From population equality to demographic alignment: normative benchmarks and institutional governance of health workforce allocation in China, 2012-2024

The health workforce is a constrained health-system input, and allocation decisions often rely on workforce-to-population indicators. Although transparent and readily comparable, these indicators may obscure heterogeneity in demographic demand across provinces and health subsystems. We examined whether provincial health workforce distributions in China became more closely aligned with subsystem-relevant demographic proxies between 2012 and 2024.

We conducted a provincial longitudinal ecological study covering 31 mainland provincial-level units and 403 province-year observations. Four prespecified relationships were assessed: hospital workforce vs. older population, primary healthcare workforce vs. older population, maternal and child health (MCH) workforce vs. child population, and MCH workforce vs. a birth-demand proxy. Alignment was assessed using provincial workforce and demographic-proxy shares, together with annual distributional mismatch, dispersion, β-convergence, rank persistence, regional alignment, and sensitivity analyses.

Hospital-older-population mismatch decreased from 0.116 in 2012 to 0.077 in 2024, with β-convergence (β = -0.0435, q < 0.001). Primary healthcare showed no consistent convergence relative to the older-population proxy: D remained 0.076 at both endpoints, whereas the primary healthcare-total-population benchmark decreased by 36.3%. For MCH, mismatch relative to child population decreased by 31.7%, with β-convergence (β = -0.0396, q = 0.031), although unweighted cross-provincial dispersion did not decline. MCH mismatch relative to the birth-demand proxy decreased by 18.9% but showed no consistent convergence and widened again after 2021.

General-population equalization did not translate into similar demographic alignment across health subsystems. Subsystem-specific demographic benchmarks function as alternative normative criteria for interpreting workforce allocation under demographic change, revealing patterns not apparent from total-population indicators. They should be interpreted as descriptive distributional measures, not as estimates of staffing adequacy or allocative efficiency.