Healthcare reform in China: challenges and opportunities

China is the world’s most populous country, with a population of ∼1.3 billion. In recent decades, China has experienced an impressive gross domestic product growth and rapid economic development, which are, however, accompanied by sharp demographic challenges¹. Societal and economical changes led to new nutritional and behavioral patterns that occurred in a historically unprecedented rhythm. Mortality patterns changed rapidly, and chronic degenerative diseases replaced infectious diseases as the leading cause of death². Thus, non-communicable diseases are attributable for 87% of all-cause mortality nowadays³. In accordance with Western societies, hypertension, smoking, dyslipidemia, type 2 diabetes (T2DM), and obesity represent the principal risk factors for cardiovascular disease (CVD) in the Chinese population⁴. Alarmingly, the prevalence of all these major risk factors is on the rise across China. One third of the world’s smokers are Chinese⁵. The prevalence of T2DM is rising, and is significantly higher in urban areas⁶. Hypertension also follows a similar trend⁷, and obesity has increased rapidly, especially in urban settings⁸. Given these alarming findings, it is somewhat expected that the rate of hospital admissions for acute myocardial infarction in China quadrupled between 2001 and 2011⁹. Even though coronary heart disease is the leading cause of death in China¹⁰, the burden of stroke is also one of the highest worldwide¹¹. However, a variety of measures have been implemented to prevent, treat, and improve the prognosis of CVD, with promising preliminary results⁴. Recent studies suggest rising rates of guideline-recommended care¹².

Despite the shifting emphasis to CVD, infectious diseases, traditionally linked to poverty and high population density, are still present and new ones are emerging in China¹³. Tuberculosis, hepatitis B, HIV/AIDS, rabies, and Japanese encephalitis are still responsible for significant mortality¹³. Even though the incidence of infectious diseases has shown a less steep rise in the last years, it is still increasing¹⁴. At the same time, the emergence of severe acute respiratory syndrome¹⁵ and several avian influenza outbreaks¹⁶ revealed the complexity of disease burden in the new millennium, demanding large resources and forming new challenges for public health.

Further complicating the prevention and management of both infectious and non-communicable diseases is the economic environment in China. Despite the fact that tremendous reduction in poverty has marked the last decades¹⁷, China remains a developing country, with a significant number of people living in poverty¹. Indeed, 20.1% of Chinese counties are labeled as poverty regions. The average poverty prevalence in the Chinese population is 21.4%, and ranges widely between 3.1% and 55.5% across different regions¹⁸. The persistent increase in the incidence of infectious diseases appears to be mostly due to the high rates in provinces near the remote Chinese border¹⁴. Furthermore, it is remarkable that there are also substantial variations in the incidence of both infectious and non-communicable diseases within each province¹⁸. The consequences of poverty and the complexity of the associated socioeconomic factors form a substantial challenge that health policy-makers face in China¹⁸. Moreover, migration and urbanization form additional challenges¹⁷.

Poverty and socioeconomic disparities translate into health disparities among the population. Differences in life expectancy, child health indicators, reproductive health, sanitation, and access to safe drinking water and healthcare are examples of health disparities across different provinces and among rural and urban populations¹⁹. In addition, the rapid growth of vulnerable groups such as the elderly and patients with obesity and T2DM poses additional challenges in healthcare²⁰.

It seems difficult to form health policies for China. Furthermore, the question on how to measure the performance of the healthcare system does not have a simple, straightforward answer. Health disparities, socioeconomic inequality, rapid epidemiological transition, internal migration, and the growth of the aging population demand several different solutions. The issue is how China’s health system performs for groups with different and unequal needs²¹. In response to the increasing challenges, China initiated major healthcare reforms to improve the accessibility and affordability of medical services^22,23. These included renovation of the primary care system, with particular emphasis on rural areas, incentives for deployment, and retention of healthcare professionals in rural areas, incorporation of essential medicines into insurance reimbursement and provision of these medicines at cost, implementation of a basic public health package, including chronic disease management and elderly healthcare, increase of subsidies for this package, increases in annual premiums, reimbursement ceilings and inpatient reimbursement rates, and coverage of some outpatient conditions^22,23. In addition, consolidation of social health insurance schemes is currently in progress to promote equity in healthcare coverage^22,23. As a result of these reforms, in 2011, 95.7% of households in China had insurance coverage²⁴. Moreover, the proportion of out-of-pocket payments in total health expenditures was reduced, and 45.9% of inpatient costs were reimbursed from insurance²⁴. Importantly, inequalities in insurance coverage and in access to care between rural and urban areas and between different districts were substantially reduced between 2003 and 2011²⁴.

In such a demanding public health environment, tackling risk factors for CVD is an especially difficult task. Chronic diseases exert pressure on China’s recently-launched healthcare reforms. Dyslipidemia is one of the major preventable risk factors for CVD²⁵. The prevalence of dyslipidemia is high in China, with striking differences between urban and rural populations and between districts with developed and less developed economies²⁶. Moreover, rates of awareness, treatment, and control are particularly low²⁶. An evidence-based, efficient, and contextual plan is essential for the identification and management of patients with dyslipidemia, considering the multitude of socioeconomic challenges that are present in China.

In this context, Yu et al.²⁷ focus on the evaluation of various global programs for the prevention, diagnosis, and treatment of dyslipidemia and on their results, aiming at assessing whether such programs would be useful in China. Their work is significant, because identification of prevention policies and learning from the global experience might lead to regional improvements in health policies. However, a major limitation of the work of Yu et al.²⁷ is that it discusses dyslipidemia management programs that have been implemented in high-income countries with different cultural characteristics; it is unclear if these programs will be as successful in China. Moreover, some of these programs had limited efficacy in achieving their goals²⁷. On the other hand, China is a prominent example of a rapidly developing country that achieved significant progress in healthcare and might set an example for other developing countries. The evaluation of the effects of implementation of dyslipidemia programs in China might provide guidance for future health reforms in other countries and contribute to the development of novel prevention plans worldwide. China’s experience may provide a model relevant and useful for other developing countries and enable the dissemination of technical knowledge on the optimization of healthcare policy reforms in these demanding settings.

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Declaration of funding

This paper was not funded.

Declaration of financial/other relationships

The authors have no conflicts of interest to declare. CMRO peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgements

None.