PHN Technical Notes GEN 15 Public Disclosure Authorized THE WORLD BANK MEDICAL EDUCATION IN CHINA Public Disclosure Authorized August 1983 Public Disclosure Authorized Population, iealth and Nutrition DIepartment This paper is one of a series issued by the Population, Health and Nutrition Department for the information and guidance of Bank staff working in these sectors. The views and opinions expressed in this paper do not necessarily reflect those of the Bank. Public Disclosure Authorized GEN 15 A B S T R A C T 1. Physicians play a critical role in shaping health policy and in health expenditure decisions. These decisions, while influenced.by the institutional environment of the physician, are also influenced by the physician' s previous education and by the 6pportunity to continue such education. Hence the quality of training provided by medical colleges greatly influences the effectiveness of re-irce allocation throughout the health care system. Moreover, because medical colleges constitute the peak of the medical hierarchy, the standards of professional ethics, skills and medical research that they uphold exert a profound influence on the entire medical community. In light of this effect, this paper examines the back- ground anid current status of medical education in China,.including plans for -medical manpower development and subject area focus.- It also discusses both subject and systems problems and issues in medical education, including gaps in the knowledge base, didactic. teaching and insufficient attention to health impact.of medical education. This paper is Supplementary Paper Number 6 to World Bank Report No. 4664-CHA, "The Health Sector in China." Prepared by John R. Evans Chairman, Allelix, Inc. and Consultant to the Population, Health and Nutrition Department August 1983 Contents Contents.............................,............ .. ...... .1. Int oduction1.....................................0.*........... 2. Background................................................... 3 3. MOPH Plans for Medical Manpower Development.................. 7 4. Problems and Issues in Medical Education..................... 15 5. Conclusion.......... ............ 26 Tables MEDICAL EDUCATION IN CHINA 1. Introduction Expenditures on physicians' salaries accounted for only about 5.6 percent of total health care expenditures in China in 1981, but this percentage greatly understates the influence of physicians on health policy and expenditure. At the upper levels of the health care system, physicians are principally responsible for presenting professional views on the magnitude and type of investments to be made in hospitals, and medical equipment, and on priorities for public health. At the lower levels, the day-to-day decisions of physicians concerning drug utilization, hospital admission and discharge, and referral help to determine the total resources 2equired by the health care system and their allocation among different uses as well as the outcome for the patient. Beyond this, by providing a model for lower-level practitioners, such as assistant doctors and barefoot doctors, the senior physicians further influence resource allocation. Senior physicians therefore exert an influence on the cost of health care and its benefits far out of proportion to the resources allocated for their salaries. 1/ Given the importance of the physician's decision-making role, a central question for health policy is that of how to improve this decision- making. The institutional environment of the physician will influence his decisions --. through its system of rewards and penalties for the physician, through the constraints imposed by drug and hospital prices and patient 1/ This is true even in industrialized market economies where physicians salaries account for a much higher fraction of health care costs. -2- insurance and willingness to pay, and through the system of professional standards. But the physician's previous education, and his opportunity and capacity to continue his education, also influence decisions. The medical the graduate who has learned only about advanced hospital procedures will lack training to perform effectively in a rural community, and, more important, will lack the scientific background necessary for informed decision-making concerning the allocation of health care resources in such a community. For these reasons the quality of training provided by medical colleges greatly influences the effectiveness of resource allocation throughout the health care system. Moreover, because the medical colleges constitute the peak of the medical hierarchy, the standards ,of professional ethics, professional skills and medical research that they uphold exert a profound influence on. -the entire medical community. Successes of the past decades have altered the epidemiological profile of China dramatically. It is important that the medical colleges should adapt their teaching to the resulting.changing pattern of needs. In particular, they will need to provide the leadership required for progressing effectively with management of chronic disease in the population as a whole, with optimizing child development and with facilitating the improvement of health care in poorer parts of the country. Alternatively, if the scientific capacities of the colleges are misdirected toward refinement of narrow points of biological science, or toward advances in high-cost tertiary care, investments in the medical .colleges will become irrelevant to improving the scientific basis for improving the health of the Chinese people. The nature of the reconstruction of medical education in the post-Cultural Revolution years will likely determine the constructive potential of the medical colleges for decades to come. -3- 2. Background There are now 116 medical colleges and faculties in China, and altogether they enroll about 30,000 new students each year. Table 1 1/ lists these colleges by province, and Table 2 provides information on numbers of institutions, enrollments and graduates in the period 1977-81. The MOPH administers 13 colleges, provincial health and education bureaus administer 99 colleges, and specific ministries such as those for railways, metallurgy and coal mining administer seven colleges. Four of the provincial colleges are faculties of wester4 medicine within general universities; the remainder are independent medical colleges. Three new provinci.al Medical colleges have not yet accepted students. The training programs, except for pharmacy, are generally for six years in the MOPH-directed colleges, and for five years in most of the other colleges. The Capital Medical College, formerly Peking Union Medical College, is a key MOPH college: its course in medicine lasts eight years, of which two-and-a-half years are devoted to premedical studies at Beijing University. The Jinan University Medical School in Guangzhou, a provincial medical college founded in 1978, offers a six-year course, and admits mainly overseas Chinese students. About 20 percent of the new students enrolled each year enter the 24 medical colleges which offer three-year ,courses. mos of whch ae Secondary medical schools upgraded during the Cultural Revolution. The Army also operates four medical colleges, but these colleges and their students are not included in the enrollment figures. 1/ During 1982 the MOPH decided to eliminate the 3-year medical curriculum and to provide training for a minimum of five years. This decision will be implemented in the course of the next few years. The'eges administered- directly by the MOPH include most of the strongest colleges. Five colleges were designated as MOPH colleges before the Cultural Revolution: Beijing First, Shanghai First, Zhongshan and Sichuan Medical Colleges, and the Capital Medical College of China. After the Cultural Revolution, these five colleges and the Beijing College of Traditional Chinese Medicine -- des.ignated key medical colleges -- and seven other medical colleges were added to the group of MOPH directed "core" medical colleges (Wuhan, Xian, Hunan, Shandong and Baiquien medical colleges, Zhongguo (China) Medical.University and Gangzhou College of Traditie"Al Chinese Medicine). The core medical colleges are selected on the basis of the' strength of their teaching and research programs and the quality of academic staff. 1/ With the exception of Capital Medical College, the core medical colleges have large undergraduate enrollments; nonetheless, the faculty to student ratio is much more favorable at the professor and associate professor level than in the provincial medical colleges (Table 3). The core colleges, in particular the key colleges, have the strongest research programs, and train one-half of all the postgraduate, masters and doctoral candidates, the future teachers for the system. Five of the core colleges serve as regional training centers in five af the six geographic regions of China: Beijing First (north), Xian (northwest), Shanghai First (east), Sichuan (southwest) and Wuhan (south central); Harbin Provincial Medical College is the center for the northeast region. The MOPH, guided by its Bureau of Medical Education and Science, prepares manpower plans, determines enrollment, prescribes curricula and 1/ A number of provincial medical colleges also have relatively high quality staff and facilities, so quality does not appear to be the only criterion for inclusion in the core group. -5- prepares teaching materials. A State Council sub-committee of 30 physicians awards degrees on the basis of recommendations