Transformation of the education of health professionals in China: progress and challenges

Summary

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 increase in the number of graduates to address human resources shortages, acceleration of production of diploma nurses to correct skill-mix imbalance, and priority for general practitioner training, especially of rural primary care workers. These developments have been accompanied by concerns: rapid expansion of the number of students without commensurate faculty strengthening, worries about dilution effect on quality, outdated curricular content, and ethical professionalism challenged by narrow technical training and growing admissions of students who did not express medicine as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 first career choice. In this Review we underscore the importance of rebalance of the roles of health sciences institutions and government in educational policies and implementation. The imperative for reform is shown by a looming crisis of violence against health workers hypothesised as a result of many factors including deficient educational preparation and harmful profit-driven clinical practices.

Introduction

China, as the world's most populous country, has a vast and complex system of health professional education. Insufficiently recognised are Chinese reforms that might be the world's most ambitious, largest, and fastest transformation of health professional education in contemporary times. In 1998, the Chinese 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. In 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, characterised by autonomous medical institutions under the Ministry of Health and focused exclusively on the training of health workers. These training institutions were disrupted during the cultural revolution of 1966–76, with some schools closing and others shifting to the briefer training of farmers as barefoot doctors.3, 4, 5, 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 Chinese health successes. 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 revolutionised 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

In 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 affect the institutional and instructional design of education? What have been the positive and negative results? What are the challenges?

In addressing these questions, our Review adopts the framework proposed by The Lancet Commission on Education of Health Professionals for the 21st century.⁹ Referring back to the Flexner report of 1910, the Commission proposes that health professional education be examined via what is learned (instructional design) and also where learning takes place (institutional design).¹⁰ These two approaches provide a framework to show the dynamics of health professional education reform.