SeriesChina's human resources for health: quantity, quality, and distribution
Introduction
China's economic reforms over the past three decades have generated unprecedented economic growth, increased household incomes, and reduced levels of absolute poverty. The benefits of growth, however, have not been fully translated into equitable social development. In the case of health, inequitable access to a poorly functioning system has generated much public dissatisfaction. The government has launched major reforms of the health-care system to address these problems. Given the success of its economic reforms, China clearly has the fiscal resources and capacity to fund improvements in its health sector.
Reform efforts will necessarily have to deal with the three major resource inputs of any national health system: financial, physical, and human. Of these three inputs, perhaps the least mapped and analysed in China is human resources for health. Yet there is clear evidence that human resources for health affect health outcomes, drive the performance of health systems, and command a large share of the health budget.1, 2 Without doubt, the success of China's national health reform will depend on developing and sustaining an adequate and appropriate health workforce.
China has a history of successful innovations of the health workforce. In the 1950s, China organised its people for mass hygiene campaigns, integrated modern and traditional health practitioners and systems, and trained para-professional workers to extend basic health services. During the cultural revolution in 1966–76, China mobilised and dispatched so-called barefoot doctors to serve rural villages throughout the country. In 1998, China began to prioritise and expand its tertiary education system when it launched a major expansion of comprehensive universities, and this has led to a rapid growth of medical, nursing, and public-health education.
In this paper, we analyse the quantity, quality, and distribution of China's health workforce. These three dimensions of human resources for health provide a systematic framework for understanding the workforce, as indicated in reports such as that released by the Joint Learning Initiative3 and the 2006 WHO World Health Report.4 Benchmarking the human resources situation seems a prerequisite to any informed discussion of health care and health in China.
Section snippets
Data and methods
Data on China's human resources for health are available from multiple sources, all in the Chinese language. The panel provides an English translation of the definitions of different types of health workers in China—including licensed doctors, licensed assistant doctors, nurses, technicians, and management staff. We have attempted to achieve consistency across various data sources which are based on different collection instruments and methodologies. Our detailed investigation of China's
Quantity
In 2005, China had 5 427 000 health workers—4 460 000 professional workers (licensed doctors, nurses, and other health professionals) and 967 000 non-professional workers (in management, logistical, and other work; table 1). About 917 000 village health workers—mostly former barefoot doctors, village workers, and traditional practitioners—were not included in these official counts. Among professionals, there were 1 938 000 doctors, 1 350 000 nurses, and 1 172 000 other health professionals.5
Quality
We use the education level of health workers as a proxy for their skill and technical competency. Table 2 shows that about a third of China's doctors have been educated to college level or above. The proportion of nurses educated to college level or greater is very small, only 2–3%. Most of China's doctors (67·2%) and nurses (97·5%) have been educated up to only junior college or secondary technical school level. About 6% of doctors and 8% of nurses have just high school or lower education. The
Distribution
With our county-level dataset for 2005, we can examine inter-county, inter-provincial, and urban-rural inequalities in availability of doctors and nurses. These inequalities may be associated with corresponding economic disparities—eg, between counties, between provinces, and between strata (ie, urban–rural). Apart from these geographical categories, however, we do not have data to examine differences in people's access to health workers by, for example, income level, education, occupation, etc.
Discussion
As China undertakes health-care reforms, effective policies will be needed to develop and manage its health workforce. In this paper, we have attempted to analyse its workforce in terms of quantity, quality, and distribution. We have not had the opportunity to examine the adequacy of health workers in these terms. To do so would require a detailed analysis of both demand and need—effective, latent, and potential—disaggregated for example by geographical, socioeconomic, epidemiological, and
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