Abstract
Purpose
This study examined the evolving synergies between education and healthcare systems (SEHS) in China's policy, based on the perspective of the theory of policy tools, to identify the existing policy defects and propose suggestions.
Design/Approach/Methods
A three-dimensional analytical framework was constructed following the literature review. Sixty-four official policies on SEHS issued during the period of 1949–2023 were analyzed. We subsequently undertook text coding, quantification, and content analysis of the policies.
Findings
China's SEHS policy has gone through four periods: germination, exploration, development, and improvement. The medical education management organization has changed according to the policy evolution. The Ministry of Education and the National Health Commission are the core subjects of the SEHS policy, and both prefer to use environmental and supply-side policy tools. Although China's SEHS policy achieved certain results, some issues have not yet been addressed, and there remains an imbalance in the structure of policy tools, insufficient collaboration among policy subjects, and poor articulation among the stages of medical education.
Originality/Value
Strengthening the continuity and balance of SEHS policies, establishing an effective SEHS working mechanism, and improving the articulation of the policies of the three stages of medical education are recommended to promote SEHS programs.
Introduction
The essence of comprehensively constructing a modern socialist country lies in safeguarding people's health, with exceptional medical expertise and premium medical education serving as a foundation for achieving this goal (Wu & Wang, 2021). The current international medical education system is a seamless continuum encompassing undergraduate medical education, graduate medical education, and continuous learning. Institutional education, grounded in undergraduate studies and administered by the education sector, contrasts with postgraduate and continued professional development, which are closely connected to the healthcare system and its management.
This bifurcated management model, coupled with the inherent unity of medical education, has fostered the notion of collaborative education between the education and healthcare sectors. In 2010, the Commission on Education of Health Professionals for the 21st century underscored this in their Lancet publication, “Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World” (Frenk et al., 2010). This publication emphasized that the education sector must adapt to the profession's demands through close collaboration with the healthcare sector, thereby nurturing high-caliber medical professionals attuned to industry needs (Frenk et al., 2010). This marked a pivotal moment in the creation of the synergies between the education and healthcare systems (SEHS) concept.
Since then, this concept has formed, integrating China's unique circumstances with a succession of policy documents advocating for SEHS. In November 2014, the Chinese government including the Ministry of Education, the National Health and Family Planning Commission, the National Administration of Traditional Chinese Medicine, the National Development and Reform Commission, the Ministry of Finance, and the Ministry of Human Resources and Social Security, jointly issued the “Opinions on Synergies Between Education and Healthcare Systems and Deepening the Reform of Clinical Medical Talent Cultivation,” officially embedding SEHS into medical education reforms (Ministryof Education, National Health and Family Planning Commission, NationalAdministration of Traditional Chinese Medicine, National Development and ReformCommission, Ministry of Finance, & Ministry of Human Resources and Social Security, 2014).
In 2017, the General Office of the State Council issued “Opinions on Deepening the Synergies Between Education and Healthcare Systems to Further Promote the Reform and Development of Medical Education,” outlining strategic measures to bolster collaboration between the education and healthcare systems, deepening SEHS in medical talent development (General Office of the State Council of the People’s Republic of China, 2017). By 2020, the “Guiding Opinions on Accelerating the Innovative Development of Medical Education” reaffirmed the pivotal role of SEHS in China's medical education transformation. Against this backdrop, academic inquiries into SEHS have flourished, making SEHS emerge as a prominent area of research in medical education.
The essence of SEHS lies in the seamless integration of the education and healthcare systems, encompassing the macro-, meso-, and micro-levels of engagement. At the macro-level, this entails cooperation between the central, provincial, and municipal educational and health authorities. The meso-level addresses the challenge of effectively bridging medical school management with clinical teaching hubs, including directly and indirectly affiliated hospitals, while rationalizing operational mechanisms. The micro-level explores specific collaborations between medical institutions and clinical teaching bases to nurture medical students (Guo & Wang, 2022; Su et al., 2016; Xu & Chen, 2016). Regarding the needs at these three levels, SEHS policy can provide the necessary support by offering a framework and direction for collaboration among various stakeholders, from healthcare authorities to medical institutions, further influencing the integration at micro-levels (Wu & Shen, 2024).
Current research often focuses on the impacts of individual policies (Liu et al., 2017; Wang, Wang, et al., 2020; Wang, Zeng, et al., 2020) and their significance (Shi et al., 2018), or systematically analyzes medical education policies (Chen, Mu, et al., 2022; Chen, Zhao, et al. 2022; Huang, 2019; Wang & He, 2015; Wang et al., 2023). Additionally, studies have explored talent cultivation and collaboration strategies within the SEHS framework (Shen, 2018). However, existing research has notable gaps. It examines policy implementation following the “Opinions on Synergies Between Education and Healthcare Systems and Deepening the Reform of Clinical Medical Talent Cultivation” (National Health Commission of the People's Republic of China, 2014), neglecting a historical policy review. Moreover, it tends to focus on single policies, exploring medical school-hospital management systems and medical student training, without undertaking comprehensive sorting or quantitative analyses of macro-level SEHS policies.
To address these gaps, this study adopted a policy tools perspective, constructing a three-dimensional “policy subject–policy tool–policy stage” analytical framework. We quantitatively analyzed 64 representative SEHS policy documents since the founding of the People's Republic of China (1949) and examined their policy characteristics across single-dimensional, two-dimensional, and three-dimensional interactions in depth. While the term “SEHS” (Synergies between Education and Healthcare Systems) was formally introduced in China's 2014 policy documents (Opinions on Synergies Between Education and Healthcare Systems and Deepening the Reform of Clinical Medical Talent Cultivation), this study applies it as a unified term to examine historical policies that implicitly pursued similar objectives, ensuring continuity in policy research. This study not only examines the structural characteristics of SEHS policies through a three-dimensional lens but also traces their historical evolution across distinct stages to identify systemic shifts and continuity in China's medical-educational collaboration. Our goal was to holistically understand the current state of SEHS policy development and offer a clear roadmap for its evolution. By identifying policy issues and proposing suggestions, we provide valuable insights for enhancing China's medical education management systems and mechanisms, and further help the training of medical talents.
Methods
Research Framework
The theory of policy tools posits that policy constitutes a harmonious blend of fundamental tools, whose amalgamation mirrors the principles of decision-making (Chen, 2003; Flanagan et al., 2011; Huang et al., 2011). Within the evolving landscape of SEHS policy, policymakers employ a diverse array of tools to achieve policy objectives that influence institutional, postgraduate, and continued education and professional development in medicine. These tools address policy challenges, fulfill policy aspirations, mediate interactions among institutions, and effectively capture stakeholder dynamics. Policy tools can be categorized into three distinct groups. First, based on their mode of operation (Hanson et al., 1981), they are segregated into supply-side, demand-side, and environmental policy tools, representing the most prevalent and insightful classification in policy analysis (Lin et al., 2013). Second, considering the extent of government intervention, they are classified as mandatory, incentive, or safeguard measures (Roy, 1985). Finally, utilization modes encompass regulatory, normative, cognitive, and other tools vital for resolving policy issues and attaining objectives. Notably, the third group is reiterated; for clarity, it comprises regulatory, normative, and cognitive tools (Gu & Wu, 2007). Given the nexus of medical education policy with societal development and its emphasis on nurturing medical students’ competencies, it exhibits unique characteristics in its supply-demand dynamics. Consequently, this study adopts the first classification, distinguishing policy tools as supply-side (e.g., talent development and technical assistance) that bolster medical education, demand-side (e.g., market requirements) that propel it forward, and environmental (e.g., preferential policies and regulatory frameworks) that influence its ecosystem.
To facilitate an in-depth understanding and analysis of the interaction between policy subjects (different institutions) and the policy itself across different time stages, this study devised an analytical framework titled “policy subject–policy tool–policy stage” (Figure 1). The choice of these dimensions aligns with policy tools theory (Chen, 2003; Flanagan et al., 2011), which emphasizes the interplay between subjects, tools, and stages in policy analysis. The three dimensions collectively capture the hierarchical structure of policy design, the mechanisms of implementation, and the temporal evolution of medical education. This approach avoids oversimplification and ensures a holistic analysis of policy synergies. This framework provides a comprehensive lens to examine the intricate relationships at play.
Three-dimensional analytical framework of “Policy Subject–Policy Tool–Policy Stage.”
This study employs a three-dimensional analytical framework to holistically examine the interplay of subjects, tools, and stages in China's SEHS policies. Multidimensional frameworks are often operationalized through decomposed dyadic interactions to balance depth and interpretability. Thus, we scrutinize policy features using a multifaceted methodology encapsulating single-dimensional and two-dimensional analyses in order to ensure analytical rigor while avoiding redundancy. Firstly, commencing with a single-dimensional analysis, it dissects the policy text into three distinct perspectives: policy subject (X-dimension), policy tool (Y-dimension), and policy stage (Z-dimension). This exercise aimed to elucidate the balance of policy coverage across these components. Subsequently, a two-dimensional interaction analysis was conducted, focusing on the pivotal dimensions of SEHS. This encompasses two pivotal examinations: an X–Y dimension interplay, emphasizing the use of varied policy tools by distinct policy subjects, and an X–Z dimension analysis, detailing the performance of policy subjects across different educational stages of SEHS (undergraduate, graduate, and continued education and professional development). This X–Z dimension specifically focuses on how policy subjects contribute to the development of SEHS policies at each educational stage, rather than the temporal periods of the policy process itself.
Data Collection
SEHS is a pivotal issue in governance and encompasses a broad spectrum of disciplines and multifaceted endeavors. Analyzing its policies requires a keen focus on the diverse frameworks that shape this field. The selection of policy exemplars adhered to the criteria of representativeness, comprehensiveness, and thoroughness. “Representativeness” refers to the selection of policies that reflect the diverse frameworks, stakeholders, and stages of the SEHS process, ensuring that key areas and different policy subjects are adequately represented. “Comprehensiveness” ensures that all relevant areas of SEHS policy are covered, while “thoroughness” involves a detailed analysis of each policy exemplar. The first cohort of policy documents was filtered through the Compendium of Medical Education Documents spanning 2010–2017, issued by the former Department of Science and Technology Education of the former National Health and Family Planning Commission (now the National Health Commission).
To further explore the nuances of policies applied across varying stages and targeted at diverse stakeholders, a subsequent screening was conducted based on categorical keywords like “SEHS,” “medical education,” and “undergraduate medical education,” among others, albeit with a redundancy in “medical education.” Subsequently, a targeted search was undertaken using keywords such as “SEHS,” “undergraduate medical education,” “graduate medical education,” “residency training,” and “continuing education” to retrieve pertinent policies and documents from official portals of the Ministry of Education, National Health Commission, and similar authorities. This exhaustive search aimed to gather all the SEHS-related policies in China since 1949, yielding a second batch of documents. The policy sample was finalized through a meticulous process involving the review and integration of both batches and gap analysis, guided by existing literature and consultations with domain experts. As of December 31, 2023, this study identified 64 policy texts spanning the years 1949–2023 (Table 1). Quantitatively, China's medical education policies exhibited a dynamic ebb and flow, peaking during 2013–2015. Collaborative policies manifest in the form of methodologies, regulations, and notifications. Content-wise, they majorly address the management of clinical teaching bases, standardization of residency training, and overall administration of medical education endeavors.
Examples of Policy Documents on Medical-Educational Synergies (Partial).
Partial Coding Process for SEHS Policy.
Data Analysis
In this study, quantitative and qualitative analyses of the policy texts were combined, and specific articles of the policy texts on healthcare-education synergism were used as the basic unit of analysis. The 64 policy documents were first coded according to the method of “policy number article number” to form a coding table. Subsequently, all the articles were categorized according to the analytical framework described in the previous section. To ensure the stability and repeatability of the coding, Lina Wei and Xinyi Chen coded the text twice in chronological and reverse order to ensure the content validity of the coding. Disputed coding items were thoroughly discussed, and for cases where consensus could not be reached, expert opinions from the relevant field were consulted. This approach aimed to minimize the influence of coders’ subjective perspectives on the results and enhance the objectivity of the coding quality. The text and the coding were double-checked and re-determined by different coders, and the controversial parts were resolved through resolution meetings, so as to ensure reliability.
After coding was completed, 1,558 coded entries were obtained. For example, “30-2-1-4” means “30th policy document–2nd stage element (graduate medical education)–1st type of policy tool (supply-side policy tools)–4th policy sub-tool (human resource development) (Table 2).” Considering the many advantages of NVivo's qualitative analysis software (Liu & Li, 2017), all content analysis processes in this study were manually coded using NVivo12 qualitative analysis software's lexical frequency and reference point numerical functions to compare and analyze the key themes of China's healthcare and education synergistic policies.
Results
Evolution of SEHS Policies
Building on the three-dimensional framework, we first contextualize SEHS policies within their historical stages to reveal how policy subjects and tools adapted to China's evolving healthcare and educational needs. Subsequent sections analyze tool-subject-stage interactions in depth. Based on key events such as significant policies affecting higher medical education and crucial conferences, this study divided the evolution of China's SEHS policies into five phases.
Policy Inception Period (1949–1990)
In the early days of the People's Republic of China, medical education management adopted the Soviet Union model. The government took over medical schools from the Nationalist government period, separating medicine from comprehensive universities to focus on the development of single-discipline and specialized medical schools. During this period, a unified curriculum, teaching plans, syllabi, and textbooks were progressively implemented across medical schools, particularly emphasizing specialties, as part of the Soviet Union model. After the establishment of the Central People's Government Ministry of Health in 1949, a medical administration bureau and medical education division were established, followed by the Department of Medical Education in 1953, which professionalized medical education management. Despite the independence of the Ministry of Education and the Ministry of Health at that time, they remained significant entities for issuing medical education policies, with some guiding principles still relevant today.
Policy Exploration Period (1991–1998)
During this period, measures such as standardized exam systems and clinical practice-based construction were implemented to strengthen medical students’ practical education and clinical competence. The education system primarily focused on reforming clinical medical education and building practice bases, whereas the healthcare system emphasized establishing regulations for physicians and improving primary healthcare services. The “Decision on the Development of the Health Industry” issued by the State Council in 1996 proposed policies to enhance medical students’ practical teaching and primary healthcare service awareness, aiming to improve their practical abilities and awareness of primary healthcare services. In 1998, the National People's Congress issued the “Law of the People's Republic of China on Licensed Doctors” (now abolished), stipulating the qualification requirements and professional conduct norms for doctors, setting clear requirements for doctors’ professionalism and competence, and providing a legal basis for medical education.
Policy Deepening Period (1999–2008)
During this period, China issued a series of policies focusing on reforming the medical education system, deepening the SEHS, and providing more specific guidance and measures. From 1999 to 2000, the State Council decided to merge and transfer universities on a large scale, clarifying the responsibilities of the Ministry of Education and the Ministry of Health in medical education. Following this, the two departments further enhanced cooperation in medical education by establishing an interministerial coordination mechanism for macro management. Except for the Ministry of Education, the Ministry of Foreign Affairs, State Commission of Science, Technology, and Industry for National Defense, State Ethnic Affairs Commission, and the Ministry of Public Security, which continued to manage their affiliated schools, other departments and units of the State Council were no longer directly involved in the management of medical schools. Additionally, most affiliated medical schools were merged into comprehensive universities, except for the China Medical University and Peking Union Medical College.
Policy Development Period (2009–2014)
This stage marked a rapid development in SEHS, emphasizing medical schools’ services to the healthcare system and medical students’ practical skills training, with the health sector playing a crucial role in macro-control and management. The National Medical Education Reform Conference in 2011 vigorously promoted medical education reform, innovated institutional mechanisms, and cultivated outstanding medical talent. Subsequently, reforms, such as the “Outstanding Doctor Training Program, Pilot Residential Physician System, 1 Integration of Four Tracks, Integration of Four Certificates,” 2 and the “5 + 3” integrated clinical medical talent training, were continuously promoted and refined in medical education. In 2014, the Ministry of Education and five other departments issued the “Opinions on Synergies Between Education and Healthcare Systems and Deepening the Reform of Clinical Medical Talent Cultivation,” adopting proactive policy orientations to promote the comprehensive and rapid development of higher medical education.
Policy Refinement Period (2015–2023)
This stage represents the continuous deepening of SEHS with comprehensive cooperation among education and health departments, and medical schools. As a core educational concept in modern medical talent cultivation, SEHS has been highly valued (Zeng, 2022). In 2015, China began fully implementing an SEHS training model integrating clinical medical master's degree education (referred to as “professional master's degree students”) with standardized training for resident physicians (referred to as “residential training”). In July 2017, the General Office of the State Council issued the “Opinions on Deepening the Synergies Between Education and Healthcare Systems to Further Promote the Reform and Development of Medical Education,” making important arrangements to deepen SEHS and promote the reform and development of medical education.
Single-Dimensional Textual Analysis
Policy Subject
From the viewpoint of policy formulation, China's SEHS policies are formulated by the Ministry of Education, the National Health Commission, and other government departments (Table 3). Among them, the relevant departments and divisions under the Ministry of Education are primarily responsible for the macro-management of medical education and teaching, as well as providing guidance on the development and modernization of educational infrastructure and reforms in teaching methods and curricula in higher education. The relevant departments and divisions under the National Health Commission are responsible for formulating health science and technology development plans and related policies and organizing their implementation; organizing and conducting post-graduate medical education, such as residency, specialist training, and continued education and professional development; and collaborating on guidance initiatives. Other government departments at the central level are typically responsible for cooperating with the Ministry of Education and the National Health Commission in the management of medical education. Overall, the collaboration between medical schools (including medical schools, departments, and centers within comprehensive universities) and clinical teaching bases (directly affiliated hospitals, non-directly affiliated hospitals, and teaching hospitals) in medical education is the focus of the policies of the Ministry of Education and the National Health Commission. Provincial departments and other lower-level administrative institutions (provincial departments of education, provincial health commissions, etc.) serve as the policy implementers. Industry associations and expert organizations, such as the Chinese Medical Doctor Association (CMDA) and the Ministry of Education's Working Committee for the Accreditation of Medical Education, are also policy implementers. Committees, other industry associations, and expert organizations also play important roles.
Core Participants in the Development of Medical and Educational Collaboration Policies.
Policy Tool
To structure the policy content, the study took the sentence as the basic unit of analysis and conducted specific coding according to “policy number–chapter number–entry number” based on the analytical framework of “subject–policy tool–policy stage” (Table 4). In terms of policy tools, environmental (40.95%) and supply-side policy tools (34.53%) dominated SEHS policies, whereas demand-side policy tools (24.52%) accounted for a lower percentage. The imbalance in policy tools distribution does not imply an ideal “average” but highlights systemic preferences for state-driven interventions over market or institutional autonomy. Environmental policy and supply-side policy tools inherently require centralized coordination and resource control, reflecting top-down governance. In contrast, demand-side policy tools rely on decentralized stakeholder agency, which is less emphasized in China's SEHS context. From this, the dominance of environmental (40.95%) and supply-side policy tools (34.53%) reflects a state-centric policy approach, where regulatory frameworks and direct resource allocation are prioritized to steer medical education reforms. This aligns with China's government-led model, where ministries like the Ministry of Education and the National Health Commission play directive roles in policy design.
Categorization of Policy Tools for Health Education Collaboration and Their Coding.
Policy Stage
China established a unified medical personnel training system in three phases: undergraduate, graduate, and continued education and professional development. In terms of the specific connotation of the policies, each policy stage has its own emphasis (Table 5). At the undergraduate medical education stage, the policies focus on the core curriculum, construction of teaching materials and clinical practice, setting of the academic system, collaboration of specialties, innovation of institutional mechanisms, the scale of talent, and international accreditation of medical education. At the graduate medical education stage, the policies focus on degree articulation and vocational training for professional master's degrees, the standardization of residency training, and the construction of bases. At the continued education and professional development stage, the policies focus on financial investment and strategic measures for training and specialty training, especially at the level of talent cultivation and strategic measures, and the policy documents convey the importance of the implementation of internal and external incentives. For example, the National Health Commission attaches importance to the continued education and professional development system, formulating and issuing the “Guiding Opinions on Further Strengthening the Work of Continuing Medical Education and the Measures for the Administration of Continuing Medical Education,” focusing on the grassroots level, shortage of specialties, and underdeveloped regions in central and western China, and increasing the promotion of a comprehensive continuing medical education to further improve its relevance and standardization of continuing medical education. Simultaneously, the National Health Commission and the Ministry of Human Resources and Social Security jointly issued “Guiding Opinions on Further Reforming and Improving the Assessment of the Titles of Grassroots Health Professionals and Technicians,” suggesting the direction of grassroots health title reform.
Coding Results for the Policy Stages of SEHS.
Note. * Order-oriented medical student education policies refer to the system introduced by the National Development and Reform Commission and other departments, starting from 2010, to provide free education for medical students with the goal of training medical professionals, particularly general practitioners, for rural areas and township health centers. The focus is on addressing the shortage of healthcare workers in underserved regions by assigning graduates to work in rural and grassroots medical institutions.
Two-Dimensional Interaction Analysis
Policy Subject and Policy Tool Dimensions (X–Y)
The results (Figure 2) show that policy subjects other than the State Council, the Ministry of Education, and the National Health Commission are also active users of policy tools, with the number of users exceeding the sum of the first three, partially indicating the diversity of policy subjects involved in SEHS. The scale of use of policy tools by the State Council is significantly smaller than that of the Ministry of Education and the National Health Commission. The frequency of use of policy tools by the Ministry of Education and the National Health Commission is similar, with the Ministry of Education using supply-side policy tools 269 times, demand-side policy tools 238 times, and environmental policy tools 259 times, and the National Health Commission using supply-side policy tools 227 times, demand-side policy tools 243 times, and environmental policy tools 201 times. The differences between the two are primarily due to the type of policy tool used. The Ministry of Education was significantly more likely to use education and training, whereas the National Health Commission used target planning more commonly. For example, in the discussion of rural students in the “Opinions of the Ministry of Education and the Other Six Departments on SEHS to Deepen the Reform of Clinical Medical Talent Cultivation,” the National Health Commission is responsible for formulating the cultivation plan and scale of cultivation for rural students, while the Ministry of Education should actively conduct order-oriented free medical education for rural people. The scale of use of policy tools varies among policy subjects, and the structural layout of policy tools also varies. The types of policy tools used by different policy subjects show their functions and policy preferences to a certain extent. However, there is also an overlapping use of tools. Specifically, the types of overlap in the use of policy tools between the Ministry of Education and the National Health Commission include appraisal and assessment, public services, infrastructure, and tax subsidies. Notably, the overlapping use of policy tools between the Ministry of Education and the National Health Commission may lead to policy conflicts that are not conducive to policy implementation. While policy overlap may theoretically enable synergy, conflicting objectives, implementation mechanisms, or resource allocation between policy subjects can create tensions. Taking China's “5 + 3” integrated clinical training program as an example, the Ministry of Education emphasizes supply-side tools by funding hospitals to establish training bases and requiring universities to integrate residency training curricula. The National Health Commission, on the other hand, prioritizes environmental policy tools by implementing strict certification standards and penalties for noncompliance. This results in overlapping evaluation mechanisms: The Ministry of Education's standards focus on educational outcomes, while the National Health Commission emphasizes clinical service indicators. Consequently, hospitals face conflicting pressures: choosing between the educational quality emphasized by the Ministry of Education and the clinical efficiency stressed by the National Health Commission. Many hospitals, in order to meet the service quotas set by the National Health Commission, have downgraded the priority of teaching, leading to underutilization of the Ministry of Education's supply-side investments and dissatisfaction among residents. This example illustrates how overlapping tools without harmonized objectives create operational friction.
Radar chart of the types of policy tools used by different policy subjects.
Policy Subject and Policy Stage Dimension (X–Z)
The results show some differences in policy subjects’ attention at each policy stage (Figure 3). The Ministry of Education paid the most attention to undergraduate medical education, which introduced 52.47% of the policy tools at this stage, whereas the National Health Commission and other departments accounted for only 20.70% and 12.19%, respectively. The Ministry of Education and the National Health Commission attached secondary importance to graduate medical education, with 32.16% and 46.14% of policy tools enacted at that stage, respectively. At the continued education and professional development stage, the Ministry of Education's attention declined significantly, with only 15.37% of policy tools, which was significantly lower than the National Health Commission's 33.16%; the other departments’ share at that stage was only 22.40%. Overall, the Ministry of Education, as a core department in the field of education, is more involved in policy formulation at the undergraduate medical education stage and less involved in policy formulation at the continued education and professional development stage; the National Health Commission focuses more on the enhancement of medical students’ professional skills and deepening of their practical abilities, paying more attention to the graduate medical education stage and the continued education and professional development stage, but less attention to the undergraduate medical education stage.
Histogram of stacked policy stages of use by different policy subjects.
Policy Tool and Policy Stage Dimension (Y–Z)
The results show that SEHS policy presents different characteristics in different development stages, and the structure of policy tools in different policy stages shows some differences (Figure 4). Overall, the proportion of environmental policy tools was always the highest at each policy stage, followed by the supply, and the lowest demand types. The three supply–demand–environmental types of policy tools in the undergraduate medical education stage show a 3:2.6:2 ratio structure, whereas the continued education and professional development stage shows a 3:2:2 ratio structure. In the graduate medical education stage, the ratio of supply-side and environmental policy tools converged, reaching 36.68% and 36.05%, respectively, while demand-side policy tools were low. Based on the different policy goal orientations and educational stage characteristics of each stage, the degree of matching for the type of policy tool varies among the education stages. Different educational stages have different characteristics and needs. For example, in the undergraduate medical education stage, more attention is paid to the teaching of basic knowledge and the cultivation of students’ basic abilities; therefore, supply-side policy tools (such as increasing investment in educational resources and improving teaching facilities) are more important. In the graduate medical education stage, demand-side policy tools (e.g., providing employment support and incentivizing further studies) are more applicable as more emphasis is placed on practical skills and career development. Optimizing policy tools to better fit the goals and characteristics of the educational stage is important for policy implementation during the SEHS process.
Histogram of stacked types of policy tools used at different policy stages.
Discussion
The policy tool structure is moderately imbalanced, showing discord between policy aspirations and effectiveness. A frequency analysis of the SEHS policy text revealed an over-representation of environmental policy tools (40.95%), closely followed by supply-side (34.53%) and demand-side (24.52%) policy tools. Based on the theory of policy tools, the preponderance of environmental tools that lack rigid constraints may diminish implementation efficiency, foster marginal decline, and potentially induce implementation distortions or stagnation. The scarcity of demand-side tools hinders the stimulation of the internal drive for self-reform among medical education entities, thereby impeding collaboration and the enhancement of China's medical education innovation capacity. Inadequate use of infrastructure (5.78%) and education and training (8.22%) may compromise teaching quality, student experience, and research progress, affecting the competency of medical educators. The current lack of demand-side tools that employ supervision and evaluation can lead to inadequate educational quality assurance and hinder the establishment of a consistent and effective evaluation framework. Furthermore, the inadequacy of policies related to forecasting exacerbates the disparity between China's medical education capabilities and actual needs. For instance, the shortage of pediatricians in China highlights the issue of an imbalanced structure in its medical and educational policy tools, despite the three-child policy in 2021; demand-side tools remain underutilized to incentivize pediatric specialization.
There are differences in the objectives of policy subjects and the dilemma of collaboration causes a policy lag. From the viewpoint of policy content, there are significant differences in the types of policy tools employed by various policy subjects and their focus on different policy stages. Differences in policy tool usage signal misalignment of objectives and operational priorities among policy subjects. As the mechanism for coordinating education is not yet sound, it is difficult to implement a systematic, global, and forward-looking layout for medical education. At present, China's policymaking lacks coordination with different types of policies, such as population, environment, education, science, and technology. Further, it lacks a macro-level perspective that integrates China's population trends, social development, and emerging patterns of economic and scientific progress, resulting in medical education policies that are insufficiently forward-looking. There are significant differences between education and health administrations in terms of departmental functions and goal orientation, as well as competition and conflicts regarding infrastructure and talent, which have constrained collaboration and consultation within the pluralistic body and the implementation of policies. At the implementation level, policy lacks specific implementation details, and a specialized medical education management body has not yet been established, making it difficult for affiliated hospitals and medical schools to work together. There is also a lack of standardized documents defining the operation, management, and construction of medical schools and affiliated hospitals. The remaining barriers make it difficult to connect undergraduate and graduate medical education with the training of medical personnel. Relevant interviews showed that the lack of specific implementation rules or relevant normative guidance documents leads to unclear boundaries between the rights and responsibilities of affiliated hospitals and medical schools, which in turn restricts the flow of talent, funds, teachers, and other resources between schools and hospitals (Wu & Shen, 2024). In addition, there is a lack of communication among medical schools, the government, hospitals, and other parties, which makes it difficult to achieve collaborative education in terms of setting goals for talent cultivation, educational and teaching reforms, construction of teaching bases, and institutional safeguards (Wang, Wang, et al., 2020; Wang, Zeng, et al., 2020).
Policy articulation is insufficient at all stages of medical education. Regarding policy articulation, SEHS is still inadequate in terms of mechanisms, institutions, and specific policies at various stages of medical education; undergraduate and post-graduate medical education are often disjointed and overlapped, resulting in duplication of training, a long training cycle, and a waste of educational resources, among other problems. Moreover, a standardized training and certification system for specialist physicians has not yet been fully implemented; the graduate medical education system remains incomplete; and the curriculum, teaching concepts, modes and methods, and teaching evaluation still require improvement. For example, the country has not issued a unified policy on the articulation of standardized residency training and postgraduate education of clinical medicine degrees, which leads to differences in the standards and requirements of standardized residency training in different places, which not only affects the quality of training but also brings troubles to the career development of doctors. Pilot colleges and universities have explored the establishment of a parallel mechanism for master's degree and practical training, and the establishment of the “four certificates in one” (master's degree certificate, master's diploma certificate, certificate of qualified residency training, and certificate of qualification for practicing physicians) training mode, which is a prominent exploration of the collaboration between undergraduate and graduate medical education, but there is still significant pressure on the training. However, problems such as the high pressure of training remain and it is at the stage of exploring (Wang, Wang, et al., 2020; Wang, Zeng, et al., 2020). Regarding the assessment of standardized residency training, although there are the “Guidelines for the Assessment of Practical Skills for Completion of Standardized Residency Training and Contents and Standards of Standardized Residency Training (for Trial Implementation)” as reference standards, the forms and requirements of the assessment have not been unified (Chen, Mu, et al., 2022; Chen, Zhao, et al. 2022). Simultaneously, the current policy does not make a clear distinction between scientific research and clinical boundaries, resulting in hospital clinicians often having to take on a large number of scientific research tasks. There is also a lack of policy guidance on the treatment and development prospects of scientific researchers and clinicians, which has led to a lack of motivation for doctors and clinical teaching bases to participate in medical education.
Policy Recommendations
This study provides several policy recommendations. (a) Supply-side policy tools should be enriched by augmenting investments, upgrading teaching facilities, and instituting oversight mechanisms to foster medical education's diverse growth. (b) Demand-side policy tools, including scale projections, incentives, and faculty development, can be deployed to cater to the diverse demands of the evolution of medical education. Concurrently, leverage environmental policy tools can refine medical management and quality oversight mechanisms, stimulating reform within policy targets. When adjusting policy tools, it is essential to ensure coordination and consistency among different types, such as supply-side, demand-side, and environmental policy tools, to maximize their collective effectiveness. (c) The government should be responsible for investing in medical education infrastructure and facilities to elevate hardware standards while concurrently focusing on soft upgrades, such as teacher quality enhancement and teaching method optimization. Additionally, they should effectively use motivational strategies and targeted incentives to engage teachers and students, balancing intrinsic rewards such as professional development opportunities with extrinsic rewards like financial support or recognition. (d) An effective SEHS mechanism to unify the interests of diverse policy stakeholders should be established. Collaborative challenges stemming from differing objectives by crafting education policies from multifaceted angles to ensure execution efficacy must be addressed. Resources should be aligned, medical education funding augmented, and supporting documents promptly issued, adhering to the directives of the six ministries and commissions, while also refining reform measures. (e) Operational frameworks must be regulated, relationships defined, and internal governance of medical school-hospital synergies achieved through policy directives, fostering deep integration between education and healthcare systems. For instance, departments must collaborate on clinical medicine enrollment policies to account for uncontrollable subjects such as student attrition and enhance institutional and hospital implementation efficiency. (f) Interdepartmental SEHS should be strengthened and regular communication and consultation fostered to address talent cultivation challenges promptly. Medical school-healthcare institution ties should be intensified, mutually supporting and collaborating to gradually refine collaborative medical education and training mechanisms. (g) The medical education management system should be improved and policy coherence fostered across the three stages. Addressing the lack of policy articulation institutionalizes the integration of institutional, postgraduate, and continuing medical education, progressively enhancing policy collaboration. Undergraduate medical education should be reformed, optimizing comprehensive university medical education management, and emphasizing linkages with postgraduate and continued education and professional development. (h) Graduate medical education should be upgraded, refining residency training processes and evaluations, expanding training in underrepresented specialties, and establishing demand-side policy tools. It also involves pioneering specialized training initiatives, fostering public health clinical talent, and integrating graduates with professional education. Finally, we clarified medical education quality standards, including early warning and exit mechanisms, dynamic management of institutions, and suspension of those failing to meet post-rectification standards.
Limitations
This study underscores several limitations in analyzing the three-dimensional policy tools of SEHS in China. First, while efforts were made to gather all relevant policy documents from 1949 to 2023, potential oversights or gaps in the policy sample may remain despite meticulous review and integration. Second, the analysis is confined to policies at the macro-level and may not fully capture the nuanced impacts and challenges faced at the meso- or micro-levels of implementation. Additionally, the study identified an imbalanced policy tool framework, where insufficient monitoring and evaluation of demand-side policy tools compromise quality assurance. However, the research did not explore the root causes of this imbalance or propose concrete solutions to rectify it. Furthermore, the analysis relies heavily on quantitative data and content analysis and may lack in-depth qualitative insights from stakeholders such as policymakers, educators, and practitioners in the medical education field. Finally, the study is restricted by its focus on China, and the findings may not be readily generalizable to other countries or regions with different policy environments and medical-educational systems.
Conclusions
This study identifies a structural imbalance in China's SEHS policy tools (1949–2023), characterized by an overreliance on environmental policy tools and supply-side interventions, alongside underutilized demand-side policy tools, which collectively exacerbate misalignment between policy objectives and outcomes. Through a three-dimensional analysis of 64 policy texts, we demonstrate how an unbalanced regulatory framework and fragmented interdepartmental priorities undermine medical education quality and workforce sustainability, as evidenced by persistent pediatrician shortages and underutilized training infrastructure. Distinct from prior studies on generic medical education collaboration, this research operationalizes SEHS as a policy-driven synergy across undergraduate, graduate, and continuing education stages, revealing how tool imbalances—rather than isolated policy flaws—hinder institutional and operational coherence. The findings underscore the urgency of rebalancing tools, harmonizing stakeholder goals, and establishing unified accreditation standards to bridge gaps between policy design and implementation. This work contributes a replicable framework for diagnosing multilevel policy inefficiencies in integrated education-health systems, offering actionable insights for China and similar contexts grappling with healthcare workforce challenges.
Footnotes
Acknowledgments
The authors would like to thank the Department of Science and Technology Education of the former National Health and Family Planning Commission (now the National Health Commission) for authorizing the use of policy data. In addition, the authors would like to thank Editage (
) for English language editing.
Author Contributions
Lina Wei contributed to the conceptualization of the study, research design, literature search, writing of the manuscript, and data management. Hongbin Wu provided overall leadership and guidance for the study, involved in the conceptualization of the study, research design and offered critical revisions and edits to the manuscript. Ziyue Shen and Xinyi Chen contributed to the data collection, manuscript revisions, and editing to refine the final version.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Natural Science Foundation of China, General Project of Key Base of Humanities and Social Sciences in Colleges and Universities of Hebei Province (grant numbers AIA210011 and 20230108).
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.