Medical education in China

PHN Technical Notes GEN 15 THE WORLD BANK MEDICAL EDUCATION IN CHINA August 1983 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. 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 graduate who has learned only about advanced hospital procedures will lack the 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 by the academic committees of the medical colleges. The Ministry of Education is responsible for the educational programs of the medical colleges, for authorizing new specialties in undergraduate training, and for assigning graduates, on the basis of recommendations by the MOPH. Similarly, at the provincial level, each provincial health bureau has a division of medical education and research which submits programs for medical colleges, hospitals and research institutes to the provincial bureaus of higher education and health. Table 4 compares the distribution of teaching in medical colleges with that in secondary medical schools. The curriculum in both,closely resembles that of medical schools in Europe and North America in the 1950s and 1960s. The dominant objective is the transfer of knowledge, the approach is didactic, the subject-matter is organized by discipline, and all students follow the same course of study. To graduate, students must pass examinations set by their own college. A national examination was tested experimentally in November.1982.. Since 1979,.graduates of medical colleges have been awarded the Bachelor of Medicine degree. In 1980, the total budget of 13 core medical colleges amounted to Y180 million, including about more than Y60 million for operating costs (at the rate of Y2,200 per student, excluding lodging costs), more than Y80 -6- million for the operating costs of affiliated teaching hospitals, and more 1/ than Y30 million for construction (see Table 5). At the national level, the Advisory Committee on Medical Sciences reviews the research programs of the colleges and evaluates the results. More than 1200 leading medical scientists and practitioners serve on its 47 sub- committees for particular subjects. The committee reports to the MOPH, which also provides funds for the Chinese Academy of Medical Sciences, which comprises 21 institutes and four hospitals specializing in various branches.of western medicine, and for the Chinese Academy of Traditional Medicine, which has four institutes and two hospitals of Traditional Chinese Medicine. In addition to conducting research on basic. and cliiical. problems, the institutes also provide technical guidance to the medical colleges and affiliated hospitals of the provinces, municipalities and autonomous regions. The institutes receive a block grant budget equivalent to Y3,600 per staff member,' all operating expenses (including hospital operations),' and special appropriations for capital development. MOPH-directed medical colleges, provincial medical colleges, affiliated hospitals,.and research institutes may also apply for support of research projects from an MOPH fund, currently Y8 million per annum. In addition, provincial and industrial authorities contract for specific research tasks with appropriate institutions. 1/ Expenditures per student per year in non-medical colleges are approximately 1250 yuan, and in provincial medical colleges they are probably also about that amount. An accompanying paper estimates that about 150 million yuan per year is spent on medical education in China, which is about 3% of total health sector expenditures. (See N. Prescott and D. Jamison, "Health Sector Finance and Expenditures in China," Supplementary Paper Number 5, The Health Sector in China, The World Bank, 1983.) -7- 3. MOPH Plans for Medical Manpower Development The MOPH estimates that the number of senior doctors (western and traditional) is currently 0.8 per 1,000 population, and that this ratio can be maintained during the 1980s without increasing medical college enrollment beyond the current level of about 30,000 new admissions each year. Projections of the output of graduates from the medical colleges in 1982, 1985, and 1990 are given in Table 6. 1/ Total enrollment is not expected to increase during this period, although it is planned to increase .enrollment in the 1990s in order to achieve a senior doctor to population ratio of 1:1,000. 2/ In the 1980s, priority will be given to consolidation rather than growth, improving the quality of.education and research, retraining staff to repair the damage of the Cultural Revolution, and building up teaching and research staff through postgraduate training. The 37 medical colleges established before 1960 have reaso:nably good basic facilities and senior staff, but require new equipment and retraining for staff. The colleges established after 1960 have poor buildings and equipment and weak staff, and require total redevelopment. The combination of redevelopment ard upgrading will place heavy demands on the health education budget during ,the decade. 1/ The projections for medical college graduates in Table 6 (and for secondary medical schools in Table 7) were supplied to the mission by the MOPE. It is not clear whether these projections were made in the normal course of planning, or whether they are ad hoc estimates prepared in response to the mission's request. 2/ Specifically, assuming the medical college enrollment plans indicated in Table 6, that 2.5 percent of doctors leave practice each year, and that the population in 2000 is 1.2 billion, the ratio of 0.8 per thousand will not have changed. Meeting a target of 1 per thousand, indicated as desirable by Ministry officials, would require increasing medical college output by 12,000 per year to over 40,000, or increasing the rate of upgrading of assistant doctors. -8- College teachers and senior hospital doctors will be retrained at national training centers established in the core medical colleges. Other strong medical colleges and affiliated hospitals will share in this task. Inc addition, about 100 medical college staff able to speak a foreign language are now selected each year for training abroad. Medical College Development - Subject Area Plans Western Medicine. There are. 92 faculties of western medicine in the medical college:s, and three new faculties are being established. The MOPH expects a 13 percent decrease in graduates 'between 1982 and. 1985, but an increase of about 10 percent by 1990. In addition to regulaz enrollment, these faculties have the heavy burden of retraining the large number of doctors who graduated during the Cultural Revolution. Public Health. Many piblic health doctors switched to medicine during the Cultural Revolution. In order to rectify the shortage, it will be necessary to increase the .number of public health graduates from medical colleges by 10 percent by 1985 and by 50 percent by 1990. The increase will be achieved in two ways: first, by upgrading assistant doctors of public health by further training, and second, by increasing enrollment in existing faculties of public health in medical colleges. Current enrollment in 'thi 24 medical colleges with faculties of public health is about 1500 new studebnts each year. Little attention seems, however, to have been given to the need for changes in the training of public health personnel (and the role of the epidemic prevention stations) now that infectious diseases are giving way to chronic diseases, which require quite different preventive measures, as principal causes of morbidity and mortality. -9- Pediatrics. Ten medical colleges have separate programs of undergraduate training in pediatrics. The number of graduates is small, and a small increase is proposed in the existing faculties by 1990 (Table 6). No new faculties of pediatrics are proposed, and consideration is being given to providing training in pediatrics as a postgraduate specialty, and,through continuing education, rather than as a separate undergraduate specialty. Traditional Medicine (TM). There are 33 faculties of TM, 24 in separate colleges of TM, and nine in medical colleges that also offer training in western medical specialties. All emphasize traditional Chinese medicine, although secondary medical schools offer training in other kinds of traditional medicine. The expected output of graduates (4,388 in.1982) will be insufficient to maintain the current number of senior doctors of TM in practice. There are no plans, however, to expand enrollment or establish new faculties, and priority will be given to improving the scientific capability of teaching staff and promoting research in TM. The cornerstone of TM is traditional Chinese drugs, which are very widely used. The extraction of the active ingredients from medicinal herbs and demonstration of pharmacological characteristics and,clinical efficacy provide an important field for research. Colleges of TI also train traditional Chinese pharmacists in a four-year program, and some colleges offer courses in acupuncture and massage. In keeping with the principle of complementarity of western and traditional Chinese medicine, western medical students receive about 140 hours of instruction in TM, and one-third of the curriculum for TM students deals with the basic sciences, clinical techniques, laboratory methods, and pharmacology of western medicine. A few practitioners are fully trained in both western and traditional Chinese medicine. - 10 - Stomatologists. Stomatologists are in short supply, and the MOPH plans to increase the medical college output by 50 percent by 1985 and by 100 percent by .1990 in order to improve the ratio of stomatologists to population from 1:150,000 to 1:70-80,000. Stomatology is offered as a separate undergraduate program of six years duration in five MOPH medical colleges, and of four or five years duration in 13 other colleges. Pharmacy. Some medical colleges offer a four-year undergraduate program in western pharmacy. There are no plans to expand enrollment or add new faculties of pharmacy. New Programs. New responsibilities proposed for the medical colleges include the training of senior level nurses in management. It is estimated that 310,000 people are engaged in management and administration of health services. Approximately 60 percent are graduates of medical colleges or secondary medical schools. They will be offered a three- to six-month refresher course at one of the medical colleges designated as a national training center. 1/ For the 40 percent with no formal administrative or health training, a three-year formal course will be provided for many of those under 35. In nursing, it is.proposed to establish high-level courses at selected NiOPH and provincial medical colleges to train leaders for nursing education and nursing service. Other fields identified for future attention are nutrition, food hygiene and clinical laboratory services. 1/ The MOPH has established six management training centers to serve the six major geographical areas of the country plus a center at Beijing College of Traditional,Chinese Medicine. Five of the six training centers are at core colleges; the sixth, serving the northeast region, is at Harbin Medical College. -11 - Medical College Development - Plans for Serving New Categories of Students Retraining. Special "aid courses" have been established for the more than 160,000 doctors who graduated during the Cultural Revolution. About one- third of those undergoing retraining take full-time courses, emphasizing pre- medical and basic medical science, over a period of one-and-a-half to two years. The remainder receive part-time instruction while continuing their work in hospitals, epidemic prevention stations, research institutes and governmental bureaus. The part-time program, which takes four to five years to complete, consists of. two afternoon or evening courses per week in the basic medical sciences, of.ten offered on television in big cities. Participants in both full-time and part-time retraining programs are given the title of Visiting Doctor after passing the final examinations, but do not receive the Bachelor of Medicine degree now given to regular graduates of the five-year medical colleges. Postgraduate Education. In order to improve the qualifications of teaching and research staff and to train new staff for the medical colleges, many medical colleges and research institutes offer courses for the degrees of master and doctor of medicine. About 2,000 students are enrolled in these programs, almost entirely-at the masters level. The Master of Medicine course lasts three years. The Doctor of Medicine degree requires two to three years of additional full-time study and a thesis. The eligibility of medical colleges to train graduate students in particular disciplines and the number of students enrolled are determined by the MOPH for selected disciplines on the basis of the quality of the teaching staff and the research achievements at the colleges. -12- Clihical Specialty Training. The MOPH has also designated 200 sites for advanced three-year courses in the clinical specialties of western medicine. The Ministry determines the number of trainees and the hospitals from which they will come and monitors the the programs. The MOPH provides operating support to the affiliated hospitals (Y750 per year per postgraduate trainee), and capital investment in facilities, equipment, and libraries for the training sites. Half of the per capita support is provided by the hospital which sends the postgraduate trainee, except in the case of minority nationalities, where the.full amount is paid by the MOPH. Candidates for spLcialty training must have had at least three years, of postgraduate clinical experience. Upon completion of training, the individual returns to the hospital from-which he or she was noininated. There are no specialty examinations. Continuing Education. Continuing education offered by medical colleges and affiliated hospitals includes short refresher courses for health personnel at all levels, exchanges of staff between teaching and non-teaching hospitals for a period of up to one year, visits by teams to municipal, prefecture and county hospitals, and workshops on subjects of special interest to the staff of medical colleges in the region. The continuing education of barefoot doctors and of the family health care workers of the commune health system is the responsibility of the training center, hospitals, epidemic prevention station and maternal and child health station at the county level, at which assistant doctors, nurses and technicians from the secondary medical schools also serve their clinical internships. It is therefore at county level that the outreach from the medical college continuing education network influences the quality of clinical training of intermediate and-lower-level health workers. - 13 - Plans for S.econdary Medical Schools Since 1949 secondary medical schools have produced 947,000 graduates. There are now 556 secondary medical schools, which enroll approximately 60,000 students each year in ten specialty courses. Half of the students are trained, as nurses. The other main courses are for assistant doctors in western medicine, public health, maternal and child health and traditional Chinese medicine, assistant stomatologists, assistant pharmacists, midwives, radiographers, and laboratory technicians. The students are usually graduates of junior middle schools in the region, but graduates of senior middle schools increasingly enter secondary medical schools if they fail to be admitted to a university. The courses include 'two to three years of academic work and a year of clinical internship, often iri county health and hospital facilities (see Table 2). Since 1980, secondary medical school-trained assistant doctors may be promoted to senior doctors on the basis of five or more years of experience, in-service training including television courses, and by passing a qualifying examination. It has been estimated that up to 20 percent of assistant doctors may have become senior doctors in this way. The number of graduates expected from the secondary medical school programs are listed in Table 7. Comparison of data for 1982 and 1985 is misleading, since the 1982 graduating classes are unusually large because in 1979 both health manpower needs and the resources of the medical schools to cope with expanded enrollment were overestimated. In nursing, it is planned to increase the number of graduates up to 1990, in particular to meet the needs of urban areas. It has been decided to reduce the numbers of assistant doctors of western medicine and traditional Chinese medicine to be trained because their - 14 - principal employers, commune health centers, are often unable to pay for more assistant doctors, and higher-level health services prefer to employ senior doctors. Consequently, the number of ,graduates in 1985 will be reduced to one-half of the 1982 output for assistant western doctors,,and to one-eighth for assistant doctors of traditional Chinese medicine. By 1990, the output of both will be raised but, in the case of assistant traditional Chinese medicine doctors, to less than half the current level. More assistant doctors of public health are needed, and output in 1990 is expected to be twice that in 1985. Plans to double the output of assistant stomatologists by .1985 and achieve a further 50 percent increase by 1990 r4flects the extreme shortage of upper- and middle-level dental personnel. The training of radiographers, laboratory technicians and pharmacy assistants will continue to be an important function of the secondary medical schools. In spite of the major changes in enrollment, there is no plan to alter the number of secondary medical schools. Their dispersed geographic distribution makes then readily available to students from rural:areas. 1/ The importance of assistant doctors and other middle-level health personnel in rural areas is illustrated by the facts that urban areas have a ratio of salaried health personnel to population of 8:1,000, and about 30 percent are senior doctors, while the corresponding ratio for rural areas is 2:1,000, 13 percent being senior doctors. The proportion of senior doctors to 1/ Qualitative improvement in secondary medical education may well be more important than quantitative expansion. World Bank education missions to China have observed that, of all the various types of vocationally- specific secondary education, that in health related fields appears to be weakest. -15 - population in rural areas is therefore only about one-tenth of that in urban areas. Since a higher proportion of the senior doctors in rural areas are upgraded assistant doctors or doctors of Chinese medicine than in urban areas, the problem of maintaining comparable standards of medical care for the population served by commune health centers can be readily appreciated. 4. Problems and Issues in Medical Education Considering the disruption caused by the Cultural Revolution and the limited resources available, remarkable progress has been made in the past -five years in restoring a sound training program. Nonetheless, important problems, mainly of a qualitative kind, remain to be addressed. Gaps in knowledge base. Certain subjects, for example, molecular, genetics, immunology and virology, the social and behavioral sciences, child development, gerontology and rehabilitation have received little attention in China. Epidemiology is narrowly linked to infectious disease, although they have recently been separated in some centers. Pharmacology is backward considering the importance of western and traditional Chinese drugs in medical care. The teaching of public health and preventive medicine are dominated by environmental considerations,, and, infectious diseases, and does not take sufficient account of the diminishing importance of infectious disease. In contrast. advanced epidemiological research in cardiovascular diseases and cancer is being conductehd in the national research institutes. Didactic teaching. Teaching is almost entirely didactic with limited scope for individual learning, elective courses, problem-oriented learning and other techniques which stimulate active student participation in the educational process. -16- Overemphasis on complex equipment. Some medical college teachers overrate the importance of very expensive and complex scientific equipment for undergraduate teaching. Most existing laboratory apparatus is outdated and cumbersome. More basic equipment is certainly required, but students will gain more from an understanding of scientific method, biological variation, observer error and principles of biological behavior than from working with expensive and complex equipment. Shortage of learning aids. Learning aids for students are in short supply, but.even the limited assortment of,books and journals in the libraries does not seem to be used for reference by undergraduates. Stude.nts.use the. library to study the standard text prepared for each course. Prices prohibit students from purchasing reference and foreign language books for their own use, and facilities for 'photocopying are .inaccessible. Anatomical and pathological specimens are of good quality but are not correlated with case histories and radiographs. Some schools are well supplied with audio-visual equipment, but it is not always used effectively by teachers. Lectures are given to classes of 200,students .or more, and improved/projection facilities are needed. The quality of film animation and video material is good, but there is little production of independent learning materials and no slide-tape machines available for individual student use. The training of teaching staff to make the best possible use of resources is as important as the provision of new equipment. Lack of information processing capacity. Information processing is largely manual. The shortage of computers limits their use to research work, and students have no opportunity to learn modern information handling techniques. -17- Modern objectives of medical education not reflected in teaching program. The teaching program is not organized in relation to the objectives of modern medical education. There is limited communication between departments, considerable duplication of course content and little correlation between pre-clinical and clinical teaching. The probable response to the current explosion of, medical information will be an increase in teaching hours, the addition of new courses and the lengthening of the curriculum in order to achieve maximum content. Other ways of dealing with this problem should be considered. This will require faculty-wide cooperation in setting objectives, establishing priorities, reducing duplication, adapting to a c-onstantly changing body of medical knowledge, and improving techniques of both teaching and learning. Some medical colleges have established educational units that could assist faculties in addressing this problem. Overemphasis on narrowly applicable subjects; underemphasis on science of population-based medicine. Preoccupation with technological advances in molecular science and sophisticated diagnostic and therapeutic methods overshadows other important sub jects that can contribute more to the improvement of health and the effective use of limited*resources. (These other sciences include biostatistics, epidemiology, population-based sciences and the evaluation of the efficacy of clinical and public health techniques. Insufficient attention to health impact of medical education. Most medical colleges are attempting to advance simultaneously on many fronts, and the authorities seem to be reluctant to single out one or two colleges to provide leadership in such special fields as automated cataloguing, search and retrieval of medical information, audio-visual aids, programmed instruction and independent learning resources and curriculum design in areas such as -18 - family planning, child behavior., nutrition, immunology, clinical pharmacology, geriatrics and management. Proliferation of weak graduate programs. 'The medical colleges are similarly trying to conduct too many post-graduate courses unrelated to projected manpower demands, and which are on too small a scale to permit the concentration of effort and resources necessary for programs of high quality. Institutional Issues for Medical Colleges Education ob5ectives and program planning. The medical colleges have many objectives: the training of doctors to provide community health care; the. training of future teachers, research scientists and :clinical leaders; and the enhancement of .the scientif ic and. prof essional status of their staff. Each of these objectives is important, but together they are in competition for limited resources, and it is necessary to strike a balance appropriate to the MOPH's priorities as a basis for the allocation of funds. Program definition is also necessary to achieve balance, for example, between molecular and population sciences, between the transmission of knowledge through didactic teaching and through student participation, and between a uniform curriculum and elective options. There is no single recipe to suit the needs of all the medtcvt olte"ges. It is Unlikety, hleve.C, th&t the aporapiate balance will be struck unless a faculty group acceptable to the individual departments is established to formulate educational objectives, to plan programs to reflect these objectives, and to evaluate how far the objectives are met. These objectives are not internal to each medical college. They mutt be based, in the first place, on the health needs of the population and the expected role of doctors and other health personnel in meeting these needs. - 19 - Examinations. A pilot national, multiple choice, computer-marked examination was introduced in a small number of medical colleges in 1982, with the intention of extending it subsequently to the entire system. There will be separate examinations in western medicine, traditional medicine, public health, pediatrics, stomatology and pharmacy. 1/ In view of the profound influence of degree examinations on the curriculum, teaching and the attitude of students, it is essential that such examinations reinforce instead of undermining the educational objectives of the colleges and the MOPH. In particular, the MOPH objective of orienting medical education towards the understanding of general principles and the development of problem-solving capacities has 'important implications for the design of examinations; examinations stressing. factual knowledge, for example, could defeat these objectives. It should be emphasized that the problem is not one of the use of multiple-choice format or computer scoring; both these techniques can be used with examinations that test grasp of principles and problem-solving skills. Coping with change in medical knowledge. As noted above, the information explosion creates intensive pressure to add new courses, extend. hours of instruction, and lengthen the course of study. Preparing doctors to cope with the rapidly changing body of medical knowledge is therefore an important -objective of the learning process which may be more important than much specialized content learning. This may be reflected by movixg -ro* a curriculum which is the same for all students to one which provides, for example, more opportunities for elective courses, independent study and problem-oriented learning. 1/ There is a separate examination for students seeking admission to postgraduate medical education. P - 20 - Strengthening preventive strategies for non-communicable diseases. Improvements in life expectancy, control of many common infectious diseases, the one-child family policy and other changes require new approaches to the teaching of preventive medicine and health. promotion in medicine, public health and pediatrics. These specialties are at an early stage of adapting their practices to the prevention of the common, serious non-communicable diseases such as hypertension, chronic obstructive pulmonary disease, cancer and heart disease; to the protection and optimal development of the child during both the antenatal and postnatal periods; and to the prevention of illness .and rehabilitation of the elderly. The current emphasis on strengthening laboratory sciences in medical colleges. and affiliated' hospitals may lead to the neglect of'coinumnity-based learning experiences, both in medicine and public health, as an important part of' training in these fields. Scientific evaluation capability and health systems research. The evaluation of new scientific methods and the effectiveness of new and traditional techniques of diagnosis and treatment is.everywhere assuming much greater importance because of the high_ cost of modern medical technology. Key medical colleges should develop evaluation capability, since they are commonly pioneers in introducing new medical techniques. The development of such capability within colleges of traditional medicine is of special importance in view of the different theoretical basis and professional sensitivity to external evaluation. Since this is a relatively new area of scientific research, seminars on design, measurement and evaluation may be of value to teaching staff and senior doctors as well as undergraduate and postgraduate students. Many of the principles are epidemiological, but have rot been more generally applied because of the tight coupling in the past of epidemiology with infectious diseases. It is important that these epidemiologieal - 21 - principles be extended not only to non-infecti6us diseases, but also to the comparative evaluation of disease control measures, and the quality of care and resource allocation in the health system, i.e. health systems research. This is .as important in clinical medicine, both western and traditional, as it is in public health. Management. The MOPH has recognized the importance of strengthening managerial and administrative capability, and three natiot al training centers, established by 1981, now offer programs in management and training. As previously indicated, the MOPH ultimately plans to have seven of these centers. In view of the task of upgrading more than 300,000 administrators, it is' of high priority to provide a greater number of well .qualified. teachers of health management and to expand training to prepare managers not only for routine administration, but also to use simple management information systems to assess health needs, to plan resource allocation, to monitor progress and to evaluate results. The training should encourage a more rigorous and analytic approach to the identification of problems and the design of programs. These skills are important at all levels of the health system, from the MOPH and provincial bureaus down to the county and commune levels. In addition, this type of training should be offered to senior administrators and departmental directors in medical colleges and affiliated hospitals, in view of their responsibilities for planning and managing education, research and health services. Manpower Issues Health manpower planning. There is need to strengthen the capacity to plan how different health personnel will be utilized, the Humber of -22- graduates needed, and the .appropriate type of training. The recent decision to maintain the current output of senior doctors of western medicine and traditional medicine, and to reduce correspondingly the number of assistant doctors, which does not seem to have taken account of the implications for rural areas of the number of assistant doctors, is an example of,the need to improve planning. Studies of health needs and the utiliation of existing categories of health personnel may lead to the revision of training programs, and may also help to avoid such unnecessary swings in enrollments as occurred in 1958 and again in 1977-79. At present it appears that fields chosen for advanced training may reflect the technical interests of the physicians being trained'(or providing training); it. is thus particularly important to base planning on health needs. Manpower 'planning capability is needed both in the MOPH and the, provinces. It should cover the health serv'ces of enterprises; since the labor insurance schemes spend one-and-one-third tiies as much on health services as the health bureaus and maintain parallel services at most levels. It should also cover the Ministry of Education because of its role in medical college and secondary medical school training. Public health and epidemic prevention. The training in medical colleges and secondary medical schools, and the service functions at all levels for public health and preventive medicine are separate from those for clinical medicine. The separate but parallel systems offered certain advantages when the chief task of preventive medicine and public health was control of infectious and parasitic diseases. While some infectious diseases persist as national problems (for example, dysentery, hepatitis and tuberculosis), the burden of illness has shifted markedly to non-infectious diseases, which require different primary and secondary preventive methods, - 23 - often closely linked to clinical care. In China, which has been so successful in modifying human behaviour through health campaigns, there is a unique opportunity to, introduce these methods. Several critical issues should be addressed. What preventive strategies are appropriate to China's epidemiological transition and social organization? What is the future role of '8te epidemic prevention stations? Should preventive and curative services continue as separate systems? What are the implications for the training of senior and assistant doctors of western medicine and public health? Should public health be a postgraduate clinical specialty of medicine, as is proposed for pediatrics? What - preventive methods should be adopted by traditioial'medicine? Traditional medicine. Traditional medicine has established an important place in- China's health services, and has been strongly endorsed politically. While almost all patients prefer western medicine for severe or acute conditions, many prefer traditional medicine for less serious problems and for chronic diseases where western medicine cannot offer a cure. It is a particularly important resource in rural areas, where traditional practitioners are almost as readily available as in urban areas. Western and traditional doctors are exposed in their medical training to information about the other system and, in most .hospitals, western and-traditional medical services and pharmacy coexist. Efforts. to integrate the two approaches have been unsatisfactory, particularly to practitionerp of 'raditional mediine, and current policy is to continue with separate;.paralll systems. One problem concerning traditional medicine is paiticularly relc-vant for medical colleges. As with Western medicine and traditional medicine in-' other countries, many of the practices of traditional medicine in Chi a may be of doubtful value, and many of the xema1dies have no more than a placebo ILI -24- f Some al herbs are almost dertaihly effective; short splint a'tion o one fractujes has been shown to(reduce both the duration 4of disL. 51 and acupuncture analgesi may be more useful than strn analgesia oranesthesia for some procedures. The problem is to sort t hich practice interventions are ef ficacious. EvaluationAis complicated by the lack of measurable parameters of successful treatment in many i s uýa',ons, and the f act tha the theoretical sis of traditional medicine trepå,is unsuppoted by experimäntal evidence. In such circumstances, the isults of evaluationmay be rejected because they challenge popular, progg na l r pblitical blief s. On groun"is öf efficacy and safety, and of efficient usé of limited resorces, it is imperative that both western and traditional ystems of" health care be sub jct b equally rigorous scrutiRy. •Unfortunately, the .scientific base to carry öUt the evaluation is much less well developed in fäcilties of traditiornal, medic4 e than in faculties of western medicine, and a bs ti4l investment will beequire< to develop internal evaluation dca? .ility. The eftert will be to no avail, howeverif the resuLts of evaluation ar.e rejected because of professional or political sensitivities. Assistant doctos, The futur of assistant doctors of western mediciié and traditional medicipe is not clear. The MOPH plans to train fewer n thes'e categories in the coming decade. There is a need foIr : senio level,doe òfes in the rural system, but it is likely that the assistant doctors wili t5ontinue to"$ä important at the commune level.- Furthermore, the prospect of quälifying for this grade provides ,primary health workers with an incentive to upgradà ýtheir skills. By a similar process, assistant doctors from secondary' dl, schools upgrade themselves to senior doctorg. Such mobility will in futur be facilitated by the higher general educational level of Sj v,1 -25- students entering secondary medical .schools, What are the implications for rural health, particularly in the poorer regions, of phasing down the training of assistant doctors in the secondary medical schools? Is there A case for at least sustaining and preferably improving these schools, particularly in regions which experience difficulty in attracting manpower for commune health services? System Impact On what grounds can additional investment in AOPH medical colleges be justified? These colleges are' already the strongest in the system, with more favorable faculty to student ratios, better equipment and facilities and better qualified staff and students than-most provincial Medical colleges. These colleges, however, are shouldering the responsibility for repairing the profound damage 62 the Cultural Revolution, and new investment in them is. designed to improve the quality, rather than the quantity of their output. The justification of such investment should be based on the impact on fhe quality of health care, including its affordability, in the' network of hospitals and health stations to which each medical college relates, and on the standards of .medical education in the provincial colleges in each region. Impact on health care. The need to restore teaching and research capability within the medical colleges may divert attention from continuing medical education and health system impact. Since continuing education is the most. immediate means by which the medical college can influence the quality of health care, it is one of the most important elements in the justification of investment in strengthening the core medical colleges. Several MOPH and provincial medical colleges have already established networks of ,continuing - 26 - education including courses, workshops, visiting teams and two-way temporary, exchange of senior staff with municipal and prefectural hospitals, and,from these institutions in turn with the county hospitals. It is not clear whether these programs also cover the substantial number of health personnel who work in enterprise health services (Table 2). The sprograms may further be strengthened by assessing what continuing education is needed at different levels and evaluating how well the programs meet these needs. Impact on provincial medical colleges. The comparative weakness of many provincial medical colleges is illustrated by the relatively high ratio of students to professors, and by the fact that about 20 percent of their students are still enrolled in three-year courses. The MOPH medical colleges already have a longer course- than the provincial colleges, are miore active in postgraduate training, and have stronger .research programs. It is important that these assets should be used to support and strengthen the provincial colleges, instead of simply offering a model for them to copy. Several key medical colleges have introduced upgrading courses for the staff of neighboring provincial medical colleges, and some have-established twinning arrangements to support .weaker colleges in remote areas.. It seems desirable for key medical colleges to survey at an early stage the needs of the provincial medical colleges in their region and develop collaboratively a plan to assist in meeting those needs. 5. Conclusion Medical education in China is rapidly recovering from the disruption of the Cultural Revolution. The patterns set by investment in redevelopment 'of the core medical colleges will shape medical education in the core colleges -27- for this decade, and in the provincial medical colleges for the 1990s as well. Beyond this, the example of these colleges -- in research, training and service -- could provide needed leadership in China's effort to address its newly emerging health problems. In selecting from among the options for upgrading the quality of medical education, it is important to determine how effective each is in meeting the most important objectives of the MOPH medical colleges, which include: (1) preparing medical graduates to deal with the changing health needs of the population within the technical and financial resources likely to prevail; -(2) supporting in-service education to improve the effectiveness of doctors and other health personnel; (3) evaluating the quality of health services, devising,innovative responses to changing needs, and to promote the more effective use of limited financial resources; and (4) preparing the, next generation of teachers, medical scientists and clinical leaders for the whole country. -The medical colleges see in expensive and complex equipment an important means of improving medical education. But the acquisition of soDhisticated equipment will have little positive benefit, and possibly negative effects, unless it is selected for carefully thought-out programs that support the major objectives of the MOP1. The prospect of significant investment challenges the medical colleges to define their objectives, to prepare programs to meet these objectives, and to decide how to execute these programs, taking into account the resources required. The clear setting of priorities and careful planning are necessary to ensure that new investments have maximum impact throughout the health care system and, ultimately, on the health of the population as a whole. Table COLLEGES OF MfEDICINE AND PHARMACY, BY PROVINCE, 1980 Provinces Medical Colleges forth Region Beijing ** Capital Medical College of China ** Beijing Medical College Beijing Second Medical College ** Beijing Traditional Medical College Beijing Military Medical College Tienjin Tienjin Medical College Tienjin Traditional Medical College Tienjin Medical Specialty School Hebei Chengde Medical Specialty School Hebei -Medical College (in,Shijiazhuang) Tangshan Medical College for the Coal Industry Zhan,gjiakou Medical Specialty School Shanxi. Shanxi ledical Coliege (in Taiyuan) Datong Nedijal College Jindorgnan (Shanxi Southeast) Medical Specialty College (in Changzhi) Nei Monggol Net Monggol Medical College (in Rahehot) Baotou Medical College Zhelimu Medical College -(in Tongliao) lortheast Region Liaoning * China Medical University (in Shenyang) Dalian Medical College (in Dalian) Liaoning Traditional Medical College (in Shenyang) Shenyang College of Phatmacy Jinzhou Medical College Shenyang Medical Specialty School Jilin * Bethune Medical College (in Changchun) Jilin Medical College (in Jilin) 2 Changchun Traditional Medical College Yanbian Medical College (in Yanji) Heilongjiang Harbin Medical University Heilongjiang Traditional Medical College (in Harbin) Jianmuxin Medical College Jijihar Medical Specialty School Mudanji4ng Medical Specialty School st Region Shanhti ** Shanghai First Medical College Shanghai Second Medical College Shanghai Traditional Medical College Shanghai Army Medical College Second Military Medical University Shanghai Railway Medical College J,angsu Nanjing Medical College Suzhou Medical College Nantong Medical College Xuzhou Medical College Nanjing Railway Medical College Nanjing College of Pharmacy Nanjing Traditional Medical College Yangzhou Medical Specialty School Zhenjiang Medical Specialty School Navy Medical School (Nanjing) Zhejiang Zhejiang Medical University (in Hangzhou) Zhejiang Traditional Medical College (in Hangzhou) Wenzhou Medical College Anhui Anhui Medical College (in Refei) Anhui Traditional Medical 'College (in Hefei) $engbUMedical College Wanan (Anhui South) Medical College (in Wuhu) Ftj ian Fuj.ian Medical University (in Fuzhou) Fujian Traditioial Medical College (in Fuzhou) Jiangxi Jiangxi Medical College (in Nanchang) Jiangxi Traditional Medical College (in Nanchang) Cannan (Jiangxi South).Medical Specialty School (in Ganzhou) Shandong Qingdao Medical College Shandong Medical College (in Jinan) Shandong Traditional Medical College (in Jinan) Changwei Medical College (in Weifang) Jining Medical Specialty School (in Jining) Yixue Medical Specialty School (in Yixue County) Heze Medical Specialty School (in Heze County) ntral South Region Hbnan Henan Medical College (in Zhengzhou) Henan Traditional Medical College (in Zhengzhou) Kaifeng Medical Specialty School Luoyang Medical Specialty School Yubei (Henan North) Medical Specialty School (in Ji County) Hubei Hubei Medical College (in Wuhan) Hubei Traditional Medical College (in Wuhan) Enzu Medical Specialty School (in Enzu County) Yichang Medical Specialty School * Wuhan Medical College Wuhan Medical Specialty School for the Metallurgical Industry Hunan * Hunan Medical College (in Changsha) Hunan Traditional Medical College (in Changsha) Hengyang Medical College Guangdong Guangdong Medical and Pharmaceutical College (in Guangzhou [Canton]) * Guangzhou Traditional Medical College Guangzhou Army Medical College Guangzhou Medical College Zhanjiang Medical College Zhangshan (Sui Yat-sen) Medical College (in Guangzhou) Guangxi Guangxi Medical College (in Nanning) Cuangxi Traditional Medical College (in Nanning) Guilin Medical Specialty School Shijiang Nationalities Medical College (in Baise Cpunty) uthwest Region Sichuan ** Sichuan Medical College (in Chengdu) Chongqing Army Medical College Chongqing Medical College Chengdu Traditional Medical College Nanchong Medical Specialty School luzhou Ifedical College Guizhou Guiyang Medical College- Guiyang Traditional Medical College Zunyi Medical College Yunnan Kunming Medical College' Yunnan Traditional Medical College (in Yunming) Xizang Xizang Medical College (in Linzhi) )rthwest Region Shaanxi *'-Xian Medical College Xian Army Medical College Shaanxi Traditional Ifedical College (in Xianyang) Huashan Metallurgy Medical Specialty School (in Ruayi) Yan'an -Medical College' Gansu Gansu Traaitional Medical College (in Lanzhou) Lanzhou M,dical College Qinghai Qinghai Medical Specialty School (in Xining) Ningxia Ningxia Medical College (in Yinchuan) Xinjiang Xinjiang Medical College (in Urumqi) Shihezi Medical College *4 * This denotes that a college is directly- resposible to the MOPH. This denotes both that a college is directly responsible to the MOPIi and .that it is a "Key" college. -rces: (i) This data provided to the World Bank by the Ministry of Public Health. (ii) Sidel, Ruth and Victor Sidel. The Health of China. Boston: Beacon Press, 1982. (iii) Orleans., Leo. "China's Manpower for Medicine and Public Health: Education and Numbers", 1982,. . Table 2: MEDICAL COLLEGES, 1977-1981: INSTITUTIONS, STUDENTS, ENROLLMENTS AND GRADUATES 1977 1978 1979 1980 1981 1982 Number of Colleges 89 98 107 109 112a/ 112 Number of students 93,822 112,990 127,400 139,569, 158,986 NA New Enrollees 34,932 47,320 31,569 31,277 -29,241 NA Graduates 34,860 27,459 13,483 17,656 9,512 29,963 of which traditional medicine '5,332 4,674 2,622 3,069 1,071b1 4,388 al In addition to these 112 medical colleges, there are four faculties '0 medicine in general: universities. b/ This reduction in number o<f graduates is the result of lengthening the program from three to rive or six years. Source: These .data were provIded to the 0ctober, 19.82, Rural Health and Medical Education mission of the World Bank by the Mihistry of Public Health. Table 3: MEDICAL COLLEGES: 1980-81 Ministry of Provincial Public Health and Other Total Number of colleges 13 99 112 - Enrollment Undergraduate 22,973 116,596 139,569 New Entrants 5,326 . 25,951 31,277 Postgradnate 1,461 .1,707 3,168. New Entrants 305 273 558 Faculty and Staff Total 7,859 22,949 30,808 Professors 394 255 649 Associate Professors 1,163 988 2,151 Lecturers 3,285 8,353 11,638 Others 3,117 13,253 16,370 Administration & Support - 46,078 a/ In addition to these 112 medical colleges, there are four faculties of medicine in general universities. Source: Data provided to the World Bank by the Ministry of Public Health. Tabl]e 4: LLOCATION OF CIRRCULtrI TIME IN HEDICAL COLLEGES AND SECONDARY YEDICAL SCRdLS RICURICULUM 1OjRS NDICAL COLLEG SECONDARY MEDICAL SCHOOL Tadi tional Assistant Assistant Assistant Istern PublIc Chinege V"stern Public Chinese ledicine Health Redicina Hdcine Health . Medicine Nurse Ceneral Education Politics, physical cultura, foretgn Ianguage, Chinese 666 666 752 752 528 "re-bled jea-l .at.hc"at"tes, phystes, ch":2s1rry, biology 486 468 309 367 292 Basie Medical Sciences Anatomy, histology, emb`yoLjpy, bocheristry, physiology, phariiccology, microbiology , -parasitology, patholoy I1I8 1088 0 . 756 598 Clintc.al Total 1494 1750 1273, 1324 963 Westera Medicine (1170) 8 $66), (1026) ( 570) (832) Traditionl Chinese MadIcine ( 144) ( 72) 171) ( 76) ( 72) Public HIeal h ( 180) ( 812) ( 76) (678) (64) Total Teachini ourå 3834 3964 3144 3199 2386 Internship Clinical (weeks) 40 16 44 16 34 Public Heaith (weeks) - 20 - 28 - Duration Total Program (yearé) 5 4 3 Sourcea: Infcration provided to the mission by th a nitry o4 Tublc halth. 7 iI Table 5: EXPRNDITURES ON MEDICAL COLLEGES BY TRE MINISTRY OF PUBLIC HEALTR, 1980-1982 (in thousands of Yuan) Medical Education Affiliated Hospital Capital Contribution 1980 1981 1982 1980 1981 1982 1980 1981 1982 Beijing Traditional Medical 2480' 3000 3490 1620 2470 3830 3230 2830 2610 College Guangzhou Traditional .Medical 2440 2620 3430 2250 2580 2660 1525 875 1580 College G Beijing Medical College 5670 6150 7600 7600 13530 16960 7880 8610 7900 Shanghai First Medical College 15570 5800 7600 8950 10950 11200 4060 2500 3110 Zhangshan Meaical College 1330 5800 7010- 5900 7370 7800 2450 3150 2060 Shardong Medical College 3000 3930 4650 2170 3140 3290 2060 1840 1400 Hunan Medical College 3320 3710 4300 5200 6440 6840- 1760 1895 1510 Wuhan Medical College 4170 4670 5160 4620 5350 5670 2420 2230 2050 Sichuan Medical College 4990 5580 6730 4850 6220 6520 2240 3010 2500 Xian Medical College 3410 3810 4460 . 4600 5730 6050 2470 2010 1990 (Shaanxi Province) Shenyang Medical College of 3860 4160 5010 6160 7420 7840 3210 3540 3180 China Bethune Medical College 4070 4660 5370 6050 7110 7540 3920 2940, 2120 Capital Medical College --1160 1600 2400 - NA NA NAc of China Total 45,470 55,490 67,210 59,970 78,310 86,200 37,225 35,430 32,010 Source: These data were provided to the October, 1982, World Bank Rural Health and Medical Education mission by the Ministry of Public lealth. Table 6. MEIDICAL COLLEGES: PROJECTIONS OFIANPOWER SUPPLY Graduates Graduates Graduates expected expected expected Medical Colleges in 1982 in 1985 in 1990 TOTAL 29,963 a/ 28,165 Increase by 10% Medicine 21,098 18,351 Public Health 1,183 1,345 Increase by 50% Pharmacy -,385 1,290 Pediatrics 266 .440 Stoinatology 462 677 Increase by 100.% Traditional Medicine . 4,388 3,944 Traditional Pharmacology 917 . 740 Others 264 1,378 a/ These numbers are unusually high due to temporarily expanded enrlment In 1977/78. Source: These data were provided to the Octobar, j982,'World Bank Rural Health and Medical Education mission by the Ministry of Public Health. Table 7: SECONDARY MEDICAL SCHOOLS; PROJEITIONS OF IMPOWER SUPPLY, 1982-1990 Graduatesý Gtaduates Graduates expected expected expected in 1982 al in i983 b/ -n 1990 c/ TOTAL 71,4 39 9 56,539 Asst. Western Doctors 5,559 42 71å 4,118 Asst. Doctors of traditional 6,464, 330 1,830 Chinese Medicine Nurses 40,742 20,081 27,085 Asst. Doctors of 3,085 1,440 2,720 Public Health - Asst, Dent sts .428 715 1,130 Othars 14,870 14,160 19,56 All figures for graduats in 1982 are -cnsidetably higher than notl due to large enrollment of students in 1979. b/ Expected graduates for 1985 are lowerthan normal reflecting provincial decisions on enrolment in 1982 influenced by the unusually large output of'graduates in 1982. c/ Figures for 1990 indicate expected outputs if current MOPH policies are implemented by the provinces. Source: Data provided to the October, 1982, WotId Bank Rural Health and Medical Education mission by the Ministry of Public Health.