Shortage of healthcare professionals in ChinaBMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i4860 (Published 22 September 2016) Cite this as: BMJ 2016;354:i4860
- Qing Wu, PhD student,
- Li Zhao, postgraduate student,
- Xu-Chun Ye, professor
- Correspondence to: Y Xu-Chun,
The global shortfall in healthcare workers will reach 12.9 million by 2035, according to the World Health Organization.1 In China, the shortage of healthcare professionals is even more acute. China Health Statistics Almanac and World Health Statistics estimate that China had only 0.43 paediatricians for every 1000 children in 2012, 0.14 general practitioners for every 1000 population in 2015, and 0.02 psychiatrists per 1000 population in 2014.2 3 4 Assuming no substantial increase, China is short of at least 200 000 paediatricians, 161 000 general practitioners, and 40 000 psychiatrists.3
China is also seriously short of nurses, with 2.05 nurses per 1000 population in 2013, well below the world average of 2.86.2 3 The turnover rate of nurses was roughly 10%-11% in 2015 and the turnover intention of nurses reached 57% according to the report on the development of Chinese medical and health services.5
Why is there such a shortage of key healthcare professionals in China? Firstly, the demand for health services in China has far outstripped supply. Demand has increased substantially in parallel with improvements in living standards, better health awareness, and increased health insurance coverage. Although the number of medical institutions, physicians, and nurses increased by 15%, 40%, and 113%, respectively, from 2004 to 2013,3 growth in the number of healthcare professionals lags far behind the increase in demand for services. During the same decade, total visits to medical institutions increased from 3.99 billion to 7.3 billion, and the number of hospital admissions rose from 46.7 million to 140 million (increases of 83% and 200%, respectively).3
Demand may increase further in the next few years because of population ageing and the introduction in 2015 of a universal two child policy.6 The proportion of people aged 60 or above, a population at high risk of chronic disease and multimorbidity, is forecast to exceed 30% by 2050.7 The two child policy may increase demand for maternity and paediatric services.
The shortages are exacerbated by a high turnover intention of staff caused by heavy workloads, deteriorating doctor-patient relationships, and a resulting increase in work related stress. The uneven distribution of medical resources and the weak role of primary care mean that patients are increasingly presenting to large hospitals, raising the burden in secondary care. Excessive or defensive care may also contribute to heavy workload. Clinical work as well as research requirements in tertiary hospitals and low salaries and poor career prospects in primary care contribute to work related stress.
Violence against health professionals contributes to staff dissatisfaction.8 Healthcare professionals are reported to have been threatened and assaulted by patients or their relatives while working in hospitals. Perhaps unsurprisingly, a survey by the Chinese Hospital Association showed that 39.8% of medical staff intended to switch jobs in 2012.9
Expansion of medical education since 1998 has had a limited effect on the workforce, and there’s some evidence that expansion may have diluted the quality of graduates.10 Although the number of students taking the physician qualification examination has increased by 46%, the pass rate decreased by 32% between 2006 and 2015. The total number of successful candidates did not increase.11 Medicine is an increasingly unpopular choice of career among young people because of the high costs and length of training, and the risks of the job. Even those who graduate in medicine may choose not to enter the profession.
Urgent action is required to respond to the crisis in the healthcare workforce. The government should assess carefully the workforce needs of the population within the strategic perspective of universal health coverage. It should then develop effective and properly financed policies to meet those needs, including reforming payment systems to attract and maintain high quality healthcare staff, particularly in primary care. The government should also legislate to safeguard health workers’ legal rights and interests and to ensure safety at work. Some progress was made in 2015, when violence against medical staff became a criminal offence.12 But more needs to be done, starting with the responsibility of hospital managers to create a supportive working environment with the aim of increasing work satisfaction and improving staff retention.
Competing interests: We have read and understood BMJ policy on declaration of interests and declare that YX-C was supported by funds from the National Natural Science Foundation of China (71073169) and Shanghai Municipal Education Commission Innovation Fund (15ZS026).
Provenance and peer review: Not commissioned; externally peer reviewed.