Health improvements for a healthy Shanghai rising

Abstract

The commentator suggests that it is necessary to extend the classical connotation of global city which focuses much on the functions of controlling global capital and production. Global city should also include the dimensions of the leading role and capacity on health improvements and well-being promotion. The commentator agrees with authors’ assessments about Shanghai’s substantial progress on health services and health system reform, however, we should pay much attention to the significant inequality of health services between central city and outskirt, and between local residents and non-hukou migrants. The commentator also suggests that future researches could study the successful experiences of Avoidable Mortality (AM) decline and also disease specific AM decline in main global cities, in order to make more effective policy implications and social schemes recommendations for health improvements in Shanghai and in other cities.

Observing the substantial decline of Avoidable Mortality (AM) in Shanghai, and comparing this with other global cities such as New York, London and Paris, Gusmano and his colleagues (1) demonstrated in this paper the big progress of Shanghai’s public health and health system since 2000, including the high investments in public health, good health management reforms especially community-based health services, and etc. The paper shows the age-adjusted AM in Shanghai is lower than in New York and in London and higher than in Paris, and the speed of decline of AM is faster than in Paris and slower than in London, and it is similar with in New York.

Overall, this study offers optimistic evaluations for Shanghai’s public health system. “Shanghai Rising” is, therefore, not only an economic rising, it is also a rising in health services, and this makes the rising a “healthy Shanghai Rising”. An important implication is that global cities should extend the classical notion of their functions of controlling global capital and production, which is emphasized by Sassen in her famous works (2). The future global cities should also focus on their leading role and capacity of achieving social progress, health promotion, cultural and technological innovation, fashion and leisure, and environmental sustainability, and so on. The future global cities should make more efforts to promote people’s overall well-being, including public health. The necessity to shape an updated understanding about global city is not only because the essence of city life is to improve people’s well-being, but not just a capital machine. Meanwhile, we also could conclude the traditional global city is based on global productive chain and related financial capital flows, and with the changes of global industrial system toward health industry, services economy and ecological and green economy, and so on, those emerging industries strongly related to human health and welfare would also influence the global capital flow and services trade patterns in the future, consequently, that will constitute new connotations, and make new guidelines for future global cities, including Shanghai.

Comparing health improvement with AM among different cities, Shanghai’s health services seem to have entered the rank of the world’s top cities. However, comparative studies among different cities are always fraught with risks. As the authors have already mentioned in the paper, one of the limitations of the study is that the analysis is just based on 14.9 million local hukou population but does not include the information of nearly 10 million non-hukou migrants. Other limitations include coding errors on causes of death, and the ambiguous relation between some disease-specific mortality rate and the health system itself.

Besides, different cities have different spatial structure and population size, and it weakens the comparability among cities. For example, New York City, with approximately 800 square kilometers land area and a population of 8 million, is totally different from the city of Shanghai, which covers an area of 6,300 square kilometers with a population of 24 million. In fact, the city of Shanghai in statistics include a “morphological CITY composed by urbanized central districts” and “surrounding large scale rural and sub-urban areas”, thus it is more like the New York metropolitan area in terms of the spatial structure, but not the New York city. Similarly, Paris intra-muros and 3 departments of the first ring has the total area of 749 square kilometers, and 6.2 million population, is not suitable to compare with the metro Shanghai either. London city is even smaller, therefore, using the area of Greater London makes a comparable strategy along with New York and Paris city. Simply comparing the Shanghai metropolitan area (allow me to use this concept here replace the Shanghai in statistics) with New York City, Paris and Greater London might conceal a serious problem that there is great inequality in health services provision between Shanghai CITY (that could be morphologically defined the place inside the outer-ring area, and is around 660 square kilometers and has 10 million populations) and the outskirt of Shanghai. The health services per capita in Shanghai central city is 5 to 6 times its sub-urban area, and health services per square kilometers in central city Shanghai is even 40–50 times higher than the city’s average (3). The spatial inequality of public health services in Shanghai needs further researches and deserves more policy attention.

In order to make a proper assessment about the health services improvements in Shanghai, I would like to further emphasize the limitations to use hukou-based mortality data to evaluate the real health services situation in Shanghai. We know that Shanghai is a large city composed by migrants. So far among the 24.15 million permanent populations in Shanghai, about 10 million are non-hukou migrants who stay in Shanghai for more than half a year and mostly have stable jobs and resident places. Meanwhile, Shanghai’s public health system and health services provision is based on the hukou-system. Therefore, most non-hukou migrants do not have equal access to health services compared to local residents. Our recent research in Shanghai shows only 39.5% of non-hukou migrants had urban worker’s medical insurance in 2012, while 75.7% of local hukou residents had. Meanwhile, only 4.4% of non-hukou migrants had urban residents medical insurance, compared to 22.1% of local residents. In addition, 30.9% of non-hukou migrants who had been sick or in need of healthcare in 2012 visited a pharmacy for medical care, yet only 3.3% of local-hukou residents selected this method for medical treatment; 44.1% of non-hukou migrants visited hospital, compared to 62.2% local-hukou residents. Although we still need more data to make an accurate examination, with consideration of the poor access to basic public health services of those non-hukou migrants, the overall health services provision in Shanghai should not be as optimistic as the paper suggests. It also indicates that the serious inequality of health services between the local residents and the non-hukou migrants is a big challenge for a healthy “Shanghai rising”.

Cerebrovascular Disease (CVD) and Ischemic Heart Disease (IHD) are leading causes attributing to the decline of AM in Shanghai. What would make the paper more interesting is to identify what kind of health improvements (schemes/intervention programs) attribute to this kind of mortality decline. What’s more, it would be valuable to show whether there are some differences in causing the AM decline among different global cities. If so, what are the main reasons? Are there any effective experiences to attribute to decline of some decrease-specific mortality in different global cities? For example, we could learn from New York’s practices, that different with investment in hospitals and disease control centers, construction of buildings, streets, neighborhoods, community gardens, local swimming pool and recreation facilities to make an active urban design (4) will have significant effect to change people’s life style to reduce obesity, as well as CVD caused high blood pressure, and to improve people’s health. Those disease-specific and item-specific researches on AM decline would lead to effective implications for improving health system and health services. Comparative studies on causes of AM decline in different global cities would give more insights for improving health system in other cities.

Despite facing a number of challenges, we could say that Shanghai as a rising global city is experiencing a “Healthy Rising” through significant health improvements caused by high investments and health system reforms. It is also caused by people’s huge demand for high quality health services. The rapid progress of health services creates new development opportunities for urban services industry, and to some extent helps the city to achieve the transformation from a manufacture-based economy into a service-based economy. In this sense, health improvements also become an important opportunity for global city’s growth, and will provide a driving force for city’s future prosperity and for citizens’ well-being advancement.

Acknowledgments

The author would like to acknowledge the editorial support of Ms. Jie Wu.

Ethical issues

Not applicable.

Competing interests

Author declares that he has no competing interests.

Author’s contribution

YR is the single author of the manuscript.

Citation: Ren Y. Health improvements for a healthy Shanghai rising: Comment on "Shanghai Rising: health improvements as measured by avoidable mortality since 2000". Int J Health Policy Manag 2015; 4: 189–190. doi: 10.15171/ijhpm.2015.33