the rest of the university. But the direct report of individual health science deans to the university presidents can fragment and disrupt coordination among interprofessional education of health professionals.
Equally important is the continuum of education from undergraduate studies to clinical training in affi liated hospitals. I n many cas, university affi liated hospitals work smoothly with medical schools and graduates. I n other cas, especially where a university hospital has been shifted to report to a non-medical university president, there might not be a smooth relationship between medical dean and hospital director, conquently affecting educational transition from classroom to clinical education.
Salient to the issues are the direction and volume of fi nancial fl ows. The fi scal relationships vary enormously
and have yet to ttle into established patterns. Medical schools in universities depend overwhelmingly on public funding and only modest revenues from tuition. Service charges from hospitals reprent a substantial source of income. Yet, health sciences schools usually reimbur hospitals for clinical teaching. The reimburment might be as high as 75% of tuition revenues in some schools, although most teaching reimburments are negotiated on a ca-to-ca basis.
数学必修一目录Paralleling the organisational merger has been the numerical expansion of institutions (appendix). Between 1998 and 2012, the number of health sciences institutions has doubled. Traditional Chine medicine institutions have had similar expansion. The expansion was particularly marked in the years immediately after the 1998 reforms, slowing down somewhat in the past few years. The expansion has been across the board of all educational programmes, although brief diploma training programmes might have had disproportionate expansion. The diff erential expansion in the appendix shows the number of graduates for the three major professions. The expansion of training in modern medicine has witnesd a parallel expansion in traditional Chine medical practice. All practices had growth, but nursing was most marked whereas public health was nearly stagnant. The overwhel
ming share of the nursing expansion was among diploma graduates, especially in the early years of the reform. The bachelors and master or doctorate nursing programmes have also shown substantial growth.
Figure 2shows the conquent trends of students, faculty members, and faculty–student ratios from 1998 to 2012.In 2012, China had half a million health professional graduates from 590 institutions, with large cohorts of graduates coming from expansion. The professions show diff erential growth by years of training: increas in nursing (36%), clinical medicine (32%), pharmacy (18%), public health (2%), and allied professions (12%). A big diffi culty is that faculty numbers (and also quality) might not have kept pace with numeric expansion of students. Figure 2 shows that the collap of the faculty–student ratio is very marked. Thus, along with qualitative organisational mergers came quantitative expansion in
the 1998 reforms. The reform goal might have been to moderni education along the developed country model,
but the infrastructure, public funding, and especially the faculty might not have kept up with the expansion of student enrolment.
Instructional design
The medical education reforms have aff ected instructional design, some directly and others through change of institutional structures. Three key questions are: who achieves admission to become a health professional? What are the pedagogic methods and curricular content of instruction? And what are some of China’s priorities for reform of instructional content?
The reform has opened two different pathways for admission into health sciences professions in universities dependent on the admissions code. One perhaps unintended result of the reforms is that some medical students did not lect medicine as their fi rst career choice. Rather, test scores for entrance into universities might result in students being assigned to medicine who
do not lect being a doctor as their top choice.
Like many other countries, admissions into medical school are mostly bad on national college entrance examination (CEE). An estimated 90% of students are admitted on the basis of CEE scores, and the more competitive Chine universities admit students with the highest CEE scores. About 10% of admitted students have special attributes like minority quotas (eg, Xinjiang and Tibet). Medical student admission into universities can follow one of two pathways. A school might have a s
eparate admission code to which students apply to join the health professions. A school might also have a university-wide admission code in which all faculties in a comprehensive university have the same code. The fi rst group of medical schools with a parate code for admission is able to accept students who express first preference for entering the Figure 2: Number of student, faculty members, and faculty–student ratios, 1998–2012
