Training sufficient and adequate general practitioners for universal health coverage in ChinaBMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3128 (Published 26 July 2018) Cite this as: BMJ 2018;362:k3128
- Yat-Hung Tam, clinical assistant professor,
- June Y Y Leung, clinical assistant professor,
- Michael Y Ni, clinical assistant professor,
- Dennis K M Ip, clinical associate professor,
- Gabriel M Leung, chair professor of public health medicine
- Correspondence to: J Y Y Leung
China introduced national health system reforms in 2009 with the aim of achieving universal health coverage by 2020, and to address growing inequalities in access to healthcare across urban and rural areas.12 Strengthening primary healthcare is considered essential for universal health coverage, which is a key target of sustainable development goal 3 (SDG3) as it provides financial protection against catastrophic healthcare expenses and ensures accessibility to necessary health services.3
The reforms have achieved substantial progress in service delivery, including nearly universal insurance coverage.2 However, China now faces rapidly rising health needs associated with population ageing, with chronic diseases already accounting for over 80% of all deaths.4 China’s health system also remains hospital centric, resulting in spiralling health expenditure.4Figure 1 summarises how a shift to primary healthcare could help achieve universal coverage and meet health needs, specifically by emphasising disease prevention and a person centred approach.5 Through gatekeeping, primary healthcare also has the potential to achieve long term health savings equivalent to 3% of gross domestic product.4
Growing the primary care workforce
China is the world’s largest producer of medical graduates yet faces a critical shortage of qualified general practitioners (GPs), particularly in rural areas.67 In cities, primary care is mostly provided by licensed doctors at community health centres and hospitals; in rural areas, many practitioners at township or village clinics resemble “barefoot doctors” with less formal training.6
Higher education reforms in the 1990s boosted the quality of schools and increased student enrolment.6 Nevertheless, the medical education system has since developed considerable heterogeneities in curriculums.8 Moreover, many medical graduates are now forgoing clinical practice, perhaps because of the relatively low social standing of doctors, escalating violence against healthcare workers, and increasingly appealing alternatives in other health related industries.7 Specialists also outnumber GPs because they are paid more.4 The proportion of health professionals who work principally in primary care dropped from 40.5% to 34.6% between 2009 and 2014.9
China’s first GP training centre was established at Capital Medical University in Beijing in 1989 and Shanghai’s Zhongshan Hospital, affiliated with Fudan University, became the first centre accredited by the World Organization of Family Doctors (WONCA) in 2015.10 However, a systematic GP training system, and one that is large enough to fill the human resources gap, is not yet established.
Recognising the need to enhance primary healthcare, the Chinese government has set a national target of having two to three GPs per 10 000 population by 2020.11 To improve the training of qualified GPs, the Ministry of Education and Ministry of Health (now the National Health Commission) jointly promulgated a plan to standardise medical training under a new “5+3” framework in 2012.12 Under this structure, GPs have to do five years of undergraduate study followed by three years of standardised residency training, like doctors in other clinical specialties.1314 Provincial governments were instructed to formulate their own implementation plans and expected to roll out the training programme by 2015.1516
We analysed progress in the implementation of 5+3 and explored potential challenges in achieving the intended progress towards more widespread primary healthcare services. We reviewed official documents and published reports of relevant government ministries, conducted a systematic online search of the formal and grey literature in English and Chinese (see appendix in supplementary file), and consulted key informants in government ministries and medical schools across China. The supplementary appendix gives the details of our methods.
Wide diversity of training pathways
China has 280 “medical-pharmaceutical” universities, of which 175 offer medical degree programmes, including the five year bachelor of medicine, seven year masters, and eight year doctoral degrees.1718 In addition, 214 universities or higher vocational schools offer a three year diploma programme that trains “assistant GPs,” who usually work in rural areas after graduation.171920 Postgraduate qualifications can be professional or academic.21 Professional degrees focus on training clinical skills, whereas academic degrees focus on research skills. Bachelor of medicine graduates can choose to enter residency training or pursue a 2-3 year master of clinical medicine followed by a three year doctorate.21 Residency training became mandatory and standardised in 2015. It consists of two stages: stage 1 comprises two to three years of rotations in general medicine or surgery, and stage 2 comprises two to three years of further specialty or subspecialty training.1721 Trainees may apply for the masters and doctorate courses after completing stages 1 and 2, respectively.21 The eight year doctorate of clinical medicine programmes for high school graduates remain the most competitive nationally.
Figure 2 summarises these different training pathways for GPs. Trainees are required to rotate through various clinical specialties for at least 33 months, including six months at grassroots healthcare institutions.22 Masters programmes that allow for simultaneous completion of the standardised residency training within the three year curriculum are known as “double track” programmes. Several medical schools now offer 5+3 masters programmes focusing on GP training. For international comparison, figure 3 shows the undergraduate and postgraduate training pathways in different jurisdictions.
Effects on pre-existing programmes
The schools we studied all implemented changes to adapt to 5+3 by 2015. The nature and extent of the changes were largely determined by the institution’s previous training courses. Some schools offering eight year doctorate programmes have simply incorporated the three year standardised residency training within their programmes. For double track masters programmes to comply with the standardised residency training, clinical rotations must be lengthened to 33 months, with course work and thesis writing reduced to three months. This has created logistical difficulties of ensuring that all prerequisite courses can be sufficiently covered.
Disconnect between academia and training sites
Postgraduate GP training involves both medical schools and clinical training institutions, which have separate administrative structures. Medical schools confer postgraduate degrees but have little control over the content or quality of residency training, which is overseen by training institutions including hospitals and grassroots healthcare institutions. Postgraduate qualifications are closely linked to career progression. Entry into postgraduate degree programmes is thus highly competitive. Training at institutions not affiliated with medical schools may not be recognised as meeting the requirements of the masters degree and is therefore less attractive to prospective trainees. Specific concerns regarding the uneasy relation between academia and healthcare institutions are highlighted in the appendix.
Insufficient training resources
Training hospitals are accredited by local experts appointed by provincial health commissions, and are ultimately approved by the National Health Commission.17 However, only top tier (3A) hospitals (comprising 13% of all hospitals) are allowed to serve as national training hospitals,23 and general practices based in tertiary centres are hardly ideal to provide realistic community based training. Furthermore, only four of the 11 schools we studied had designated clinical departments for GP training. Given this is the first generation of GP trainers, some are not GP specialists themselves, and they are generally not required to undertake specific training.
Generally, performance evaluation of GP trainees is based on continuous assessment by individual trainers, formative and summative examinations administered by individual training institutions, and final examinations organised by the provincial health commissions. Although the National Health Commission has established national assessment standards, the format and content can vary substantially between institutions. For example, each school we studied still had its own written examination, although the Chinese Medical Doctor Association is leading an intense drive for national standardisation.24 In contrast, nationwide specialty boards or colleges administer standardised specialist examinations in many Western countries and in Hong Kong Special Administrative Region.25262728
Mismatch of supply and demand for training
Admission quotas for postgraduate degrees and residency training programmes are determined by the Ministry of Education and National Health Commission, respectively. However, enrolment into masters programmes is often determined solely by medical schools without involvement of the actual training sites. Although 87 000 to 92 000 graduates compete for 50 000 training positions across all specialties each year,6 GP training positions are generally not filled; this is despite the relatively small number of positions on offer (<10% of all positions) and may be because of poor career prospects. The number of GPs almost doubled between 2012 and 2016, reaching 1.5 per 10 000 population by January 2018,29 but it falls short of the 2020 target of two to three GPs per 10 000 population.
China has no unified regulatory and financing system focused on producing the founder cohort of formally trained GPs. A harmonised regulatory environment would lead to policy coherence internally and clarity externally. Multiple disconnects between policy areas, not commonly seen elsewhere, make it difficult to fully realise the 5+3 directive.
Specifically, the currency that a masters or doctorate in clinical medicine carries in terms of professional career advancement, almost regardless of whether the candidate has had formal residency training, is unusual compared with other jurisdictions. In addition, degree granting universities have little influence over the hospital based training that is required as part of the degrees. We suggest that a government designated agency, akin to a national “specialty board” of GPs, be established to provide an academic lead for the development of university and clinical departments for GP training. Moreover, as in many other jurisdictions, accreditation of training programmes by an independent agency may promote quality and consistency of training across institutions. The Expert Committee for Education and Training of General Practitioners was established in 2016 but it is too early to see its influence.
Financing is often a strong lever to drive policy coherence and has almost immediate effect. Many international examples show how the funding of residency posts can align institutional objectives of different stakeholders, particularly across the education and health sectors. We suggest that a new national budget should be earmarked specifically for GP training. This would shift the locus of control to give more centralised coordination. Furthermore, if such funds were disbursed through medical schools, or perhaps UK style postgraduate deaneries,30 they would have more say in determining the content and quality of training at the clinical sites.
The present income differential between hospital based specialists and GPs is a strong deterrent to aspiring GP trainees. It must be urgently redressed through financial incentives31 that would be comparable to those for specialist consultants, whose income potential has risen substantially with the exponential growth of “special need services” (ie, private patients) within public hospitals and “multisite practice” that allows for private “moonlighting.” For instance, a generously funded capitation scheme with quality and volume weighted bonuses might be considered, similar to the many experiments in the UK and Canada in the past decade.
One area we did not discuss but which is critical to the equity ethos of universal health coverage and SDG3 is one of scale and population coverage. However successful the 5+3 rollout may become, it is unlikely China would be able to satisfy its target number of GPs by relying solely on medical graduates. This is exacerbated by the diminishing appeal of medicine as a vocation. Even in advanced Western economies, physician assistants and nurse practitioners have long been key parts of the primary healthcare team. In China, assistant GPs would be an important resource towards ensuring access to good primary healthcare, especially in rural areas. Therefore equal, if not greater, emphasis should be placed on the training of assistant GPs through the 3+2 programme,3233 in which high school leavers have three years of basic training followed by two years of supervised postgraduate training, with a direct view of providing for the rural population.
Ultimately, the goal of realising universal health coverage requires effective implementation of more fundamental health system reforms. The current emphasis on hospital based care must shift to primary healthcare, which is best delivered in the community. The Healthy China 2030 Plan for health system reforms and a recent directive issued by the Chinese government prioritise primary healthcare and the training of GPs by enhancing incentives for trainees,3134 which are important steps forward. Nonetheless, the concept of general practice remains weak among the general public; many patients prefer to seek care at hospitals, mostly because of a lack of confidence in the quality of care provided by primary healthcare facilities.35 This highlights the importance of defining and promoting the precise role of GPs as gatekeepers to the health system.36
An adequate and well functioning primary healthcare workforce is essential for universal health coverage and to meet China’s growing health needs from population ageing
Current challenges for recruiting and training sufficient GPs in China include the lack of training bases, qualified trainers, a national GP residency matching system, as well as uncertain career prospects
A unified regulatory and financing system for GP training, in addition to targeted, facilitative policies to incentivise potential GPs, trainers, and training institutions are needed
The training of other primary healthcare providers, such as assistant GPs, is equally important to achieve universal coverage
We thank the China Medical Board for funding this study; government officials, academics, and medical students who were interviewed; KK Cheng (University of Birmingham and Peking University Health Sciences Center) and Donald Li (Hong Kong Academy of Medicine and WONCA) who provided sources and references; and Jessica YW Kwan, Yvonne Y Ng, Wey-Wen Lim, Zoe J Xiao, and Betty Y Yuan for assisting in data collection, analysis, and presentation.
Contributors and sources This article is a summary of a landscaping assessment of China’s postgraduate primary care medical training under the new “5+3” framework commissioned by the China Medical Board. YHT, JYYL, and MYN are clinical assistant professors at the School of Public Health, The University of Hong Kong. DKMI is clinical associate professor at the School of Public Health, the University of Hong Kong. GML is dean of medicine and chair professor of public health medicine at the University of Hong Kong. YHT, JYYL, MYN, and DKMI acquired, analysed, and interpreted the data for the study. GML conceived of, designed, and secured funding for the study. YHT, JYYL, and GML drafted the manuscript, and MYN and DKMI revised the manuscript critically for important intellectual content. All authors approve of the final version of the manuscript for publication and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. YHT is the guarantor of the study.
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Not commissioned; externally peer reviewed.