Despite the momentous development of rehabilitation services in China, meeting the rehabilitation needs of people in China is a continuous challenge. The growth of rehabilitation services in China corresponds to an overall increase in the Chinese population, including significant growth in the number of people with a disability (Peng, Song, Sullivan, Qui, & Wang, 2010; Xiao, Zhao, Ma, Li, & Qiu, 2017). According to the Sixth National Population Census of the People's Republic of China, conducted in 2010, there is a total population of 1,339,724,852, with persons with disabilities numbering approximately 85 million (China Disabled Persons' Federation, 2012). Among people with disabilities, it is estimated that 12.63 million have visual impairments, 20.54 million have hearing impairments, 1.30 million have speech and hearing impairments, and 24.72 million are classified as having some type of physical disability. Further, 5.68 million people have cognitive impairments and 6.29 million people have mental health conditions (China Disabled Persons' Federation, 2012).
China's rehabilitation services and resources are growing at a remarkable rate to meet the needs of persons with disabilities. The growth and improvement seen in rehabilitation services in China is a priority of the Chinese health reform that intends to integrate “preventive, therapeutic and rehabilitative” services (Central Committee of the Communist Party of China, 2009, as cited in Xiao et al., 2017, p. 75). Moreover, the advancement of rehabilitation services in China is an essential part of China's 12th Five-year Plan and pilot programs (Zhang & Shen, 2014). This article provides an overview of the development, challenges, and future direction of occupational therapy in China. We first discuss the brief history of occupational therapy in China. Then we describe current occupational therapy practice in China, in particular, the current Chinese government policies and regulations that support and incentivize the development of this profession. Next we describe the current state and development of professional occupational therapy education in China. Finally, we discuss the challenges and future development of occupational therapy in China.
Occupational Therapy Practice in China
It is often said that rehabilitation in China has a long tradition, but a short history. Although the history of rehabilitation in China can be traced back to ancient times, the development of contemporary and westernized rehabilitation is relatively recent. Rehabilitation practice in China, including traditional Chinese medicine, is often referred to as “rehabilitation medicine.” In the early 1980s, rehabilitation medicine in China was primarily provided by rehabilitation physicians (physiatrists) and physicians who practiced traditional Chinese medicine. The first treatment room that focused on occupational therapy was established in Beijing in 1988 (Lin, 2015). Shortly thereafter, the Ministry of Health in China required all secondary and tertiary Chinese hospitals to provide rehabilitation services that included occupational therapy (Ministry of Health, 1989).
The recognition of occupational therapy practice was reinforced after a significant turning point, the 2008 Sichuan earthquake. At the time of the Sichuan earthquake, the Chinese rehabilitation workforce consisted of only 100 occupational therapists (OTs) and could not meet the complex rehabilitation needs of the vast number of people who were affected. Because of the heightened demand for rehabilitation, including occupational therapy services, foreign OTs entered the earthquake-stricken area. Two years after the earthquake, foreign OTs trained local Chinese therapists to administer occupational therapy. In the meantime, Hong Kong Polytechnic University recognized the need for formal occupational therapy education and worked with Sichuan University to develop an advanced occupational therapy program. Slowly, the value of occupational therapy and its contribution to the rehabilitation of patients with traumatic injuries requiring orthotics (splinting), wound care, and scar management received recognition.
Rehabilitation services in China have evolved into a multidisciplinary approach, and the rehabilitation team often consists of rehabilitation medicine physicians, rehabilitation therapists, and rehabilitation nurses. In China, rehabilitation therapists include OTs, physical therapists (PTs), and sometimes speech-language pathologists (SLPs). Most rehabilitation services are in urban areas and in hospitals that commonly treat patients with stroke, traumatic brain injury, spinal cord injury, orthopedic pain, and cerebral palsy (Zhuo, 2006). Shi and Howe (2016) found that occupational therapy treatments in China focus on therapeutic activities and therapeutic exercises. Typically, instrumental activities of daily living, such as meal preparation, home management, and environmental modifications, are addressed by family members who provide care for patients. Most rehabilitation hospitals do not have environments to support activities of daily living, such as adaptive kitchens, bathrooms, and bedrooms to allow practice of functional activities (Shi & Howe, 2016). Gradually, occupational therapy practice has begun to shift from a focus on the medical model to transitioning back to the community, although most current occupational therapy practices remain based at hospitals (Lee, 2014).
One of the barriers to the development of occupational therapy services in China is limited public awareness and understanding. Occupational therapy in China must increase its recognition as a health care profession. According to the PricewaterhouseCoopers China Rehabilitation Market Analysis and Outlook (2016), only 10% of patients recuperating from surgery are aware of rehabilitation, and occupational therapy as a rehabilitation profession has even less recognition. Often patients are exposed to occupational therapy based on a referral from a physician or through the experiences of family members and friends.
Rehabilitation Needs and the Occupational Therapy Workforce
The challenge to meet the need for rehabilitation services in China, the most populated country in the world, is immense. According to a survey by Zhang and Shen (2014), approximately 1 billion people in China, including persons with disabilities or chronic disease and the elderly, require rehabilitation services. The number of people with disabilities continues to increase annually because of a growth in industrial and traffic accidents as a result of the development of industry and transportation. Advances in medical treatment have increased survival rates from traumatic events and neurological injuries, with a resulting need to improve patient function (Bo, Hong, Xuezong, & Zhongxin, 2008). Survivorship and improved living standards contribute to the growing aging population. With the increase in life expectancy, China is also experiencing an upsurge in geriatric conditions, and OTs are needed to prevent and treat functional decline as a result of heart disease, diabetes, and stroke (Zhang & Shen, 2014). Although 51 million persons in China with disabilities could benefit from rehabilitation, in 2007, only 19% received rehabilitation services (Zhang & Shen, 2014). Further, although 29.5% of persons in urban areas who had disabilities received rehabilitation services, only 15.7% of those in rural areas received rehabilitation services (Li, 2011).
The current shortage of OTs in China is alarming. In 2013, it was reported that the total number of rehabilitation professionals practicing in China, including OTs, PTs, and SLPs, was 32,076. Among rehabilitation professionals, it was estimated that 70.83% are PTs, 22.40% are OTs, and 6.77% are SLPs. The ratio of OTs to China's population is 0.24 to 10,000, whereas the average ratio of OTs to the population is 2.55 to 10,000 for countries in the Organization for Economic Cooperation and Development (Center for Health Statistics and Information, 2008; National Health Professional and Technical Qualification Examination Committee, 2013).
Government Policies and Regulations
In recent years, the Chinese government has implemented a series of policies and regulations to promote the development of rehabilitation services. The Ministry of Health in China published an administration guide and criteria for the department of rehabilitative medicine in general hospitals (Ministry of Health, 2011) that explicitly required the department of rehabilitative medicine to provide occupational therapy assessment and treatment. The Ministry of Health emphasized that occupational therapy is an integral part of rehabilitation services, which primarily have been considered part of the medical profession (i.e., medicine). The Ministry of Health advocates that occupational therapy is a health care profession, not a medical profession, as in the United States and other developed countries. In 2012, the Guiding Opinions on Rehabilitation Medical Work in the 12th Five-year Plan from the Ministry of Health of the People's Republic of China mandated that China must comprehensively enhance the capability of rehabilitation medicine. This enhancement involves incorporating the development of rehabilitation medicine and the service system for rehabilitation medicine into overall reform of public hospitals and improvement of management of rehabilitation facilities.
Along with this rapid development of rehabilitation medicine, massive professional rehabilitation medical centers and nursing centers in China have been established. The Ministry of Health of the People's Republic of China (2017) instituted policies and regulations to standardize the minimal requirements for rehabilitation medical and nursing centers. These regulations established standards for the number of required inpatient rehabilitation beds in medical and nursing centers. Rehabilitation medical centers that offer inpatient rehabilitation services must be equipped with at least 20 inpatient beds. Although no patient beds are required for rehabilitation centers that do not provide inpatient services, these centers must maintain at least 10 patient beds for rehabilitation outpatients. For rehabilitation centers that provide occupational therapy, OTs must provide functional assessments with the goal of enhancing function and provide services that address interventions and training in activities of daily living, cognition, social interaction and relationships, community integration, adaptive equipment, and environmental modifications. The policies and regulations for rehabilitation centers also mandate that each patient bed be equipped with five health care professionals, including physicians, rehabilitation therapists, nurses, and other providers. The ratio of health care providers at rehabilitation centers must be 1 physician to 2 rehabilitation therapists to 3 nurses (Center for Health Statistics Information, 2008; National Health Professional and Technical Qualification Examination Committee, 2013). The development and implementation of these policies and regulations will facilitate the increase and quality improvement of rehabilitation and nursing centers in China.
To ensure and advance quality care, many rehabilitation centers and hospitals in China are acquiring accreditation from the Commission on Accreditation of Rehabilitation Facilities (CARF) International. Table A (available in the online version of the article) lists the current rehabilitation facilities in China that have acquired CARF accreditation (CARF International, 2019). The growth in CARF-accredited Chinese medical rehabilitation facilities has improved quality assurance for occupational therapy and other rehabilitation professions.
CARF Accredited Health Care Facility in China
Occupational Therapy Education in China
Occupational therapy education in China originated with the onset of rehabilitation therapy services in the 1980s. At that time, OTs, PTs, and SLTs collectively provided services that were regarded as rehabilitation therapy. At its inception, rehabilitation therapy education (i.e., occupational therapy, physical therapy, and speech-language therapy) was limited to nondegree or certificate programs and training at the vocational high school level. In the 1990s, rehabilitation therapy education became more structured, moving to the associate's degree level. In the 21st century, however, Chinese rehabilitation therapy education moved to the bachelor's degree level and beyond (Jones & Skinner, 2013). In 2006, a national standard for rehabilitation therapy was recommended by the Ministry of Education for the degree of rehabilitation therapy. Before that, occupational therapy education in China was a focused area of study within rehabilitation therapy education and was not regarded as a separate, independent department or a separate degree track. Even today, most occupational therapy education in China is a focused area of study in the overarching field of rehabilitation therapy education. Rehabilitation therapy education is currently taught at more than 200 institutions in China, including medical universities, traditional Chinese medicine universities, sports medicine institutes, and training programs in high schools. Most practicing OTs in China trained as rehabilitation therapists before being assigned to the role or position of occupational therapist (Jones & Skinner, 2013).
Capital Medical University in Beijing, China, was the first university to develop separate programs within rehabilitation therapy for OTs and PTs. The occupational therapy program at Capital Medical University was recognized by the World Federation of Occupational Therapists (WFOT) at the 2006 WFOT Congress in Sydney, Australia. Capital Medical University and Nanjing Medical University developed the first series of textbooks for use in 4-year programs for OTs and PTs in China (Shi & Howe, 2016). Slowly, additional universities have separated these areas of study, and five universities have acquired WFOT recognition. The occupational therapy programs that are recognized by WFOT, along with their degree offerings, are shown in Table B (available in the online version of the article) (WFOT, 2016). Occupational therapy degree programs are usually housed within medical schools or medical universities and are strongly associated with a medical model of practice. This linkage with medical universities coincides with strong support from the Chinese government to provide rehabilitation in hospital settings. Therefore, occupational therapy education and rehabilitation education and practice follow a medical model rather than a functional model (Shi & Howe, 2016). Because of the rapid growth of occupational therapy in China, more students have entered degree programs, and they account for the majority of trained OTs practicing in China. Although there are degree programs, China has not developed a set educational standard for entry into occupational therapy practice. Some practicing OTs previously worked in other health care professions and only received on-the-job training or training through specialized sessions. Currently, China has different degree levels and structures for occupational therapy education. Rehabilitation therapists, including OTs and PTs, can obtain associate's, bachelor's, or master's degrees. Some universities in China separate OTs, PTs, and SLPs from the beginning of 4-year undergraduate programs. Some universities separate OTs and PTs after 2 years of study in a 4-year program. In addition, some colleges and universities in China combine occupational therapy and physical therapy education during all 4 years of education and training, and graduates choose to enter either field of practice.
WFOT Certified OT Programs in China
Currently, China has no national examinations to certify or register rehabilitation therapists or practitioners of specialized professions, including OTs. However, the Health Human Resources Development Center of the Ministry of Health in China administers examinations to promote the practice of rehabilitation therapists, including OTs, PTs, and SLPs. Rehabilitation therapists, including OTs, must pass specific examinations to be promoted to the next rank of employment at a health care system, such as promotion from a beginning level to an intermediate level (Fu et al., 2012). In China, professional associations have no independent Level I national association for OTs or PTs. In China, an independent national association is regarded as a Level I association. Currently, OTs are organized in a subcommittee under the oversight of the Chinese Rehabilitation Medicine Association. Under the oversight of this association, the subcommittee of OTs is considered a Level II association in China, which is a lower rank than a Level I association.
Since its inception in the 1980s, the field of rehabilitation services in China has made remarkable strides. With a growing overall population and a corresponding growth in the number of aging people and those with disabilities, there are tremendous challenges involved in meeting the need for rehabilitation services in China. Such challenges, however, provide opportunities to advance all aspects of rehabilitation services. To address the tremendous need, the Chinese government has implemented various policies and regulations that have helped to promote and incentivize the development and advancement of occupational therapy services and education. The effect of such policies and regulations has been promising, as evidenced by the awareness and recognition of the value of occupational therapy services, increased services to meet the occupational needs of Chinese citizens, improved quality of care in rehabilitation centers and hospitals, and standardization and advancement of occupational therapy education.
An exciting milestone in the history of the occupational therapy profession in China was becoming a full member of WFOT in 2018 at the WFOT Congress in Cape Town, South Africa (WFOT, 2019). The Chinese government and occupational therapy professional associations and organizations continue to foster the development of occupational therapy practice and education. These efforts include developing a set educational standard for entry into occupational therapy practice and a national system to certify, license, and relicense OTs to provide quality services, with an ultimate goal of meeting the needs for rehabilitation in the People's Republic of China.
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CARF Accredited Health Care Facility in China
|Health Care Facility Name||Location|
|Shanghai Fifth Rehabilitation Hospital||Shanghai|
|Xiangya Boai Rehabilitation Hospital||Changsha|
|JIHUA Orthopedic & Rehabilitation Hospital||Henan|
|Chongqing Yuxi Hospital||Chongqing|
|Henan Provincial Rehabilitation Hospital||Luoyang|
|Rehabilitation Medicine Center, Jiangsu Province Hospital (1st Affiliated Hosp, Nanjing Med University)||Jiangsu|
|Fujian University of Traditional Chinese Medicine Subsidiary Rehabilitation Hospital||Fuzhou|
|Guangdong Work Injury Rehabilitation Hospital||Guangzhou|
|Ningbo Rehabilitation Hospital||Ningbo|
|General Hospital of Heilongjiang Province Land Reclamation Bureau||Heilongjiang|
|Shiyan Taihe Hospital Rehabilitation Branch||Shiyan City|
|Jiangsu Zhongshan Geriatric Rehabilitation Hospital||Jiangsu|
WFOT Certified OT Programs in China
|University||Year OT Courses Commenced||Year Firs/Last Approved by WFOT||Degree Awarded||Location||Website|
|Kunming Medical University||2005||2010/2017||Bachelor of Science in Occupational Therapy||Kunming, Yunnan||http://www.admissions.cn/kmmu/index.html|
|Fujian University of Traditional Chinese Medicine||2011||2016/2016||Bachelor of Science in Occupational Therapy||Fuzhou, Fujian||https://www.fjtcm.edu.cn/|
|Shanghai University of Traditional Chinese Medicine||2006||2016/2016||Bachelor of Occupational Therapy||Shanghai||https://www.shutcm.edu.cn/|
|Institute for Disaster Management and Reconstruction (IDMR)/Sichuan University-Hong Kong Polytechnic University||ND||2015/2015||Master in Occupational Therapy||Chengdu, Sichuan||http://www.polyu.edu.hk/cmao/eng/?p=gallery&cname=5&pname=32|
|The Capital Medical University||2002||2006/2017||Bachelor of Occupational Therapy||Beijing||http://www.ccmu.edu.cn/|
|West China Medical School, Sichuan University||2008||2014/2014||Bachelor of Occupational Therapy||Chengdu, Sichuan||http://www.cd120.com/|