Prioritizing Top Health Issues in China Beyond 2018: A Health Equity Perspective

China, the most populous country in the world, has experienced fast economic growth since the establishment of its market reform policy in the early 1980s. After 35 years of rapid economic growth, China is now an upper-middle-income country. Chinese people are living longer and healthier than they did 30 years ago. Life expectancy at birth reached 76.5 years in 2017, an increase of 8.6 years in 35 years.¹ Coverage of basic health insurance has reached 95%, and total health expenditures have increased almost 40-fold over the past 20 years to reach 5.6% of the country’s gross domestic product.²

Despite these achievements, Chinese residents experience significant disparities in health according to urban and rural residence, ethnicity, income status, and geographic region.^2,3 In 2014, for instance, the neonatal mortality rate per 1000 live births was 6.9 in rural areas and 3.5 in urban areas (rural–urban ratio = 2.0), the infant mortality rate was 10.7 in rural areas and 4.8 in urban areas (rural–urban ratio = 2.2), and the under-five mortality rate was 14.2 in rural areas and 5.9 in urban areas (rural–urban ratio = 2.4). Table 1 presents examples of regional differences in life expectancy in China.²

TABLE 1—

Average Life Expectancy at Birth by Province, Autonomous Region, and Municipality: China, 2014

Province, Autonomous Region, or Municipality	Life Expectancy, y	Difference From Shanghai, y
Beijing municipality	80.2	−0.1
Tianjin municipality	78.9	−1.4
Hebei province	75.0	−5.3
Shanxi province	74.9	−5.3
Inner Mongolia autonomous region	74.4	−5.8
Liaoning province	76.4	−3.9
Jilin province	76.2	−4.1
Heilongjiang province	77.0	−3.3
Shanghai municipality	80.3	0.0
Jiangsu province	79.6	−0.6
Zhejiang province	77.7	−2.5
Anhui province	75.1	−5.2
Fujian province	75.8	−4.5
Jiangxi province	74.3	−5.9
Shandong province	76.5	−3.8
Henan province	74.6	−5.7
Hubei province	74.9	−5.4
Hunan province	74.7	−5.6
Guangdong province	76.5	−3.8
Guangxi Zhuang autonomous region	75.1	−5.2
Hainan province	76.3	−4.0
Chongqing municipality	75.7	−4.6
Sichuan province	74.8	−5.5
Guizhou province	71.1	−9.2
Yunnan province	69.5	−10.7
Tibet autonomous region	68.2	−12.1
Shaanxi province	74.7	−5.6
Gansu province	72.2	−8.0
Qinghai province	70.0	−10.3
Ningxia Hui autonomous region	73.4	−6.9
Xinjiang Uyghur autonomous region	72.4	−7.9

Note. Data were derived from the United Nations Development Programme.²

About 70 million residents of China still live below the poverty line,⁴ which also influences their health status. Fast economic growth and urbanization have led to major shifts in lifestyles (e.g., overnutrition and sedentary lifestyles) and created new environmental problems (e.g., air pollution, water pollution, and global climate warming). Chinese media outlets frequently report major incidents related to unsafe food and drugs. High out-of-pocket medical care expenditures have become a significant challenge for many Chinese residents, especially senior citizens and those living in poverty. Furthermore, the Chinese population is aging rapidly; 13.7% of the country’s residents were aged 65 years or older in 2011, a figure that is predicted to climb to 35% by 2050.⁴

Against this backdrop, it appears that China will face challenges in further improving its health indicators, an important national goal of Healthy China 2030.⁵ Targets include increasing life expectancy at birth to 79.0 years by 2030, reducing infant mortality from 8.1 deaths per 1000 live births in 2015 to 5.0 deaths by 2030, and reducing under-five mortality from 10.7 deaths per 1000 children to 6.0 deaths. If these national health indicators are to be achieved, it is imperative that top health problems be identified so that the limited resources available can be used to address important and preventable health concerns.

In this issue of AJPH, Wu et al. (p. 1592) from the Chinese Center for Disease Control and Prevention use a modified Delphi process to synthesize the opinions of a panel of 70 top Chinese health experts on the 20 most important and most preventable health problems in China. The surveyed participants included a group of eminent and knowledgeable experts who were mostly academicians in the Department of Medicine of the Chinese Academy of Engineering and actively worked in the fields of medicine, medical research, and public health. The top 20 health problems identified by this group covered nine noncommunicable diseases, four communicable diseases, two unhealthy behaviors, two types of environmental pollution, depression, nutrition and food safety, and road injuries.

SCOPE OF THE LIST

Overall, the list of health problems included nine of the top 10 causes of death in China. Yet, surprisingly, stomach cancer, which is ranked as the sixth-leading cause of death the country (with an increasing incidence of cases),⁶ was omitted from the list. The findings showed that the panel viewed prevention as better and more important than treatment; the list included multiple preventable risk factors—both behavioral (smoking, unhealthy diet) and environmental (air pollution, water pollution)—that have contributed significantly to the occurrence of noncommunicable diseases. In fact, air pollution (ranked fourth), smoking (ranked seventh), and water pollution (ranked ninth) were ranked among the top 10 health problems on the list. The high ranking for water pollution is surprising given official health statistics showing that more than 95% of Chinese residents use improved drinking water sources.⁶

Road injuries, ranked as the seventh-leading cause of death in 2012,⁶ were surprisingly ranked low by this panel (at 16th). Finally, Chinese culture stigmatizes mental illness, and China is ill equipped to treat mental conditions. The panel’s inclusion of depression (ranked 15th) indicates the dire need for mental health interventions in China in the future.

NEED FOR INCREASED PANEL DIVERSITY

One study limitation not mentioned by the authors is the external validity of their list. Because the panel members were mostly male (82%), were 63.6 years of age on average, and had worked in biomedical fields for a mean of 36 years, their opinions about the 20 most important health problems in China may be biased by their own demographic backgrounds. Inclusion of more women and younger experts on the panel could have offered more focus on health issues faced by other populations or vulnerable groups such as women, those of young or middle age, less educated or rural residents, and members of ethnic minority groups. No information other than panel members’ gender and age was provided.

These factors may explain the omission of maternal and infant health issues from the list despite the growing recognition of the role of the intrauterine environment, early life circumstances, and life course approaches in prevention of future noncommunicable diseases. This omission is also inconsistent with Healthy China 2030, wherein infant mortality, under-five mortality, and maternal mortality rates are listed as the leading health indicators and both mothers and children are priority service populations to be targeted in health service delivery.⁵ Similarly, future efforts to prioritize key health issues should consider inclusion of other stakeholders such as community health workers, hospital leaders, insurance payors, and leaders from provincial health departments.

ALTERNATIVE APPOACHES

The US Centers for Disease Control and Prevention offers other interesting approaches that can be used to solicit opinions from a group of selected participants as a means of prioritizing health problems.⁷ For example, small group discussions and explanations of the reasons behind the rankings might lead to a better consensus on top health issues. Also, panels could consider broader criteria, including the seriousness of a problem, the availability of current interventions, public health concerns, political will, availability of resources, and equity considerations.⁷

Wu et al. point out that their list covers 61% of total deaths in China but accounts for only 36% of total lost disability-adjusted life years. This gap suggests that the list places a reduced emphasis on conditions that affect premature deaths and quality of life. If the panel had been more diverse and had been required to consider broader criteria, the list may have included a higher percentage of health issues contributing to disability-adjusted life years.

LINKS TO HEALTHY CHINA 2030

Healthy China 2030 also offers concrete action plans or strategies on how to achieve health objectives. The Wu et al. list of the top 20 health problems is well reflected in this action plan, which includes increasing life expectancy, reducing premature deaths caused by major chronic diseases, and improving air and water quality. Healthy China 2030 also includes food safety and healthy weight as components, along with well-balanced diets, tobacco control, mental health, and road traffic safety. These overlapping areas suggest the importance of lists such as that described by Wu et al. for future health planning and policymaking. Despite the limitations of their methodology, Wu et al. clearly demonstrate the need to search for a scientifically, statistically, and culturally appropriate strategy to assess health priorities for a population of 1.4 billion individuals.