It is a measure of the importance of China's health system and public health that The Lancet has dedicated a series of papers to it. And the introductory “Comment” to the series sets out the importance of China for global health: China accounts for one fifth of the world's population; it is a major source of health innovation; it is “a major contributor in the control and spread of global health risks” as its participation in trade grows; and its health system is now extending globally, notably through its influence in the World Health Organization (WHO) and in sending health teams to Africa.
The series consists of seven main papers on “Health system reform in China,” and 12 short “Comment” pieces. Together these provide readers with an up-to-date and wide-ranging picture of China's most important public health problems and a sense of the key issues facing the health system. The papers draw – though not necessarily very systematically – on some of the latest data and research. The Comments provide brief but illuminating summaries on important related issues, including biomedical science and technology, the current role of traditional Chinese medicine, reproductive health, the HIV/AIDS epidemic, schistosomiasis control, barefoot doctors; medical research ethics, government policy and organ transplantation, and internal migration and health. There is a fascinating brief anthropological account of why smoking is so prevalent among Chinese men and rare among women.
Three of the main papers examine China's most important public health problems, and the four others discuss aspects of its health care system's finance and delivery. The papers on public health (that is, the health of the Chinese population) focus on the big issues to give an overview of key trends in infectious diseases, chronic non-communicable diseases, and in injury-related fatalities. They then assess the implications of these trends for the health system. Wang and colleagues argue that many infectious diseases are in decline, though there are new challenges from HIV/AIDS, SARS and avian flu. Of particular concern for the future are infections – like SARS and avian flu – that are transmitted from animals. The risk that such infectious diseases will continue to emerge is high because China's growing wealth has resulted in rising meat consumption and therefore a rapid increase in the number of animals raised to provide food.
At the same time, China is seeing the same kind of increase in non-communicable diseases that wealthier countries have experienced. Yang and colleagues argue that China has now completed the transition from infectious diseases and maternal and perinatal conditions as the predominant causes of death, to chronic diseases and injury. They show rising trends in mortality from lung cancer, cerebrovascular diseases, heart disease and diabetes. And they trace the growing prevalence of these chronic illnesses to behavioural factors: changing diet (more fat and salt, fewer cereals), reductions in physical activity, and increases in smoking among men.
The paper on injury fatalities is particularly interesting. Strikingly, it points out that the 69,000 deaths in the Spring 2008 Sichuan earthquake would have contributed less than ten per cent of China's 800,000 injury-related deaths that year. Here, Wang and colleagues discuss the three main sources of injury-related death. Traffic accidents are most common, due in large part to increased motorization. Second is suicide, which in China is most prevalent among women (in other countries it is usually more common among men). But it is declining, perhaps, the authors suggest, because of rising incomes and reduced access to pesticides (widespread in rural areas) due to urbanization. Third is drowning: while many Chinese live near water, few can swim.
These papers all suggest ways forward: policies and interventions that might reduce risks and help improve health interventions. While some policies do not directly involve preventive or curative health care – for example teaching children to swim, many do. And yet the four main papers in the series that deal with the health system and its socio-economic context reveal, alongside some encouraging recent developments, the enormous fundamental problems that still need to be tackled.
China's health system has been radically transformed in the three decades since China began its shift from state planning to markets in the economy. The four main papers in the series look at aspects of that transformation, though they focus more on where China is today than on how it got there. They look in turn at “challenges to health equity,” human resources, the financing of health, and China's health system performance. Tang and colleagues examine the health equity issues in China, showing the significant “disparities in health,” including differences in life expectancy between rich and poor provinces and in child malnutrition between urban and rural areas. They trace these to inequities in the social determinants of health (notably income inequalities) and “imbalances in the role of government and market” – a reference to the negative impact that the commercialization and marketization of China's health system. They also see “public perceptions of unfairness” as contributing to the problems, though they do not explain how.
Several other papers in the series also demonstrate the great inequities in the health system. Anand and colleagues contribute an excellent paper on the human resources for health, assessing their quantity, quality and distribution. They note that, unusually by international comparison, China has more doctors than nurses. They then demonstrate the higher density of doctors (and nurses) in urban areas and inter-county inequalities in the distribution of doctors, and using 2000 census data show that the density of health worker has a significant impact on infant mortality rates. Hu and colleagues also, in their paper on health finance, vividly show the enormous problems with health coverage and affordability that result from financing problems: the massive rise in “out-of-pocket” payments; poor health insurance coverage; escalating costs; inefficient use of resources; “misaligned incentives”; and regional disparities in health spending. All these have led to serious inequities in people's access to health care.
China has experienced three decades of sustained economic growth since 1978 and several of the papers point out that it should therefore be able to afford to tackle the problems of inequity. Some papers in fact indicate that it might have begun to do so, noting what may turn out to be a series of major policy shifts since the turn of the 21st century: the Chinese government has increased health spending, instigated a major review of health system reform, established better systems for disease surveillance, and begun new health insurance programmes. These all indicate substantial political will to tackle the many public health challenges and improve equity.
But most of the papers in the series also indicate the significant obstacles to turning around China's troubled health system. These include not only the risks from new infectious diseases, the growing burden of chronic diseases, and the negative consequences of socio-economic change for injuries and accidents, but also opposition from powerful vested interests. The Comment by Dong and Phillips that sets out the “Evolution of China's health care system” provides some important background that helps make sense of the other papers' references to marketization, privatization and inequity in a system that was once internationally acclaimed for its equity and contribution to dramatically improving health outcomes. This paper also notes likely sources of opposition to reform, including drug companies and large hospitals that have benefited from marketization and weak regulation. It is apparent from the paper by Tang and colleagues that some of the problems lie outside the health system, in China's decentralized fiscal system and unequal economic development. Political opposition and poor state capacity make these wider problems even more difficult to tackle than those within the health system.
What is perhaps lacking in the series, however, is a more thorough exploration of these issues and of why China's health system over the last 30 years shifted so dramatically from a highly equitable one to one that is amongst the most unfair in the world. This might help health researchers and policy makers better understand and deal with the obstacles to the current health reform policies.
While it is difficult to be very optimistic about the prospects for turning around a large and complex health system that is embedded in such a diverse, rapidly changing and unequal society, the papers do give some sense of the opportunities as well as problems. Indeed the papers themselves are encouraging in demonstrating the extent of research collaboration among the Ministry of Health and Chinese and international health researchers. These collaborations are analysing and developing new datasets and research projects that provide vital evidence for Chinese policy makers. And The Lancet's series itself is the beginning of a planned collaboration involving Chinese governmental organizations, the China Medical Board and the WHO. All this activity shows the extent of change within Chinese research and policy-making circles, and indicates that productive partnerships are emerging to tackle Chinese and global health problems.
