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Purpose This study compares doctor staffing level and the scale of medical education in China with those of other countries and proposes policy recommendations for future adjustments to the scale of China's medical education. Design/Approach/Methods This study employs a literature review and descriptive analysis. Findings China had 1.98 medical doctors per 1,000 people in 2018, ranking 85th out of the 193 member-states of the World Health Organization (WHO). In 2017, China had 1.99 practicing doctors per 1,000 people, only ranking above Turkey (1.88) in Organisation for Economic Co-operation and Development (OECD) countries. China had only 10.28 medical graduates per 100,000 people—placing in the bottom third of OECD countries. China's provision of 1.4 medical schools per 10 million people was also significantly lower than the global average (3.9). However, the average number of students enrolled in medical schools (509) in China was significantly higher than the global average (160). Originality/Value Although the scale of admission in undergraduate medical education must be expanded in China, this needs to be achieved while controlling the average number of medical students per school and reducing enrollment in low-quality medical schools. Furthermore, it is necessary to establish new medical schools while improving the operating level of existing ones.

In this study, the data of fertility indicators of soil samples (0–20 cm) in 1980s, 2000 and 2015 in Chenzhou city were used, and the soil integrated fertility index (IFI) was calculated. The results showed that the soil pH was decreased, total nitrogen (TN), organic matter (OM), available phosphorus (AP) and potassium (AK), exchangeable calcium (Ca2+), magnesium (Mg2+) and available copper (Cu) contents were increased, total phosphorus (TP), available sulfur (S) and water-soluble chlorine (Cl−) contents were decreased, total potassium (TK), available boron (B), iron (Fe), manganese (Mn) and zinc (Zn) were decreased first and then increased. In 2015, most of the fields were higher in pH, OM, TN, AN, AK, Ca2+, Mg2+, S, Fe, Mn, Cu and Zn, suitable in B, but lower in TP, AP, TK, available molybdenum (Mo) and Cl−. Most of the fields were in the middle grade of IFI in 2000 and 2015, and the mean IFI increased from 0.492 to 0.556 from 2000 to 2015. Thus, for soil improvement, more attention should be paid to adjust soil pH, reduce the application of organic, nitrogen and calcium fertilizers, while increase the fertilizer application of other nutrients.

Objective Mergers of health science faculties in China have resulted in two different admission pathways for medical students. A uniform-code model prioritizes admission to a specific institution with secondary assignment to major. A separate-code model prioritizes admission directly to a school within an institution. This study investigates the impact of these two admission pathways on medical student selection and on the satisfaction of students with their major. Methods Medical students at 16 medical schools across China completed a questionnaire survey. Descriptive calculation, chi-square tests, and probit models were used for analysing the data. Results A total of 3132 completed surveys were included in the analysis. Compared with the students admitted under the uniform-code pathway, a significantly larger proportion of the students admitted under the separate-code pathway had medicine as the first preferred major (89.6% vs 79.6%, p=0.000); compared with those students enrolled into medicine not as their first preferred major, a significantly larger proportion of students enrolled into medicine as their first preferred major were willing to study medicine if choosing again (80.1% vs 62.4%, p=0.000) or to recommend the major to other students (73.3% vs 65.2%, p=0.000). Probit models showed that medical students admitted under the separate-code admission pathway were more likely to choose medicine as their first preferred major at application (β=0.96, p=0.000); medical students admitted into medical school as their first preferred major were more likely to be willing to study medicine if choosing again (β=0.53, p=0.000) or to recommend the medical major to other students (β=0.18, p=0.010). Conclusion Separate-code admission is more likely to result in matriculants who choose medicine as their first preferred major and are more likely to be intrinsically interested in medicine than those applicants assigned to medicine from the uniform admission process.

Background China has a shortage of physicians and nurses in primary care and rural health. This study explores factors that influence the choices of medical and nursing students in China to select a career in primary care, or in rural health. Methods A total of 3826 medical students and 1771 nursing students were surveyed in China. Data were analysed using descriptive statistics, Chi-squared tests, and logistic regression models. Results The majority of medical and nursing students were willing to practice primary care (55% and 59%, respectively). Yet, only 16% and 5% of medical and nursing students, respectively, desired to work in a village or small city. The most common reasons cited to not practice primary care is the lack of opportunities for clinical skills improvement, academic and personal development, and networking. Medical students who were living in a rural residence between ages 1 and 15 years were more likely to report a willingness to work in a rural location (OR: 2.18, 95% CI: 1.33–3.58) or in primary care (OR: 1.72, 95% CI: 1.31–2.25). Conclusion More efforts are needed to understand how preferences among medical and nursing students influence their career choices and change in choices over time. Understanding the concerns of students can help to tailor interventions in healthcare education and training to increase student satisfaction with their career choice and enrolment counts in medical and nursing fields.

Purpose Most countries are faced with the challenge of inadequate human resources for health in rural and remote areas. In China, approximately 41% of the total population reside in rural areas where there is a severe shortage of qualified practicing physicians. The Chinese government adopted a plan to strengthen the primary healthcare workforce by increasing enrollment of students from rural areas and providing free medical education. The purpose of this study is to examine the design and implementation of this plan in China, including its construct, outcomes, and challenges. Methods Three databases and Baidu were searched to find literature relating to targeted enrollment of medical students for rural China. Official government documents were also reviewed. Results Targeted enrollment of medical students from rural areas was implemented in 2010 throughout China. For example, under financial support from the Ministry of Finance, over 5000 5-year medical students per year were admitted from central and western China. Most graduates went to rural primary care settings to provide health services in accordance with their signed commitments to provide service as intended by the government. These medical school initiatives are faced with a number of challenges, including unfilled enrollment vacancies, low motivation to study among these students along with a reluctance to serve a rural population, and unguaranteed job opportunities. Conclusion Targeted enrollment of medical students and free medical education in exchange for obligatory services contribute to improve the allocation of physicians in rural China. However, there are opportunities to improve the design and implementation of these programs. This review of the approach taken in China may be informative to other countries in their efforts to address the shortage of health professionals in rural and remote areas.

Background Health expenditure efficiency (HEE) is an important research area in health economics. As a large agricultural country, China is faced with the daunting challenge of maintaining equality and efficiency in health resource allocation and health services utilization in the context of rapid economic growth in rural areas. The reasonable allocation of limited rural health resources may be achieved by scientifically measuring the current rural HEE. This subject may help to formulate effective policy or provide incentives for the health sector. Methods The combination of a super-slack-based measure (SBM) model with the Malmquist productivity index (MPI) is proposed to evaluate the static health expenditure efficiency (HEE) and dynamic health expenditure efficiency (DHEE) in rural China from 2007 to 2016. Results The results show that the HEE and DHEE values exhibit unstable trends over time. The HEE does not follow China’s economic development and presents an average of 0.598 (

Having the two largest nursing workforces across the globe, both China and the United States have implemented licensure examinations to standardize the qualifications of registered nurse. China established the National Nursing Licensure Examination (NNLE) in 1995. Like the National Council Licensure Examination for Registered Nurses (NCLEX-RN) in the United States, the NNLE has become an important link in the nurse registration process and contributed a lot in quality assurance and development of nursing profession. It may be necessary for the NNLE to learn from NCLEX-RN in several aspects, including increasing the frequency of exam, providing examinees with individualized services, and continuing reforming exam content and format. By better aligning the content and format of the examination with the current nursing paradigm and clinical requirements, nurses may enter the healthcare field better prepared to care for patients. Considering the magnitude of their nursing workforce, both China and the United States have great potential to serve as a role model for other developing countries as they look towards establishing national nursing education programs. As new policies around standardized nurse education in China take form, we urge that the NNLE be included alongside curricular reforms. As these reforms are implemented, continued research will be needed to evaluate the effectiveness of curriculum and licensure exam regulations upon nurse preparedness and quality of nursing care in China. Keywords: China, Examination, Licensure, Nursing education, The United States

Despite China���s large and growing global presence, data about global health (GH) education (GHE) in China���s medical schools are limited. We aimed to describe GHE in these schools and determine whether some may teach GH concepts without labeling them as such. In 2019, 161 Chinese medical schools eligible for accreditation by the Ministry of Education were invited to complete a questionnaire as part of a national survey. Data were analyzed using descriptive analyses, Chi-square tests, Fisher exact tests, and logit models. Approximately 57% of schools completed the survey (n = 93). 33 (35.5%) indicated that GHE was included in the curriculum. Although the majority of responding schools reported the absence of GH in the curriculum, GH topics were identified at many institutions. Schools affiliated with the central government or an aspiring world-class university were more likely to report the inclusion of GHE and offered more opportunities at international away sites. Chinese medical schools are frequently teaching GH topics, but may not label the instruction as such. Policy-makers and educators should be equipped with a global perspective to facilitate GHE at China���s medical schools and take measures to address differences between schools.

Global health education (GHE) continues to be a growing initiative in many medical schools across the world. This focus is no longer limited to participants from high-income countries and has expanded to institutions and students from low- and middle-income settings. With this shift has come a need to develop meaningful curricula through engagement between educators and learners who represent the sending institutions and the diverse settings in which GHE takes place. The Bellagio Global Health Education Initiative (BGHEI) was founded to create a space for such debate and discussion and to generate guidelines towards a universal curriculum for global health. In this article, we describe the development and process of our work and outline six overarching principles that ought to be considered when adopting an inclusive approach to GHE curriculum development.

Purpose Most countries are faced with the challenge of inadequate human resources for health in rural and remote areas. In China, approximately 41% of the total population reside in rural areas where there is a severe shortage of qualified practicing physicians. The Chinese government adopted a plan to strengthen the primary healthcare workforce by increasing enrollment of students from rural areas and providing free medical education. The purpose of this study is to examine the design and implementation of this plan in China, including its construct, outcomes, and challenges. Methods Three databases and Baidu were searched to find literature relating to targeted enrollment of medical students for rural China. Official government documents were also reviewed. Results Targeted enrollment of medical students from rural areas was implemented in 2010 throughout China. For example, under financial support from the Ministry of Finance, over 5000 5-year medical students per year were admitted from central and western China. Most graduates went to rural primary care settings to provide health services in accordance with their signed commitments to provide service as intended by the government. These medical school initiatives are faced with a number of challenges, including unfilled enrollment vacancies, low motivation to study among these students along with a reluctance to serve a rural population, and unguaranteed job opportunities. Conclusion Targeted enrollment of medical students and free medical education in exchange for obligatory services contribute to improve the allocation of physicians in rural China. However, there are opportunities to improve the design and implementation of these programs. This review of the approach taken in China may be informative to other countries in their efforts to address the shortage of health professionals in rural and remote areas.

Background Although China’s modern education for public health was developing over the past 60 years, there is a lack of authoritative statistics and analyses on the nation’s development of education for public health at higher education institutions (HEIs). Few quantitative studies on this topic have been published in domestic and international peer-reviewed journals. To address this knowledge gap, we aimed to use national data to quantitatively analyse the scale, structure, and changes of public health education in China’s HEIs, and to compare the changes of public health education with those of other health science disciplines. Methods This study uses previously unreleased national data provided by the Ministry of Education of China that includes the number of health professional students by school and major. The data, which spans from 1998 to 2012, are descriptively analyzed. Results The number of HEIs for public health education per 100 million population increased from 7.2 in 1998 to 11.3 in 2012. The total enrolment, number of students, and number of graduates increased at rates of 7.3, 7.4, and 5.8% per year, respectively. The percentage of junior college students dropped drastically from 24.0 to 8.4% from 1998 to 2012. During that same period, the number of undergraduates, master and doctorate students increased. Undergraduates accounted for the majority of public health graduates (63.1%) in 2012, and master and doctorate students increased by 10.0 and 5.1 times, respectively, from 1998 to 2012. The relative percentage of public health enrollment, students, and graduates to all health education disciplines dropped from about 6.0% percent in 1998 to around 2% in 2012. Conclusions The overall scale of public health education has clearly expanded, though at a slower pace than many other health science disciplines in China. The increase of public health graduates helped to address the previous shortage of public health professionals. Gradually adopting a modern model of education, public health education in China has undergone notable changes that may be informative to other developing countries though it still faces a complex situation in terms of graduates’ adherence to public health, student recruitment, teaching and training, program planning and reform.

Background Public institutions have been the major provider of education for health professionals in China for most of the twentieth century. In the 1990s, the Chinese government began to encourage the establishment of private education institutions, which have been steadily increasing in numbers over the past decade. However, there is a lack of authoritative data on these institutions and little has been published in international journals on the current status of private education of health professionals in China. In light of this knowledge gap, we performed a quantitative analysis of private institutions in China that offer higher education of health professionals. Methods Using previously unreleased national data provided by the Ministry of Education of China, we conducted time-series and descriptive analyses to study the scale, structure and educational resources from 1998 to 2012 of private institutions for health professional education. Results The number of private institutions that educate health professionals increased from two in 1999 to 123 in 2012. Private institutions displayed an average annual growth rate of 44.2% for enrolment, 59.0% for the number of students and 53.3% for the number of graduates. In 2012, nursing, clinical medicine and traditional Chinese medicine had the most students (37.2%, 32.8% and 8.9% respectively), representing 78.9% of all students in these institutions. Ninety-seven private institutions located in the more economically advantaged eastern and central China and only 26 ones were in the less economically advantaged western China, respectively turning out 85.2% and 14.8% of health professional graduates. There were less educational resources, such as the number of faculty members, physical space and assets, at private institutions than at public institutions. Conclusions Private institutions for the education of health professionals have emerged quickly in China, contributing to the demand for health professionals that exceeds what public institutions are able to offer. At the same time, the imbalance of geographical distribution and poor educational resources of private institutions are of concern. It may be of utmost importance to enhance administration and supervision to better regulate private institutions and their development plans. Future studies may be needed to better examine the effects of private institutions on the production and allocation of health workers.

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 (PCPs). This study investigates the career preferences of medical students in China and the impact of rural backgrounds on these preferences. Methods Medical students in the final year of their program in 16 medical schools across China 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. Descriptive calculation and Logit model were used for the analysis. Results Completed surveys from 3020 students were included in the analysis. Upon graduation, 48.5 % of the medical students preferred to work in urban public hospitals and this percentage rose to 73.6 % when students were asked to state their anticipated preference five years after graduation. Students’ top three ranked reasons for preferred careers were “good career prospects”, “living close to parents/families”, and “remuneration”. Those who preferred to work in rural areas upon graduation were more likely to be those who lived in rural areas when 1–15 years old (β = 2.05, p

Results of Logit Model 3 Estimation: predicting medical undergraduatesâ willingness to work in rural areas (N=3020) (DOCX 17 kb)

Results of Logit Model 2 Estimation: predicting medical undergraduatesâ willingness to work in rural areas (N=3020) (DOCX 17 kb)

Reasons for Preferred Career by Gender (DOCX 16 kb)

Results of Logit Model 1 Estimation: predicting medical undergraduatesâ willingness to work in rural areas (N=3020) (DOCX 17 kb)

Results of Logit Model 6 Estimation: predicting medical undergraduatesâ willingness to work in PCPs (N=3020) (DOCX 17 kb)

Graduating Medical Undergraduatesâ Career Preferences by Gender (DOCX 15 kb)

Results of Logit Model 5 Estimation: predicting medical undergraduatesâ willingness to work in PCPs (N=3020) (DOCX 17 kb)

Results of Logit Model 4 Estimation: predicting medical undergraduates willingnessâ to work in PCPs (N=3020) (DOCX 17 kb)

In the new era of globalization, it has become a trend that health education institutions around the world are collaborating with one another in establishing and advancing collaborative education programs through cooperation, communication, information, and resources sharing. In this chapter, we first present the current main forms and models of collaborative education programs, including degree programs (sandwich, dual degree, joint degree, and others) and nondegree programs (clinical rotation, lab rotation, summer school, international student forums/symposia/workshops). We then discuss the barriers and challenges of advancing collaborative global education programs, which include cultural and language barriers, regulatory differences, financial barriers, unbalanced development among countries/institutions/disciplines, institutional barriers, and personal barriers. And lastly, we discuss the strategies to overcome the barriers and conclude with the future trend of the development.

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.

Background Shortages and maldistribution of nurses remain significant problems in many countries. Having appropriate intervention strategies to retain nurses in underserved areas, where they are most needed, are crucial for health system strengthening. This study aimed to quantify attitudes to working in rural areas, perceived competencies, and intention to work among final-year nursing students, and to analyze the associations between those factors and their background characteristics across five countries in the Asia-Pacific Network for Health Professional Education Reforms (ANHER), namely Bangladesh, China, India, Thailand, and Vietnam. Methods A descriptive comparative cross-sectional survey was conducted between July 2012 and July 2013, using a self-administered questionnaire to assess students’ attitudes towards working in rural areas, their perceived competencies, and their intended job choices. A total of 10,169 final-year nursing students in five countries were selected. Bivariate models were constructed to compare students’ characteristics. Statistically significant variables were further analyzed using multivariate models. Results Most nursing students in five countries had rural backgrounds. Students in India (67.1%) and Thailand (65.1%) held more positive attitudes towards working in rural areas. Students in Bangladesh (78.8%) and India (62.6%) believed that their schools prepared them well, and inspired them, to work in rural areas. The ‘Lifelong learning’ competency was ranked highest by students in all five countries, ranging from 76.2 to 91.7%. Their perceived competencies were significantly related to their background of having graduated from rural high schools and being admitted to study through rural recruitment. Rural upbringing and rural recruitment were significantly associated with more positive attitudes towards rural areas (p-value