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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of the number of students without commensurate faculty strengthening, worries about dilution effect on quality, outdated curricular content, and ethical professionalism challenged by narrow technical training and growing admissions of students who did not express medicine as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.

Background China faces major challenges in the distribution of health professionals, with serious shortages in rural areas and in the development of Primary Care Providers. The aim of this study was to investigate the career preferences of medical students in China and the impact of rural backgrounds on these preferences. Methods This cross-sectional survey was done in 16 medical schools across China. Medical students in the final year of their programme completed a 58-item survey that included questions regarding their demographic characteristics, attitudes toward practice in low-resource areas, postgraduate planning, self-assessed competency, university facilities assessment, and financial situation. We used descriptive calculation and Logit model for the analysis. Peking University Institutional Review Board reviewed the research design and exempted the study from additional ethical approval. Participation in the study was voluntary and anonymous. Findings We included completed surveys from 3020 students in the analysis. Upon graduation, 1465 (48·5%) medical students preferred to work in urban public hospitals, and this number rose to 2223 (73·6%) students when they were asked to state their anticipated preference 5 years after graduation. Students' top three reasons for preferred careers were "good career prospects", "living close to parents or families", and "remuneration". Those students who preferred to work in rural areas upon graduation were more likely to be people who had lived in rural areas at the age of 1–15 years (β=2·05, p=0·0000), had attended highschool in rural areas (β=1·73, p=0·0000), or had parents currently living in rural areas (β=2·12, p=0·0000). Similar results were found for those students who preferred to work for Primary Care Providers. Interpretation To address the serious shortages of health professionals in rural areas and working for Primary Care Providers, medical schools should consider strategies to recruit more medical applicants with rural backgrounds and to orient students to rural and primary care interests. This study has a few limitations. The logit models might be biased and inconsistent due to selection bias and omitted variables. Furthermore, the process of administering questionnaires at each medical school varied and the return rates were not determined. Nevertheless, to the best of our knowledge, this was the first nationwide questionnaire survey of graduating medical students in China to map their career preferences and to study the relation between rural backgrounds and preferences for working in rural areas/PCPs. The study results provide insightful implications for policy making in medical education, including student admission, student career planning, and reforms in medical education. In the future, research might be needed to study the relation between medical graduates' career determinations and their demographic backgrounds. Funding None.

Background China has a vast and complex system of health-professional education, which underwent fast changes beginning in 1998. Because of the notable shortage of international published work on quantitative characteristics of the system, we aimed to analyse the scale, distribution, and changes of this system. Methods Using previously unreleased datasets from China's Ministry of Education, we did a time-series analysis by studying the changes and tendency of health-professional education institutions, students, faculty members, and infrastructures from 1998 to 2012. Only routine statistics of education institutions were analysed, and no informed consent was necessary. Findings In 1998–2012, the number of health-professional education institutions increased from 189 to 590 in the field of regular higher education. 123 private institutions existed in 2012, compared with zero in 1998. In the same period, the number of health-professional students increased from 0·3 million to 2·1 million, with an average growth rate of 14·9% per year. By contrast, a much slower growth rate or a decreased rate was seen for faculty members (7·6%), campus area per student (–1·4%), classroom area per student (1·9%), number of library books per student (–5·6%), and number of computer per 100 students (5·7%). Furthermore, a widening gap was seen between western China and the other two parts of the country (eastern and central China) in terms of health-professional educational resources and output. Interpretation Expansion of health-professional education has a positive role in addressing the shortage of health workforce in China. Nevertheless, the quality of education might be compromised because of the rapid increase in the number of students without commensurate strengthening of faculty and infrastructure. The widening gap in educational resources and output among different regions might worsen the unequal distribution of health professionals in the country. Funding Chinese Academy of Engineering.