The Lancet: China-themed issue

China's rapid emergence as a global power has coincided with a series of unprecedented challenges to Chinese people's health. The fifth China themed issue of The Lancet provides a picture of the complex health issues facing China, and looks at how better health outcomes for Chinese people can be achieved into the future.

In this issue, the journal highlights the dire consequences that urbanisation and increasing affluence are having on China's chronic disease burden. The journal also reports systematic and comprehensive assessments of China's health-care system and revamping the world's largest medical education system.

Important advances have been made in expanding health insurance coverage to 96% of the population in China. However, these increases have not been accompanied by improvements in the "wasteful and inefficient" health-care delivery system, whilst poor working conditions including underpaid and overworked doctors are fuelling an escalating crisis of violent attacks against medical workers. The Series looks at how China has moved closer to its goal of affordable, quality basic health care for all, and reviews the challenges that still lie ahead and adjustments needed for successful reform.

China has increasingly emerged as an important player in global health and the Series concludes by looking at China's global health strategy. In particular, how China is reshaping the global health landscape with its distinctive approach to foreign aid, and in global health policy-making via its active participation in important international organisations such as WHO, UNAIDS, and the Global Fund.

• China must act now to tackle timebomb of chronic diseases, warn experts
• "Wasteful and inefficient" health-care delivery could derail China's ambition to achieve affordable and quality basic health care for all
• Revamping the world's largest medical education system: mixed results of progress
• China: reshaping the global health landscape

The Lancet: China must act now to tackle timebomb of chronic diseases, warn experts

China must act now to tackle the growing challenges posed by injuries, mental illness, obesity, smoking, environmental pollution and other public health threats or face the huge toll of largely preventable health loss suffered by high-income countries, warn experts in a Review published as part of a Lancet themed issue on China.

Rapid and extraordinary economic growth over the past few decades has resulted in some shocking statistics on death and illness from injuries and chronic diseases in China. Injuries cause around 800 000 deaths a year and are the leading cause of death in people aged 1 to 39 years old. Some 173 million adults have a mental health disorder but the vast majority (92%; 159 million) have never received professional help. The number of people living with dementia has more than doubled from about 3.68 million in 1990 to 9.2 million in 2010. Ambient air pollution kills more than 1.2 million people a year, while indoor air pollution from solid fuels accounts for a further 1 million premature deaths a year. Tobacco kills roughly 1 million people each year, and if present trends continue, this is expected to rise to 3 million by 2040. Finally, there have been alarming increases in levels of obesity, with the number of overweight or obese adolescents rising from 16.1 million in 2000 to 20.4 million in 2010.

In this Review, Dr Jeffrey Koplan, Vice President for Global Health at Emory University, Atlanta, USA and colleagues take a critical look at progress in tackling chronic diseases since the 1990s, lament the inadequate coverage of basic interventions that could make a massive difference, and urge China to urgently adopt a number of cost-effective interventions to improve individual and population health (eg, increasing taxes on tobacco and alcohol and introducing regulations for seat belts and helmets for cyclists).

According to Professor Koplan, "Similar to the focus on prevention, which was the hallmark of China's remarkable success against infectious diseases, its new challenge will be to make this progress in chronic disease control in a much shorter time-frame than high-income countries. If China takes advantage of lessons learnt in other countries (including taxation, regulation or legislation, and information or education) and uses its own scientific and creative resources to increase our knowledge of better disease control and prevention, it will provide a health model for the world."*

Notes to Editors:

*Quote direct from authors and cannot be found in text of Review.

The Lancet: "Wasteful and inefficient" health-care delivery could derail China's ambition to achieve affordable and quality basic health care for all

China has done well in expanding the coverage of health insurance to 96% of the population since it launched nationwide health-care reforms in 2009, but poorly in reforming the "wasteful and inefficient" health-care delivery system. These substantial challenges, together with a new policy to promote private hospitals is endangering China's goal of providing affordable and quality basic health care to all by 2020, according a Review published as part of a Lancet themed issue on China.

"Chinese health care still faces considerable challenges to transform from a poorly governed, hospital-centred system that puts profit above patient welfare, to a primary care-based delivery system that is cost effective and better able to respond to a population increasingly affected by chronic diseases and disabilities associated with ageing", explain authors Winnie Yip, Professor of Health Policy and Economics at the Blavatnik School of Government, University of Oxford, UK, and William Hsiao, research Professor of Economics at Harvard School of Public Health, Boston, USA.*

Despite the government almost doubling annual health spending to ¥836.6 billion (£1 is roughly equal to ¥10) between 2009 and 2012, with substantial investment in primary health care, most visits and admissions continue to take place in hospitals. As a result, primary health-care facilities have not been able to perform their key functions of prevention, case-detection, gate-keeping, and referral—essential for chronic disease prevention and control.

Take hypertension (high blood pressure) as an example. Despite being the second largest risk factor causing disability and death (the first being tobacco), only 42%­–57% of adults with hypertension are aware they have the condition, whilst just a third to half of patients with hypertension receive treatment. What is more, admission rates for complications from diabetes in China are more than five times the rate in countries of the Organization for Economic Cooperation and Development (OECD) countries—a sign of poor primary health care.

Worryingly, say the authors this might only be the tip of the iceberg: "The government's latest strategy to promote private investment for hospitals, with the target of private hospitals meeting a 20% market share by 2015, would result in escalating health-care expenditure, with patients bearing increasing costs; a two-tiered system in which access and quality of care are decided by ability to pay; and poor population health outcomes."*

They conclude that to steer China back on course to achieve its health goals an alternative strategy is needed to reform public hospitals to pursue the public interest and be more publically accountable, with public hospitals as the benchmarks against which private hospitals would have to compete. They add, "China should assess how the entry of private hospitals affects its health-care system before it makes any decision to further expand their market share. Otherwise, China might not be able to rein in a runaway delivery system plagued with inequity and cost escalation."

Notes to Editors:

*Quotes direct from authors and cannot be found in text of Article.

The Lancet: Revamping the world's largest medical education system: mixed results of progress

Beginning in 1998, China launched sweeping reforms to the higher education system in which medical education was also substantively promoted to ensure that health professionals were trained more effectively and efficiently to produce a workforce of sufficient size, specialty mix, and skill to meet public needs. A Review in The Lancet themed issue on China reports mixed results of progress and highlights the urgent need for further reform.

The reform was urgently needed, explained Professor Yang Ke, author and Executive Vice President of Peking University Health Science Center, Beijing, China. "Before the reform, China had more doctors than nurses, and many nurses had only been educated to high school or secondary school level. Doctor density in urban areas was more than twice that in rural areas. And despite efforts to train very large numbers of medical graduates, many did not enter the health workforce and took jobs in industry or changed occupations, highlighting inefficiencies in the system."*

The ambitious education reforms have successfully merged training institutions into universities and greatly increased the enrolment of health professions. In 2012, China produced 500 000 health professional graduates from 590 institutions, including 29 000 nurses with bachelor degrees and 156 000 with diplomas to help correct the very low nurse-to-doctor ratios. Furthermore, new policies offering incentives for doctors to work in rural areas were launched in 2010, and more recently, a target to train 300 000 general practitioners (GPs) by 2020 was announced.

There is more to be done, say the authors. "Some educational reforms appear to be on the mark—more nurses, GPs, and rural doctors, but other needed reforms have yet to begin. Infrastructure, public funding, and faculty size have not kept pace with rapid student expansion, raising concerns about the impact on academic quality. Worryingly, since 1998 there have been insufficient curriculum changes. Biomedical sciences and clinical practice continue to dominate the curriculum to the detriment of content that would enhance patient care (eg, humanities, social sciences, communication skills, ethics, public health, and patient exposure)."*

Worse still, they say, "Poor health-care system conditions including underpaid and overworked doctors with only brief time for patients; poor communications between doctors and patients; and a lack of patient trust in profit-driven doctors ordering of tests and drugs, are fuelling an escalating crisis of violent attacks against medical workers and medical disputes. Medical disputes have increased by about 23% every year since 2002, and medical violence has tripled in 8 years, from around 5000 incidents in 2002, to over 17 200 in 2010."*

Notes to Editors:

*Quotes direct from authors and cannot be found in text of Review

The Lancet: China: reshaping the global health landscape

In this paper, published as part of a Lancet themed issue on China, Professor Peilong Liu from Peking University Health Science Center, Beijing, China and colleagues discuss China's distinctive approach to, and increasing participation in, global health.

Taking foreign aid as an example, they show that the type of health aid China offers is different from other developed countries, driven by its unique history and competencies, and complex motivational factors—political, economic, social, and humanitarian. Rather than offering general financial support, China focuses on some important aspects of the health system such as deploying medical teams, constructing hospitals and clinics, donating drugs and medical equipment, training personnel, and supporting malaria control efforts using artemisinin based on traditional Chinese medicine.

Over the past 50 years, China has dispatched around 23 000 medical personnel to about 66 countries providing services for an estimated 270 million people and constructed more than a hundred health facilities mainly in Africa and Asia. Recently, China has also been an active member in the UN and other related bodies such as WHO, and has become a contributor to multilateral funding pools such as the Global Fund.

The Review concludes that, "the scope and depth of China's global engagement are likely to grow and reshape the contours of global health."

Provided by Lancet