VIEWPOINTS in burden of noncommunicable addressing the growing A healthpolicyandsystemsapproachto health problems (8,9). child and maternal in decrease the been has transition one of the most remarkable outcomes of China’s extensive middleincome countries (7). Inpopulation health terms, population, and the relative performance of other low and China’s of size the considers one when significant more the all is achievement This (6). schedule of ahead years Goal 4 (reduction in child mortality by 2/3 by 2015) nine showed that China has achieved Millennium Development clineinchild mortality yielded bythese investments, and My colleagues and I recently documented the dramatic de population. mentsinaccess andtreatment forall strata oftheChinese mentinvestment in infrastructure, including health invest (4,5).Thistransition period alsomarked massive govern sole investment in terms of care, education and mentorship parents’ their represent and shareresources withsiblings to need not did who dren chilChinesegenerationsof new produced has 1979 in introducedpolicyone-child by 2009 (3). The effect of the most half were living in cities ruralinareas until 1990, al theChinese population lived quartersthreeof whilethat, estimatedis change(1,2).It O School of Public Health, Peking University Health Sciences Center Nossal Institute for Global Health, University of Melbourne Kit Yee Chan 28 June, 2011 • man history in terms of its scale and the speed of socio-economictransition unprecedented inhu ver the past two decades, China has undergone a Vol. 1No. 1 www.jogh.org - - ral areas. eases (NCDs) burden in both urban and ru placed by a chronic non-communicablere be dis soon will burden health child and ofits population, where the fall in maternal itablyleadchangesto thehealthin burden China’s socio-economic transition will inev - - - - the interaction between an aging population, increased ex growexponentially overthenexttwodecades because of Chinesetheneedsofalhealth system. Costs arelikelyto merit a re-thinking of the future development and structur Thesemassive changes and shifts inChina’s health burden likely to worsen. (12–16).Without appropriate inventions,problem theis pression,dementia andother neuropsychiatric conditions road traffic accidents, of multiple sites, asthma, de diseases,degenerative diseases musculoskeletalof system, risingepidemic ,of ,type2 cardiovascular areas(10–11). Thesefactors arealready contributing a to health-seeking behaviour of people in both urban and rural andcare improved(iii)to access use;tobacco and cohol workstyle, and exposure tooutdoor air pollution, and al tion,increased use of personal transportation, achange in re healthchildburdenbematernalsoon andwillin fall changesin the health burden of its population, where the to lead inevitably China’swill transition socio-economic - - - - high-energy food consump food high-energy marked by sedentary lifestyle, life, of ways urban to rural population; (ii) a change from an by marked shift key factors: (i) a demographic diseases will be driven by three burden of non-communicable the increaseinareas.The ral burden in both urban and ru (NCDs) diseases municable placed by a chronic non-com

------This will become unsustainable as the NCDs burdenin NCDs theunsustainable becomeas will This gested with patients better treated in a primary care facility. (19).This has led to long queues in public hospitals, con low,isics manyandpreferseek treatment to hospitalsin Patient confidence in the performance of primary care clin and career opportunities. graduatescal lowertosalaries,dueprestige lackof a and nity health clinic positions do not attract the best of medi formsthetourban primary systems, commu referralsecondarypowerofreto healthspiteof care. In systems,doctors inthese clinics donot have anexclusive compulsory.nothealth westernisreferrals many Unlike specialistshospitalor er,for clinics these consultation at health doctors with basic university degrees (18). Howev public and/or medical and nurses by centreshealth nity In urban areas, primary health care is provided at commu level of health care are low and few choose this career path. (17). Incentives for medical graduates to work at this basic licencetreatto andprescribe drugsforcommon illnesses (TechnicalCollege)a trainingprovideswhichwiththem level relativelylow with doctorsvillage by out carried is West. At present, in many rural areas, primary health care tained,primary carepractices comparable thosetothein doctor-mainof system a have not doescurrently China mented in a standardized way in all urban areas. programmesatthenational level, which would beimple problemtherequireco-ordinatedwill a preventiveof set are small, usually isolated preventive efforts, but the size of ment investment to support the programs. Currently there lic health network in urban areas, and a significant govern a sizeable portion of the burden. This requires a strong forpub chronic non-communicable diseases, and delay or avert tive activities will reduce exposure to the main risk factors care service that must not become over-burdened. Preven eas, which represent a reasonably strong secondary health alleviate the congestion of the hospital services in urban ar addressthemajority healthof demands. Thiswould help tivemeasures with stronga primary health care system to ing problem will be to use a combination of strong preven The most cost-effective strategy for dealing with this grow for NCDs are most immediate. live, and where population aging and exposures willChinese majorityof thegrowingareas,where urban burden. This problem will first become apparent in the fast- managementlargesuchofa andgrowing chronic the address efficiently to structured not currently is tem fic accidents and certain types of . China’s health sys number of new cases of type 2 diabetes, strokes, road traf eases such as Alzheimer, and up to a 4-fold increase in the dis of cases of millionsface soon will Chinapectations. changingand patternscare-seeking of healthcareand ex posures to the key environmental and lifestyle risk factors,

------will certainly continue over the next two decades), is to: crease in the burden of non-communicable diseases (which tem restructuring in China, to help address the massive in I propose that a critical point of intervention in health sys economic growth. healthcare, which over time, might interfere with China’s of cost the to add and system, health existing the strain to continue will NCDs of burden increasing rapidly the reverseover-relianceplacetothe in put are hospitals,on over-medicationtoover-treatment. and strategies Unless fractionhospitalcostofthealsowhichofprone careis – managed through prevention and primary health care, at a effectively be can NCDs that acknowledged widely is It point of entry into the . attractpatients awayfrom secondary carehospitals theas velopa stronger primary health care system, which would creasesdemand for care. Not enough is being done to de lems infuture. tries which will inevitably face similar prob many other low- and middle-income coun for model a provide may China success, of level the to Subject China. in diseases re the sponse of to the burden of non-communicable cost-effectiveness the prove im- to needed be will China in structuring re system health in interventions Critical • • • • structuralenvironmentaland underliefactors that preventionincludestothetacklestrategiesthat to Ministry of Health (China), adopt a holistic approach trol of Chronic Disease and Prevention set out by the Buildingupon the National Standards for the Con should be made available to the public; evaluation Program evaluated. and monitored be programsshouldbasedsoundbe onevidence and through the network of public health institute. The workplace accidents) in both urban and rural areas eases (eg, cardiovascular diseases, cancer, traffic and that target common chronic non-communicable dis Implement large-scale national prevention programs tion and intervention strategies; of China and use it for the development of preven commonNCDs andtheir causes fordifferent parts Establish sound evidence base on the distribution of Chinese society; non-communicablefactorsfor moderndiseasesin tions to monitor and evaluate the role of the key risk urbanareas,in promote themintoleadinginstitu instituteshealthpublicStrengthennetworkof the www.jogh.org June, 2011 • Vol. 1No. 1 29 ------

VIEWPOINTS VIEWPOINTS Photo: courtesy of Dr Kit Yee Chan, personal collection 30 June, 2011 • requireco-ordinationsoundmedia,local the with plementationtheseofprogrammes willnecessarily the risks of chronic diseases (20). The successful im Vol. 1No. 1 www.jogh.org form at form Competing interests: Ethical approval: Medical Research Council of Australia. Funding: that could appear to have influenced the submitted work. inthe submitted work in the previous 3 years; no other relationships or activities work; no financial relationships with any organizations that might have an interest sponding author) and declare: no support from any organization for the submitted www.icmje.org/coi_disclosure.pdf The author was supported by a fellowship from the National Health and Not required. The author has completed the Unified Competing Interest - • (available on request from the corre the fromrequest on (available

eas by significantbyeas government investment hu into Strengthen primary health care networks in rural ar regulators, health authorities and other stakeholders; time delay. slight a with problems, similar face bly dle-incomecountriesinevitawillwhich tialmodel formany other low-and mid level of success, this will become a poten problem of NCDs in China. Subject to the growing the to response the of tiveness cost-effecimprovemendations,thewill Appropriately implemented, these recom • • • as ways of creating provider incentives; studies of payment reform (like capitation) Lessonsshould be learned from on-going self-management.diseasethe in support patientpreventiondiseaseand in pation ing of rural doctors towards active partici skilled health workers, and target the train manresources improveto thenumber of

mary care facilities as the gate-keepers. specialistprireferralmechanismwith Trialcompulsory aintroduction theof directed to primary care facilities. be patientsshouldcategoriesofwhich identify (ii) and strategies, care tive tals to (i) determine optimal, cost-effec patient data from secondary care hospi Undertake ongoing case-mix analyses of NCDs patients; care acute but all for system health the into entry of point the them make raise the status of the health centres and will This centres. health these at main re and work to practitioners medical for incentives necessary the creating skills and training of the providers, and works in urban areas by improving the net care health primary Strengthen ------REFERENCES 20. 19. 18. 17. 16. 15. 14. 13. 12. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. in China. Health Econ. 2010;19 Suppl:69–94. FengXL, Shi G,Wang Y, XuL, Luo H,Shen J,et al. Animpact evaluation ofthe Safe Motherhood Program to 2005. Bull World Health Organ. 2009;87:913–920. Yanqiu G, Ronsmans C, Lin A. Time trends and regional differences Millenniumin maternal Development mortality Goal 4. Lancet.in 2010;375:1988–2008.China from 2000 childhood,under-5and mortalitycountries, 187for 1970–2010:systematic a analysis progress of towards RajaratnamNeonatal,MarcusWangal.Flaxmanpostneonatal,JK,AD,JR, etLevin-Rector L,DwyerH, A, Lancet. 2010;375:1083–1089. idemiology2008.ReferenceinChina neonatal,Groupdeaths childin(CHERG).causes ofinfant andThe Rudan I, Chan KY, Zhang JSF, Theodoratou E, Feng XL, Salomon J, et al., WHO/UNICEF’s Child Health Ep Yang J. China’s one-child policy and children in the 1990s. Soc Sci Med. 2007;64:2043–2057. China Statistical Yearbook 2010. : China Bureau of Statistics, 2010. Sim KS. China in transition. New York: Nova Science Pub Inc, 2003. 2009. Guthrie D. China and globalization: the social, economic and political transformation. New York: Routledge, istry of Health, China, January 2011. NationalStandards for the Control of Chronic Disease and Prevention (Trial Implementation). Beijing: Min Heidleberg: Springer, 2007, pp. 267–273. istration solution in China. In Dainoff M, ed. Ergonomics and health aspects of work with Yuecomputers.OY, Berlin/Li SH, Chen XP, Kang GX. Investigation and implementation of the advanced wireless medical reg ical graduates. Chinese University Students Employment. 2007;14:115–116. Xu H, Kong B. An analysis of countermeasures in regard to the present situation of the employment of med Decree No. 386. StateCouncilChina.ofRegulations Administrationtheon Employmentof RuralDoctors. of State Council children is due to difference in lifestyle factors. Zhonghua Er Ke Za Zhi. 2006;44:41–45. WangHY, Chen YZ, Ma Y, Huang YJ, La QW, Zhong NS. Disparity of asthma prevalence in Chinese school of China: a systematic analysis of 1980–2004 studies. Age Aging. 2007;36:619–624. DongMJ, Peng B, Lin XT, Zhao J, Zhou YR, Wang RH. The prevalence of dementia in the People’s Republic Inj Prev. 2009;15:55–59. Naci H, Chisholm D, Baker TD. Distribution of road traffic by road user group: a global comparison. comes. 2010;3:226–227. ZhengandZ-J.impendingSmithJrTheSC cardiovascular pandemicChina. inCirc Cardiovasc QualOut trends in obesity and . Int J Obes (Lond). 2006;31:177–188. WangXY,ShanY,J, MiWang KY. obesityGeChinafacingQJ, epidemicconsequences?anIsthe and The inequities persist. Health Aff (Millwood). 2010;29:2189–2196. JianW, ChanKY, Reidpath China’sDD,L.Xu rural-urban care gapshrank forchronic disease patients, but 2010;3:107–119. University. Peking at (CCER) Research Economic for Centre China the of Journal Official The Journal: ic Fang C. Demographic transition, demographic dividend, and Lewis turning point in China. China Econom 55:1295–300. 2007; Soc. Geriatr Am J giant. aging the China: al. et X, Li Q, Ding B, Dong L, Ding ML, Liu JH, Flaherty www.jogh.org June, 2011 • [email protected] Australia Carlton Victoria 3010 University of Melbourne Nossal Institute for Global Health Dr Kit Yee Chan Correspondence to: Vol. 1No. 1 31 ------

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