63426 HUMAN DEVELOPMENT UNIT East Asia and Pacific Region Toward a Healthy and Harmonious Life in China: Stemming the Rising Tide of Non-Communicable Diseases World Bank Report Number 62318-CN ON THE COVER “Tai chi under the morning sun in Beijing.� Tai chi is a Chinese martial art practiced for defense training and health benefits. Photo taken by Mr. Chunsheng Bai, Beijing, China, June 2, 2011. HUMAN DEVELOPMENT UNIT East Asia and Pacific Region Toward a Healthy and Harmonious Life in China: Stemming the Rising Tide of Non-Communicable Diseases Contents Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix 1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 2 Why This Report? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 3 China’s Rising NCD Epidemic: 2010–2030 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 3.1 Explosive Increase in the Number of People with at Least One NCD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 3.2 Morbidity Makes Up the Bulk of the Burden Attributable to NCDs and about 50 Percent of That Burden Occurs in People under 65 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3.3 NCD Mortality Is Higher in China Than in Other Leading G-20 Countries . . . . . . . . . . . . . . . . . . . . . . 3 4 Socioeconomic Determinants and Health Risk Factors for NCDs and Consequences In China . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 4.1 Growing Urbanization and Changes in Behavioral and Biological Factors . . . . . . . . . . . . . . . . . . . . . . . . 4 4.2 Over 50 Percent of the Increased NCD Burden Is Preventable by Modifying Behavioral Risks . . . . . . . . . . . 4 4.3 Rapid Population Aging May Increase China’s NCD Burden by at Least 40 Percent by 2030 If the NCD Epidemic Is Not Controlled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 4.4 NCDs Contribute to Inequalities in Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 4.5 Economic Impact of the NCD Burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 5 Role for Government on NCDs Prevention and Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 5.1 Economic Rationale Justifying Government Actions on NCDs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 5.2 Confronting NCDs Effectively: A Litmus Test of China’s Health Sector Reform . . . . . . . . . . . . . . . . . . . . . . 8 6 Launching a Multisectoral Strategy for NCD Prevention and Control . . . . . . . . . . . . . . . .10 6.1 Suggestions for Comprehensive and Effective NCD Strategies in China . . . . . . . . . . . . . . . . . . . . . . . . . . 10 6.2 What Actions to Take? From Governmental Policy to Program Implementation . . . . . . . . . . . . . . . . . . . . 11 6.3 Addressing Information Gaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 7 The Way Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 Map IBRD 33387 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 FIGURES Figure 1: Distribution of Disease Burden in China . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Figure 2: Projected Number of NCD Cases (People Aged 40 Years or Over) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Figure 3: Total Years Lost due to NCD Morbidity per 1000 Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 Figure 4: Total Years of Life Lost from Death per 1000 Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 Figure 5: Mortality (per 100,000) from Major NCDs in China and Selected Countries . . . . . . . . . . . . . . . . . . . .3 Figure 6: Number of Adults above 40 Years Old with at Least One Risk Factor, 2010 . . . . . . . . . . . . . . . . . . . . . .5 Figure 7: Population Growth and Share of Population Aged 65+ and 80+ in China, 2010–2050 . . . . . . . . . . . .5 Figure 8: The Effect of Aging on the Future Number of People with at Least One NCD by Gender . . . . . . . . . . . .6 Figure 9: Three Scenarios of the CVD Working-age Mortality Rate, 2010–2040 . . . . . . . . . . . . . . . . . . . . . . . . .7 Figure 10: Simulated per Capita GDP Path . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Figure 11: Diabetes Acute Complications Admission Rates, 2007 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Figure 12: Coverage of NCD Programs at County Level in China . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Figure 13: Preventing and Controlling the NCD Tide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Figure 14: Proposed Expansion Path for an NCD Prevention Package . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Figure 15: Effective Approaches to Reducing Mortality from Coronary Heart Disease . . . . . . . . . . . . . . . . . . . . .17 Figure 16: Health Expenditure by Type of Health Care Service, 2007 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Figure 17: Expenditures on CVD Treatment by Treatment Type, Tianjin, 2008 . . . . . . . . . . . . . . . . . . . . . . . . .19 Figure 18: “Pyramid of Care� Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Figure 19: “Chronic Care� Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 TABLES Table 1: NCDs and Care-seeking Behavior among Low-income Groups, 2008 . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Table 2: Impact of a Change in Self-assessed Health on Hours Worked and Income in China . . . . . . . . . . . . . . . . .8 Table 3: Characteristics of NCDs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Table 4: Examples of Inter-Institutional Coordination Mechanisms for Health-Related Activities in China . . . . .12 Table 5: Priority Interventions for NCDs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Table 6: Tobacco Prices and Taxation in BRICS Countries, 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Table 7: HiAP for NCD Prevention and Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Table 8: Life Course Approach for NCD Prevention and Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 Table 9: Examples of Financial Incentives for NCD Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 BOXES Box 1: Projected Impact of Priority NCD Prevention Interventions in China . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Box 2: Quality and Outcome Framework in the United Kingdom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 iv Toward a Healthy and Harmonious Life in China Abbreviations BMI Body mass index MI Myocardial infarction BP Blood pressure MOF Ministry of Finance BRICS Brazil, Russia, India, China and South Africa MOH Ministry of Health CDC China Center for Disease Prevention and Control NCD Non-communicable disease COPD Chronic obstructive pulmonary disease NICE National Institute of Health and Clinical Excellence CHD Coronary heart disease NPFPC National Population and Family Planning CVD Cardiovascular diseases Commission DALY Disability-adjusted life year OECD Organization for Economic Cooperation DM Diabetes mellitus and Development DMP Disease management program OOP Out of pocket expenditures DRG Diagnostic-related groups P4P Pay for performance EHR Electronic heath records PPP Purchasing power parity EU European Union PHC Primary health care FCTC Framework Convention on Tobacco Control QOF Quality and outcome framework GDP Gross domestic product RF Risk factor GP General practitioner UNDP United Nations Development Program HALE Healthy life expectancy VSL Value of a statistical life HIP Health Impact Assessment WHO World Health Organization HT Hypertension WTP Willingness-to-pay Human Development Unit | East Asia and Pacific Region THE WORLD BANK v Foreword The scientific concept of development means putting people first and aiming at comprehensive, coordinated and sustainable development . To put people first, we should take people’s interests as the starting point and foothold of all of our works, make continuous efforts to meet various needs of the people, and promote an overall development of the people . 17th National Congress of the Communist Party of China, 2007 In the late 1980s, China’s Ministry of Health started to fo- that is, what interventions should be included in NCD pre- cus on the transition in the country’s demographic and dis- vention and control programs, taking into account cost–ef- ease pattern. The Disease Prevention Project, launched in fectiveness, equity, local relevance, and political and other 1997, formalized the collaboration between the Government predefined criteria? and (b) how can the proposed NCD of China and the World Bank in fighting the rising tide of prevention and control interventions be implemented? Step non-communicable diseases (NCDs). The project introduced three is to put the proposals from Steps one and two into for the first time innovative behavior risk factor surveillance practice by developing and implementing a National Program surveys and health promotion for NCD disease prevention for NCD Prevention and Control in China. and control in China. Despite having achieved encouraging The present report is part of Step two. The evidence pre- results in reducing the prevalence of smoking among the lo- sented in the report strongly suggests that the coming 10 cal population and improved institutional capacity in seven years are a critical time for China to prevent and control project cities and one province, these early successes could not the threat posed to the country’s prosperity by the growing be sustained, mainly because the health system was geared to NCD burden. The challenge ahead is significant, but with combat only acute and infectious diseases and insufficiently political commitment and support at the highest levels of prepared to tackle chronic diseases, including NCDs. government, both at the central and provincial levels, an ef- The new round of health sector reform in China presents fective multisectoral response could be developed, including the adoption of critical changes in the current health system an opportunity for a revitalized focus on NCDs that have building on ongoing health care organization, financing, become the most prominent threat to people’s health in the and service delivery reforms in China. And, as noted in this country. Mutual benefits will likely derive from addressing report, a combination of population-based interventions NCDs and implementing health sector reform. and treatment targeted at NCD-related, high-risk groups, The Ministry of Health and the World Bank have jointly ad- would reduce the NCD burden by 50 percent when imple- opted a three-step approach with the aim of placing NCDs mented at full-scale. It is our sincere hope that this report at the top of the Government’s agenda. Step one is to raise will provide a useful reference to policy makers for moving awareness about NCDs among policy makers, particularly forward a multisectoral agenda for NCD prevention and those outside the health sector, through a number of high- control over the short and medium term. level conferences, seminars, and workshops. Step two is to Klaus Rohland implement further analytical studies to address key questions the Government has raised, particularly: (a) what should the Country Director, China Government do in response to the escalating NCD burden; World Bank Office, Beijing Human Development Unit | East Asia and Pacific Region THE WORLD BANK vii Acknowledgements also received from Madame Zhijun Sun and Mr. Qichao Song from the Ministry of Finance (MOF), Mr. Wei Ren, This report was prepared over December 2010–April 2011 Mr. Heyu Zhou, and Ms. Chunfang Li from the National by a World Bank team comprising: Development and Reform Commission and Ms. Fanglin Wang and Ms. Xiaoli Tang from the Ministry of Human Mr. Shiyong Wang (East Asia and Pacific Region, Resources and Social Security. Without the support of Mr. EASHD), Yanning Wang and his colleague, Mr. Weifeng Yang, Mr. Mr. Patricio Marquez (Europe and Central Asia Region, Jiangnan Qian from MoF, Mr. Yong Feng from MOH, this ECSHD), and report, would not have happened. Mr. John Langenbrunner (EASHD). The work was carried out under the supervision of Mr. Klaus Rohland (World Bank Country Director, China), Contributions for preparing this report were provided Madame Hsiao-Yun Elaine Sun (Country Manager, China), by Professor Louis Niessen from Johns Hopkins Univer- Mr. Emanuel Jimenez (Director, EASHD), Mr. Juan Pablo sity Bloomberg School of Public Health; Professor Marc Uribe (Sector Manager, Health, Nutrition and Popula- Suhrcke and Dr. Fujian Song from the University of East tion Unit, EASHD), Mr. Ardo Hansson (Lead Economist, Anglia (UEA), United Kingdom; and Professor Wenhua China, World Bank), and Ms. Fadia Saadah (former Sector Zhao, Dr. Yong Jiang, Dr. Yichong Li, Dr. Nan Hu, Dr. Manager, Health, Nutrition and Population Unit, EASHD). Zhuoqun Wang, Dr. Xiaoming Shi and Dr. Xiaoyan Li from Guidance and support were also provided by Philip O’Keefe China Center for Disease Prevention and Control. (Lead Economist, EASHD). Background information for this report originated from This report was reviewed by Professor Vivian Lin from La an analytical and advisory activity (AAA) on non-com- Trobe University, Australia; Ms. Jill Farrington, former municable diseases (NCDs) in China carried out in 2009 NCD Coordinator at the WHO Regional Office for Eu- and 2010 as a collective effort by a team comprising Pro- rope; Mr. Louis Kuijs (Poverty Reduction and Economic fessor Suhrcke, Dr. Song, Ms. Xia Wang, Ms. Philomena Management Unit, World Bank); and Ms. Montserrat Bacon, and Mr. Peter Moffatt from the University of East Meiro-Lorenzo (Human Development Network, World Anglia (UEA), United Kingdom; Professor Niessen and Bank), and Mr. Juan Pablo Uribe. The quality of this report Mr. Andrew Mirelman from the Johns Hopkins University benefited greatly from their valuable comments. Bloomberg School of Public Health; Mr. Lorenzo Rocco from the University of Padova, Italy; and Mr. Shiyong Excellent administrative support was provided by Ms. Lisa Wang, Ms. Huihui Wang, and Mr. John Langenbrunner Rowe of the University of East Anglia; Ms. Lansong Zhang, from EASHD/World Bank. Ms. Tao Su, and Ms. Limei Sun of the World Bank Country Office in Beijing; and Ms. Imani Rasheedah Haidara from Many World Health Organization (WHO) colleagues EASHD, World Bank. worked closely with the Ministry of Health (MOH) in China and the World Bank. Valuable advice was provided During the final consultation mission held in Beijing on by Dr. Ala Alwan from WHO Geneva; Dr. Hans Troedsson April 11–15, 2011 by a World Bank team comprising Mr. and Dr. Cherian Varghese from WHO’s Western Pacific Re- Shiyong Wang, Mr. Patricio Marquez, Mr. John Langen- gional Office; and Dr. Sarah Barber, WHO Office, Beijing. brunner, and Mr. Philip O’Keefe, comments on a draft report were received from and discussed with the follow- The Government of China collaborated in many ways. The ing Chinese Officials: Mr. Heyu Zhou, Ms. Chunfang Li, World Bank is particularly grateful for the overall guidance National Development and Reform Commission; Dr. Sen provided by Dr. Lingzhi Kong, Deputy Director General, Gong, Development Research Center of State Council; Bureau for Disease Prevention and Control, MOH. Special Dr. Lingzhi Kong, Dr. Liangyou Wu, MOH; Ms. Fanglin thanks go to Dr. Zhenglong Lei, Dr. Guanglin Li, Liangyou Wang, Ms. Xiaoli Tang, Ms. Li Dong, Ms. Xin Zhao, Min- Wu and Dr. Jia Fei from the NCD Division, Bureau for istry of Human Resource and Social Security; Mr. Dezhi Disease Control, MOH, for their coordination with dif- Yu, Dr. Yanhua Chi, and Dr. Maowei Liu, Center for Proj- ferent technical agencies and provinces for data collection ect Supervision and Management, MOH; Professor Dong- needed for the analysis and for organizing workshops for feng Gu, Fuwai CVD Hospital; Professor Yangfeng Wu, disseminating interim reports. Advice and comments were George Institute China; Dr. Wanqing Chen, Institute of Human Development Unit | East Asia and Pacific Region THE WORLD BANK ix Cancer Research, China Academy of Medicine; and Pro- Jeffrey McFarland and Ms. Alison Kelly, as well as Dr. Mi- fessor Kun Zhao, China National Health Development chael Engelgau from the U.S. Centers for Disease Control and Research Center. and Prevention; Dr. Felix Li, Health Canada; as well as from Mr. Geoff Bowan and Ms. Linna Cai from the Australian Additional comments and suggestions were provided dur- Agency for International Development. ing the mission by: Dr. Michael O’Leary, Dr. Pillay Mu- kundan, Dr. Sarah England, Dr. Yanwei Wu, Dr. Jing He, The co-authors would like to document their appreciation to and Dr. Pingping Zhang from the WHO Office Beijing; Dr. Ms. Elizabeth Goodrich for her meticulous editing service. x Toward a Healthy and Harmonious Life in China 1 INTRODUCTION cause of ill health, premature mortality, and disability. Tak- ing advantage of this opportunity would enhance the health China’s 12th Five-year Plan (2011–2015) aims to promote and welfare of China’s population. Challenges abound, but inclusive, equitable growth and development by placing an with a carefully laid-out approach, China can lead the way increased emphasis on human development (1). globally in tackling NCDs and advance its social and eco- nomic development in the decades ahead. Good health is an important component of human develop- ment, not only because it makes people’s lives better, but also because having a healthy and long life enhances their ability 2 WHY THIS REPORT? to learn, acquire skills, and contribute to society (2). Indeed, good health is a fundamental right of every human being (3). NCDs1 are China’s number one health threat. They account Good health among a population can also enhance economic for over 80 percent of its 10.3 million annual deaths (10) performance by improving labor productivity and reducing and Figure 1 shows that they contribute to 68.6 percent of economic losses that arise from illnesses (4,5,6,7). the total disease burden (11). The main NCDs in China are cardiovascular diseases (CVDs), diabetes mellitus (DM), While China has had an enviable economic growth and de- chronic obstructive pulmonary diseases (COPDs), and lung velopment performance for more than 30 years, its human cancer. These conditions account for a significant share development has lagged behind the most advanced econo- of the total NCD burden in China and share common, mies. China ranked 89th in the 2010 human development amendable behavioral and biological risk factors. index prepared by the United Nations Development Program (UNDP) (8). The Chinese population’s healthy life expec- In 2010 and again in 2011, the World Economic Forum tancy (HALE) at birth is about 10 years shorter than in some singled out NCDs as a leading risk to the global economy of the leading G-20 countries (9). China could narrow these (12) due to their high likelihood of occurrence and their gaps in human development vis-à-vis these countries by iden- huge potential to cause severe economic loss. The Forum tifying the priority health issues affecting its population, mus- recommended that governments mount a serious policy tering political support to overcome them, and implementing and programmatic response to this economic and social appropriate interventions, as described below. development risk. China has made impressive gains in recent decades to con- 1 NCDs are a set of chronic diseases, including cardiovascular disease, trol communicable diseases, ushering in an opportunity to cancers, chronic respiratory diseases, and diabetes, characterized by a long confront non-communicable diseases (NCDs), its leading latency period, prolonged clinical course and debilitating manifestations. Figure 1: Distribution of Disease Burden in China Communicable, maternal, perinatal and nutritional conditions 1.40% 13.40% Malignant neoplasms 3.30% 17.90% Diabetes mellitus and other endocrine disorders 1.20% Neuropsychiatric conditions 3.10% Sense organ diseases 9.30% Cardiovascular diseases 7.60% Respiratory diseases 2.10% Digestive diseases 12.40% Genitourinary 17.60% diseases Musculoskeletal diseases 9.80% Congenital diseases Injuries Source: WHO, Burden of Disease Study, 2009. Human Development Unit | East Asia and Pacific Region THE WORLD BANK 1 As is discussed herein, there is a substantial avoidable and longer terms. The findings and recommendations can in- economic burden associated with NCDs. For example, form and promote a broad dialogue toward the development estimates for China done for this report indicate that the of a multisectoral response to effectively address the growing economic benefit of reducing CVD mortality by 1 per- burden of NCDs, including a better alignment of the health cent per year over a 30-year period (2010–2040) could system with the population’s health needs. The report also ad- generate an economic value equivalent to 68 percent of vocates implementing “Health in All� policies and actions for China’s real gross domestic product (GDP) in 2010, more a multisectoral response to NCDs in China to help achieve than US$ 10.7 trillion (valued in purchasing power the ultimate goal of “harmonious� development and growth. parity terms-PPP). However, if an effective response is not mounted in China to deal with NCDs, the disease burden posed by these conditions will aggravate the economic and 3 CHINA’S RISING NCD social impact of the expected population explosion of older EPIDEMIC: 2010–2030 citizens and smaller workforce in China. And, a reduced ratio of healthy workers to sicker, older dependents, will 3.1 Explosive Increase in the Number of certainly increase the odds of a future economic slowdown People with at Least One NCD and pose a significant social challenge in China. The number of NCD cases (CVDs [myocardial infarction This report, prepared on the basis of assessments conducted and stroke], COPDs, DM, and lung cancer) among Chi- by the World Bank in 2008–2010, outlines why the Govern- nese people over 40 will double or even triple over the next ment of China should pay priority attention to NCDs, artic- two decades, most of it during the next 10 years (Figure 2). ulates what would constitute an effective NCD response, and Diabetes cases will be the most prevalent disease, while lung proposes how to operationalize the response over the medium cancer cases will increase fivefold. Figure 2: Projected Number of NCD Cases (People Aged 40 Years or Over) 70,000,000 60,000,000 50,000,000 40,000,000 30,000,000 20,000,000 10,000,000 2010 2012 2014 2016 2018 2020 2022 2024 2026 2028 2030 Total MI Pop Total Stroke Pop Total COPD Pop Total Lung Ca Pop Total DM Pop Estimated Number of Cases 2010 2020 2030 Myocardial infarction 8,101,001 16,081,550 22,630,244 Stroke 8,235,812 21,356,978 31,773,456 COPDs 25,658,483 42,527,240 55,174,104 Lung cancer 1,412,492 4,621,900 7,391,326 Diabetes mellitus 36,156,177 52,118,810 64,288,828 Total 79,563,965 136,706,478 181,257,958 Source: China Nutrition and Health Survey, 2002, China National NCD Risk Factor Surveillance, 2007 2 Toward a Healthy and Harmonious Life in China 3.2 Morbidity Makes Up the Bulk of the (Figure 3); stroke has the largest health and well-being im- Burden Attributable to NCDs and pact on an individual. The burden due to deaths from these about 50 Percent of That Burden NCDs will increase by more than 80 percent (Figure 4). Occurs in People under 65 NCD-related morbidity accounts for more than 90 percent of the total NCD burden. About half of China’s disease bur- The burden of the four leading causes of ill health—MI, den from NCDs occurs in people under 65. The growing stroke, diabetes, and COPD—is expected to increase over NCD burden is ominous for the country as disability will 2010–2030 by almost 50 percent. More than 50 percent of likely be substantial in the years to come, including a signifi- the disease burden will be caused by CVDs (MI and stroke) cant and growing burden to the health system. Figure 3: Total Years Lost due to NCD Morbidity Figure 4: Total Years of Life Lost from Death per 1000 Population per 1000 Population 1,500 200 150 1,000 100 500 50 0 0 2010 2020 2030 2010 2020 2030 MI Stroke COPD Lung Ca DM Injury MI Stroke COPD Lung Ca DM Injury Source: Death Cause Surveillance from China Disease Surveillance Points, 2005, and China Nutrition and Health Survey, 2002, and China National NCD Risk Factor Surveillance, 2007. 3.3 NCD Mortality Is Higher in China higher than that in Japan, the United States, and France; for Than in Other Leading G-20 Countries COPD it is about 30 times as high as in Japan; and its rates for cancers are also slightly higher than comparators. China’s China has very high mortality rates due to the major NCDs mortality rate for diabetes is lower than that in the United (Figure 5). Its mortality rate for stroke is four to six times States, but higher than in Japan and the United Kingdom. Figure 5: Mortality (per 100,000) from Major NCDs in China and Selected Countries 300.0 250.0 200.0 150.0 100.0 50.0 0.0 CVD Stroke COPD Cancers Diabetes Infectious parasite China Japan USA UK France Australia Source: Data and Statistics, World Health Organization (2004). Note: Standardized according to world’s population age structure in 2000. Human Development Unit | East Asia and Pacific Region THE WORLD BANK 3 4 SOCIOECONOMIC education); among rural males (56.1 percent versus 49.2 percent among urban males); and among males in the DETERMINANTS AND HEALTH western regions (60.1 percent versus 50.1 percent among RISK FACTORS FOR NCDs AND males in the east region) (16). CONSEQUENCES IN CHINA The prevalence of hypertension, high blood glucose, over- China’s shifting disease profile is deeply rooted in the so- weight/obesity, and high blood cholesterol, which are re- cial, economic, and environmental changes the country has lated to dietary intake (e.g., high intake of saturated fat and experienced in recent decades, particularly changes in ex- salt and low intake of vegetables, fruits, and vegetable and posure to and the magnitude of different health risk factors fish oils) is lower than those in Organization of Economic and, as will be discussed in the later sections of this report, Co-operation and Development (OECD) countries but has limitations in the access to, use of, and effectiveness of pub- been increasing rapidly. The estimated prevalence of hyper- lic health and medical care services. tension among adults over 18 increased from 7.5 percent 4.1 Growing Urbanization and Changes in in 1979 to 18.1 percent in 2004 (17). The prevalence of Behavioral and Biological Factors diabetes has increased alarmingly: from 0.67 percent in the 1980s, 2.5 percent in 1994, 5.5 percent in 2001, to 9.7 per- Internal migration, particularly to big cities, is altering cent in 2007/08 (18). the spatial distribution of China’s population. The UNDP estimates that there will be more than 900 million peo- The overall prevalence of overweight and obesity increased ple—60 percent of the total population—living in cities from 1992 to 2002, by 38 percent and 81 percent, respec- by 2030 (13). More than 250 million of the increased 350 tively, and reached 22.8 percent and 7.1 percent, respec- million will be migrants. At least six out of the eight mega- tively, in 2002 (19). It is estimated that about 200 million cities—the country’s “economic engines,� Shanghai, Bei- people in China are overweight or obese. Also, obesity and jing, Tianjin, Shenzhen, Wuhan, Chongqing, Chengdu, overweight have been increasing at an alarming rate among and Guangzhou—are each projected to have a population adolescents. The prevalence of overweight plus obesity in well above 10 million. children/ adolescents aged 7 to 18 years old from urban centers reached 32.5 percent for boys and 17.6 percent for While rising incomes, an improved food supply, and a girls in the northern coastal cities: this rate is the same or variety of food products contributed to the significant even higher than that for the same groups in developed reduction in malnutrition and improved health status in countries (20,21). China over the past 20 years, changes in dietary patterns, unhealthy behaviors, and pollution associated with urban- The fundamental drivers of the obesity epidemic in China ization are now involved in the rapid increase of NCD- have been reduced daily energy expenditure due to increased related risk factors, particularly among low-income groups physical inactivity in cities and fat intake, particularly from and migrants (14,15). growing consumption of fast foods and sugar-rich soft drinks, both of which have a high energy density. While tra- Excessive salt intake, by far the most prevalent modifiable ditional Chinese diets had only 15 percent fat and negligible risk factor for NCDs in China, is greater than 12 g per day sugar, between 1982 and 2002 average fat consumption in per person, twice the maximum intake recommended by urban areas rose from 25 percent to 35 percent and from WHO. China’s high level of consumption has not changed 14.3 percent to 27.7 percent in rural areas (22). for a decade. 4.2 Over 50 Percent of the Increased NCD At 54 percent, the prevalence of tobacco smoking among Burden Is Preventable by Modifying men aged 15–69 is among the highest in the world. Behavioral Risks Among daily smokers aged 20–34 years, 52.7 percent started smoking daily before age 20. Although the over- At least 580 million Chinese were estimated to have at least all smoking level among females is relatively low at 2.1 one modifiable NCD-related risk factor in 2010 (Figure percent, it has been increasing among young females. The 6). Between 70 and 85 percent of these people were under highest rates of smoking are among males with lower edu- age 65. By 2030, those risk factors—behavioral and nutri- cation levels (63.2 percent for those with a secondary edu- tional—could contribute to a 50 percent increase in China’s cation versus 44 percent for those with college or above NCD burden if not controlled. 4 Toward a Healthy and Harmonious Life in China Figure 6: Number of Adults above 40 Years Old with at Least One Risk Factor, 2010 600,000,000 500,000,000 400,000,000 300,000,000 200,000,000 100,000,000 0 At least one Excessive Smoking BP Inactivity BMI High RF salt cholesterol Age group: 40–64 Age group: 65–80 Age group: 80+ Source: China Nutrition and Health Survey, 2002, and China National NCD Risk Factor Surveillance, 2007. Note: “RF� means risk factor. 4.3 Rapid Population Aging May Increase 1. The low fertility rate in the past several decades China’s NCD Burden by at Least 40 is the demographic driver shaping China’s future Percent by 2030 If the NCD Epidemic Is population profile (23). By 2040, it is anticipated Not Controlled that China will have fewer people under the age The aging of a population—where the absolute number of of 50 and many more elderly in their 60s to 80s adults and elderly grows—inevitably leads to a shift in the (24) (Figure 7). The cohort of the oldest-old (aged burden of disease from younger to older age groups and to- 80 plus) is forecast to increase from 12 million in ward NCDs. The changes in the age structure of China’s 2000 to over 40 million in 2030. This population population have the following important features that sug- explosion of older citizens will result in about 240 gest the potential geographic foci for mounting an effective million people 65 or older by 2030, up from 115 response to NCDs in China: million today. Figure 7: Population Growth and Share of Population Aged 65+ and 80+ in China, 2010–2050 25 20 15 10 5 0 2010 2015 2020 2025 2030 2035 2040 2045 2050 Population growth rate (%) Percentage aged 65 or over (%) Percentage aged 80 or over (%) Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: The 2008 Revision, http://esa.un.org/unpp. Human Development Unit | East Asia and Pacific Region THE WORLD BANK 5 2. China’s rural areas are aging more rapidly than its in China. While aging is not avoidable, premature death can cities, largely due to rural-to-urban migration. In be prevented, disability due to NCDs can be postponed, and 2008, the aged proportion (60 years old and above) healthy aging can be achieved as demonstrated in leading was 9.4 percent in rural areas and 6.9 percent in ur- G-20 and European Union (EU) countries (29, 30, 31). ban areas, a gap of 2.4 percentage points. By 2030, the aged proportions in rural and urban areas will 4.4 NCDs Contribute to Inequalities in be 21.8 percent and 14.8 percent, respectively, a gap Health of 7.09 percentage points (25). The socioeconomically and otherwise disadvantaged popula- 3. Chongqing, Sichuan, Anhui , Hunan, and tions in China are often hit harder by NCDs than the affluent Hubei have a relatively higher level of population members of society since (a) chronic diseases and at least some aging in relation to their level of economic develop- of the risk factors leading to NCDs, e.g., hypertension, tend to ment (26). be more prevalent among the poor; (b) the poor are often lack- ing in or have limited access to quality health care when they 4. Most of China’s mega-cities (Shanghai, Beijing, develop an NCD; and (c) the adverse impact of chronic diseases Tianjin, Shenzhen, Wuhan, Chongqing, Chengdu, on income and overall family welfare is proportionally larger for and Guangzhou) already have people 65 and older the poor. NCDs also contribute to high out-of-pocket (OOP) exceeding more than 10 percent of their popula- payments for health services and drugs and exacerbate inequity tions, while the national average for this age group in both health status and access to health care. While low-income is 8.5 percent (27). groups in China experience a similar or even higher prevalence of China’s rapid population aging is estimated to increase the NCDs than the rest of the population, their lower hospitalization NCD burden by at least 40 percent by 2030 (Figure 8). The rates suggest that they are less likely to seek health care (Table 1). expected population explosion of older citizens and reduced The incidence of catastrophic health spending tends to be higher size of the labor force (people aged 15–64 years) will place among low-income groups as well (32). Even in cities, 37.6 per- severe economic and social pressures as the country strives to cent of low-income patients reported not being hospitalized, de- meet the needs of the elderly, particularly of a growing cohort spite advice to do so, because a majority of them (89.1%) faced of people with chronic ailments that last years or even a life- financial constraints. A recent study also showed that because of time (28). Furthermore, a reduced ratio of healthy workers to high health care expenditure, rural patients with chronic condi- sicker dependents will certainly increase the odds of a future tions were more than twice as likely to drop out of treatment for economic slowdown and pose a significant social challenge financial reasons, as were patients in urban areas (33). Figure 8: The Effect of Aging on the Future Number of People with at Least One NCD by Gender 100 95 women men 90 85 80 75 age 70 65 60 55 50 45 3,500,000 2,500,000 1,500,000 500,000 500,000 1,500,000 2,500,000 3,500,000 2010 2020 2030 Source: Authors. 6 Toward a Healthy and Harmonious Life in China Table 1: NCDs and Care-seeking Behavior among Low-income Groups, 2008 National Average Low-Income Group Accessibility to Inpatient Care Urban Rural Urban Rural NCD prevalence 28.3% 17.1% 27.2% 23.1% Annual hospitalization rate 7.1% 6.8% 5.8% 5.9% % not being hospitalized against medical advice 26.0% 24.7% 37.6% 34.6% % who cited economic hardship as the main reason 67.5% 71.4% 89.1% 81.5% for not being hospitalized Prevalence of catastrophic health expenditure — — 5.9% 10.2% Source: Ministry of Health (MOH), National Health Services Survey in China, 2008. 4.5 Economic Impact of the NCD investment into people’s productivity and hence Burden their earnings potential (Table 2). Recent estimates indicate that China’s overall economic bur- • At the macro-economic level: reducing CVD mortal- den from NCDs could be very high. In the absence of a ity by 1 percent per year over a 30-year period (2010– scaled-up Government response, CVDs, stroke, and diabe- 2040) could generate an economic value equivalent tes alone are expected to result in a loss of US$ 550 billion to 68 percent of China’s real GDP in 2010, more in China between 2005 and 2015 (34). An analysis by the than PPP US$ 10.7 trillion (Figures 10 and 11). World Bank calls attention to the following potential gains • The society wide “economic costs� of NCDs are stemming from effective NCD policies: even larger if the value people attribute to health • At the micro-economic level: A change in adult is captured.3 Reducing CVD mortality by 1 per- health status can result in a 16 percent gain in cent per year produces—if the intrinsic value that is hours worked and a 20 percent increase in indi- vidual income.2 Tackling NCDs, on top of being a 3 One way to make the value attributed to health explicit is by measur- ing the extent to which a person is willing to trade health for specific valuable health investment, may thus be seen as an market goods for which a price exists. Willingness-to-pay (WTP) studies undertake this measurement. A large number of WTP studies make it possible to calculate a “value of a statistical life� (VSL), which can be 2 Surveys typically ask respondents to assess their health on a five-point used to value changes in mortality. WTP can also be inferred from risk scale ranging from “very poor� to “excellent.� The “change� means a one- premiums in the job market: Jobs that entail health risks, such as mining, step improvement along the range, such as from “poor� to “fair.� pay more in the form of a risk premium. Figure 9: Three Scenarios of the CVD Working-age Figure 10: Simulated per Capita GDP Path Mortality Rate, 2010–2040 90 18000 80 CVD mortality rate age 15-64 17000 Per capita GDP (PPP US$) 70 16000 60 (per 100,000) 50 15000 40 14000 30 13000 20 10 12000 0 11000 2010 2012 2014 2016 2018 2020 2022 2024 2026 2028 2030 2032 2034 2036 2038 2040 2010 2012 2014 2016 2018 2020 2022 2024 2026 2028 2030 2032 2034 2036 2038 2040 Status quo (no change) Scenario 1 (1%-reduction p.a.) Scenario 2 (3%-reduction p.a.) Status quo Scenario 1 Scenario 2 Source: Authors, 2010. Note: Assuming 2005 CVD mortality rate according to Abegunde et al. (36). Human Development Unit | East Asia and Pacific Region THE WORLD BANK 7 attributed to life is measured—an annual benefit of attained. Global evidence suggests at least three sources of about 15 percent of China’s 2010 GDP (PPP US$ market failure that could justify government intervention 2.34 trillion), while a 3 percent reduction would for tackling the risk factors that give rise to NCDs: amount to an annual benefit of 34 percent (PPP • Externalities: There are substantial external costs US$ 5.40 trillion). resulting from second-hand smoke and alcohol-in- The combination of exceptionally fast population aging in duced road traffic injuries and fatalities. NCDs also China and a low fertility rate will strain China’s labor force impose costs on health care and the social insurance participation rate by 3–4 percentage points by 2030 (35). system and hence on “third parties.� The increase in NCDs, if not addressed effectively as a top • Imperfect information: People are not always fully governmental priority in the years to come, would not only aware of the health (and other) consequences of exacerbate the expected labor force shortages, but also com- unhealthy lifestyle choices such as smoking, alcohol promise the quality of human capital because more than 50 abuse, physical inactivity, and poor diet. They may percent of the NCD burden currently falls on the economi- also be misled by deliberately distorted information cally active population (aged 15–64). promoted by the food, alcohol, and tobacco indus- Table 2: Impact of a Change in Self-assessed tries. Government intervention in the form of the Health on Hours Worked and Income in China provision (and production) of NCD-related health information (such as the health consequences of Hours Worked Income smoking) provides a public good that generally is Overall 16.0% 20% undersupplied compared to the social optimum. Urban 21.0% 5.2% This also includes the role for a government to en- Rural 12.0% 14.6% gage in research about the health consequences of Source: Authors. unhealthy behavior. To optimize labor productivity as the population ages, inter- • Non-rational behavior: Children and adolescents ventions to improve the quality and skill mix of the existing (and even adults) tend not to take into account the labor force and extend the retirement age could only pro- future consequences of their current choices, irre- vide a short-term solution. The success of these interven- spective of whether they are informed about them. tions in the medium and longer terms would depend on the Their current choices may well conflict with their working-age population’s staying healthy. Indeed, the rise of long-term best interests. This provides, in principle, the “epidemic� of NCDs, if not addressed, will dilute and a justification for government to support interven- hinder the expected positive effects of these policy measures. tions to prevent people from harming themselves when they do not fully appreciate the consequences Inertia in response to NCDs and the resulting aggravation of behaviors that pose health risks. of health inequalities and economic growth slowdown have the potential to exacerbate social tensions in China. 5.2 Confronting NCDs Effectively: A Litmus Test of China’s Health Sector Reform 5 ROLE FOR GOVERNMENT ON NCDs PREVENTION The chronic nature of NCDs, their “chronicity,� poses a ma- jor challenge to health systems worldwide because with the AND CONTROL onset of NCDs people often spend substantial parts of their 5.1 Economic Rationale Justifying lives in less than perfect health and in need of medical care Government Actions on NCDs (37). Well designed and sustained prevention and treatment interventions, which are mutually reinforcing, are required From an economic perspective, government intervention is to reduce the burden of NCDs and control their potentially justified as a means to achieve a net improvement in social enormous pressure on the health system. welfare. That is, it is justified when private markets fail to function efficiently or when the social objectives of equi- The Government of China, therefore, will need to tackle the ty in access to health services are otherwise unlikely to be main risk factors of NCDs following a multisectoral approach 8 Toward a Healthy and Harmonious Life in China Table 3: Characteristics of NCDs Characteristics of NCDs Needs of NCD Care Etiology, behavior risk factors, Behavioral interventions pollutants, viruses Continuous, long-term care, particularly at the primary care level Care planned in advance and pro actively Patients trained in goal setting, problem solving, self-management and Duration: long-term and repeti- actively involved in decision making and treatment planning, since the tive, acute episodes composition of services will change if the condition deteriorates or per- sonal priorities change Regular interaction between health professionals and patients Multi-disciplinary teams Frequent co-morbidities Coordination between different service providers Involvement of patients themselves and their family members Frequent disability Other forms of social services Source: Adopted from E. Nolte and M. McKee. Caring for People with Chronic Conditions: A Health System Perspective. 2008. to prevent their onset in the first place, while at the same time complications of diabetes in China relative to the rates in redesigning and improving the performance of the health sys- OECD comparators4 provide strong evidence of the poor tem to deal with NCDs that do occur in spite of prevention performance of the Chinese health system (Figures 5 and 11). efforts (e.g., heart attacks, strokes) (Table 3). Additional evidence of the organizational and operational China’s health system is not currently responding effective- deficiencies in the Chinese health system is provided by the ly to the needs and demands of its population. The higher findings of a recent survey on institutional capacity for NCD mortality rates for major NCDs (such as CVDs, COPD, and prevention and control in the country. The survey findings re- cancers) and the higher hospital admission rates for acute vealed that more than 55 percent of counties had no specialized Figure 11: Diabetes Acute Complications Figure 12: Coverage of NCD Programs at County Admission Rates, 2007 Level in China Age-sex Standardized Rates per 100,000 Aged 15 and Over 80% 70% New Zealand Netherlands (2005) 60% Iceland Italy (2006) Switzerland (2006) 50% Germany Republic of Korea 40% Span Sweden Denmark 30% Norway OECD 20% Austria (2006) Belgium (2006) Canada 10% Poland (2006) Finland 0% United Kingdom Ireland No institution No budget No intervention United States (2006) No staff No surveillance China (2008) 0 20 40 60 80 100 120 140 160 Source: China CDC, Capacity for NCD Prevention and Control of the Center for Disease Control System in China, 2009. Source: Health at a Glance 2009. China’s datapoint is an estimate based on the 2008 national household health surveys. 4 The variations in hospital admission rates across countries can only be partially explained by the differences in prevalence rates (R2=0.17). To a great extent, this variation reflects effectiveness and efficiency of each country’s health system in addressing NCDs. Human Development Unit | East Asia and Pacific Region THE WORLD BANK 9 institutions for NCDs, and around 15 percent had no staff work- occur within two–seven years after the elimination of the ex- ing on NCDs at the local level (38). In terms of work performed, posure to risk factors, and they are beneficial even for people less than 45 percent of county-level Centers for Disease Control in older age groups (45, 46, 47). (CDCs) carried out any form of NCD-related surveillance activi- 6.1 Suggestions for Comprehensive ties, and only about 30 percent of them implemented any NCD- and Effective NCD Strategies related interventions in the year before the survey (Figure 12). in China The surging NCD epidemic, if not checked, may pose a severe At the international level there is agreement on what con- challenge for containing the escalation of health expenditures in stitutes an effective set of policy options and interventions China. Globally, effective containment of health care costs and for tackling NCDs effectively (48,49). As this consensus is expenditures has proven very difficult. For instance, in the past based on accumulated evidence from different countries, the 10 years, health expenditures in OECD countries have increased Government of China may consider adopting the following by 50 percent in real terms (39). In China, health expenditures policy options for the short and medium terms: tripled between 2000 and 2009, with the most rapid increase in 2008 and 2009, reaching, respectively, more than 16 percent and • Health in All Policies (HiAP)5: HiAP seeks to im- 20 percent of total health expenditures. It is estimated that total prove health and contribute to the well-being and health expenditure might further grow by almost 50 percent in the wealth of nations through structures, mechanisms, next five years (40). Such a skyrocketing increase would not only and actions planned and managed mainly by sectors constrain government budgets, but also those of the Chinese other than health, because improved health status of population, particularly the rural poor, since OOP payments for the population has, in turn, important effects on the health represent 37 percent of total health expenditures (41). This realization of social and economic objectives. situation would significantly undermine China’s effort to expand health insurance coverage in the face of growing health care costs; • Fiscal and regulatory measures: These measures in- it could also increase the odds of impoverishment among vul- clude pricing policies; marketing of healthy prod- nerable populations due to catastrophic health events that would ucts such as fruits and vegetables; and increasing the require high OOP expenditures to cover the cost of needed drugs social and economic costs of unhealthy products and medical care services. (e.g., cigarettes, alcohol, and fast food for children). • Health sector actions: The health sector needs to be 6 LAUNCHING A MULTISECTORAL restructured to adopt novel care organization and STRATEGY FOR NCD financial models with a strong primary health care (PHC) system that is structured for delivery of well- PREVENTION AND CONTROL defined, integrated NCD care and that creates an While NCDs cannot be totally eliminated, preventing them enabling environment for individuals to assume and managing those cases that remain through a continuum greater responsibility for their own health by mak- of care can make a substantial difference in minimizing pre- ing informed, healthier choices. mature mortality, ill health, and disability, as confirmed by • Community actions: In OECD countries, fitness the experience in developed countries, such as Finland, Eng- programs are subsidized by employers, who can land, Canada, France, and Germany. Many preventive NCD also provide tobacco-free workplaces. Health pro- interventions can be highly cost-effective (42), such as the motion activities are implemented by communi- interventions recommended under the Framework Conven- ties. Indeed, companies, as employers, can have a tion on Tobacco Control (FCTC, 43) and multidrug therapy strong influence on the behavior of their staff and administered to individuals at high risk of developing CVDs (44). And, improvements occur in a shorter time frame than 5 The two most important instruments to practice HiAP are the health people commonly believe—indeed, recent evidence from impact assessment (HIA) and health lens projects. HIA is defined as “a England indicates that reducing direct and second-hand ex- combination of procedures, methods and tools by which a policy, pro- gram, or project may be judged as to its potential effects on the health of posure to tobacco smoke has immediate health and economic a population, and the distribution of those effects within the population.� benefits, as the burden of CVD is reduced along with related Designed and implemented by non-health sectors, health lens projects mainly aim to accomplish a sectoral development agenda but also include health care expenditures within one year. Finland’s long- some activities or components to mitigate the negative impacts or enhance documented experience also shows that health improvements the positive impacts on a population’s health. 10 Toward a Healthy and Harmonious Life in China can make them aware of health risks in ways not Implementing population-wide interventions, such as HiAP open to a government. As shown by the experience and other measures, including fiscal and regulatory mea- in the United States, these types of programs have sures, community actions, and a health sector response— very good “returns�: a recent study documented such as screening and treating individuals for/with NCD- that medical costs fell by about US$ 3.27 for ev- related biological risk factor(s)—will result in a reduction ery dollar spent on wellness programs with similar in the share of the population with at least one NCD risk “returns� achieved from reduced absenteeism (50). factor (compared to the no-intervention scenario). These re- China’s experience in Daqing and Beijing demon- sults are also observed among NCD patients: some of them strated that community-based NCD interventions have been diagnosed and identified (the brown bar), but were not only effective but also had long-lasting im- concurrently a significant number of them are not; among pacts on health improvement (51,52). those who have been diagnosed, again, only some are un- Figure 13 illustrates the linkage between the above-proposed der medical care (the pink bar). Lastly, among those under policy options (including the intervention packages) and medical care, only some achieve improved health outcomes the expected outcomes. The population in China can be di- (the green bar). An effective health system response would vided into two groups: the population without any known ensure that more NCD patients are being diagnosed as early NCD-related risk factor (the blue bar) and the population as possible and managed properly; over time, a greater share with at least one NCD-related risk factor (the yellow bar). of NCD patients will have improved outcomes. Figure 13: Preventing and Controlling the NCD Tide Population-wide interventions Whole population • health in all policies • tobacco, alcohol control • healthy city initiative • workplace- & school-based interventions Population with speci�c NCD risks High-risk group interventions • screening & treating individual biological risk factors • workplace- & school- based interventions NCD patients Individual-based interventions Diagnosed NCD patients • primary health care for NCDs • patient-centered NCD management models • behavior change interventions NCD patients managed • improved quality of care NCD patients with improved outcomes Source: Authors. 6.2 What Actions to Take? From • A mid- and long-term multisectoral national plan for Governmental Policy to Program NCDs should be prepared with clear, time-bound Implementation objectives and targets and a fully costed action plan to guide related budgetary and investment decisions. 6.2.1 Improving the Government’s Commitment and Response to NCDs Such plan could serve as a framework for developing required laws, regulations, and enforcement mecha- Improving the population’s health should be among the pri- nisms, as well as policies and programs, assigning in- ority social objectives to be pursued under the programs, tersectoral responsibilities and accountability for the activities, and investments required to implement China’s results at the central, provincial, and local levels, and 12th Development Plan over 2011–2015. As argued before, coordinating international cooperation. this would require improved Government commitment to tackle NCDs effectively in the medium term. • Epidemiological surveillance systems and other data collection mechanisms should be strengthened to To that end, the Chinese Government may consider sup- monitor regularly the achievement of time-bound porting the following actions in the short term: targets, and well-structured strategic communication Human Development Unit | East Asia and Pacific Region THE WORLD BANK 11 activities should be supported to communicate the 6.2.2 Putting in Place an Effective Multisectoral results achieved to policy makers, program managers Coordination Mechanism and the population as a whole. The Government could consolidate, streamline, and • Large-scale (province-wide) demonstrational NCD strengthen the coordination of health actions and invest- prevention and control pilots in collaboration with ments for health-related activities, including those for tack- international organizations should be designed and ling NCDs, by establishing an overarching multisectoral implemented. Such projects would: (a) mobilize inter- National Health Committee (Table 4). This committee national technical assistance to support project prepa- should be chaired by at least a Vice Prime Minister-level of- ration and implementation, based on global best prac- ficial to raise the political importance of the NCD effort and tices, and (b) generate evidence about new approaches involve representatives from different sectoral ministries and before scaling up to the rest of the country. other stakeholders. Table 4: Examples of Inter-Institutional Coordination Mechanisms for Health-Related Activities in China Name Institutional Characteristics National Food Safety Committee A Vice Premier is the leader of this long-term institution. The State Council Leading Group for Strength- A Vice Premier is the leader of this temporary institution, ening Health System Reform with equivalent structures at the local level. National Population and Family Planning Minister of NPFPC, a long-term institution having local Commission (NPFPC) branches. Inter-ministerial Coordination Mechanism for Minister of Industry and Information is the leader, holding Framework Convention on Tobacco Control irregular meetings. (FCTC) implementation in China Inter-ministerial Meeting Mechanism for Mental The Vice Minister of Health is the leader, holding irregular Health meetings. Source: Prepared by authors on the basis of available Government information. To strengthen coordination and a multisectoral response stems from the onset and prevalence of these diseases and to NCDs, China can introduce different financial mecha- conditions; (b) these diseases share common risk factors nisms, such as establishing a “start-up grants� mechanism and, hence, common interventions; and (c) equity and fea- to support the development of the new approaches, as done sibility criteria for China support a focus on these diseases. in such countries as Australia, Denmark, England, France, 6.2.4 The Priority for Immediate Action: Germany, and Canada. Adopting Population-Wide Prevention 6.2.3 An Initial Focus on Four Major NCDs before and Targeted Treatment Expanding to Cover All NCDs to High-Risk Individuals An effective NCD response in China can begin with avert- Accumulated evidence at the international level indicates ing and delaying as much as possible the onset of four major that population-wide prevention, which aims to change dis- NCDs: namely, CVDs (heart attacks and stroke), diabetes ease-related risk behaviors, environmental factors, and their mellitus, COPDs, and lung cancer, along with alcohol-related social and economic determinants for NCDs in an entire injuries. A sustained effort is required to reduce the prevalence population, are the most effective for NCD prevention and of four major behavioral risk factors: smoking, unhealthy diet, control, along with those that target treatment to people at physical inactivity, and alcohol abuse. This in turn would con- high risk of NCDs (Table 5). It should be clear however tribute to the reduction of the four major related biological that international experiences cannot be simply transplant- risk factors at the population level: hypertension, high choles- ed into China. Turning this evidence into actionable policies terol, high blood sugar, and overweight/obesity. and practices in China will require careful assessment and adaptation that takes into account particular cultural, so- This proposed initial focus is justified by the following con- cioeconomic, and institutional factors that influence policy siderations: (a) a significant share of total NCD burden decisions and program development. 12 Toward a Healthy and Harmonious Life in China Table 5: Priority Interventions for NCDs Risk Factor Intervention Accelerate implementation of the Framework Convention on Tobacco Control: • Raise taxes on tobacco Tobacco use • Enforce bans on tobacco advertising, promotion, and sponsorship • Ban smoking in public places and protect people from tobacco smoke • Offer help to quit tobacco use and warn about the dangers of tobacco use • Regulate salt concentration limits in processed and semi-processed foods • Reduce dietary salt levels through voluntary action by food industry Excessive dietary salt • Promote low-sodium salt substitutes intake • Implement information and education campaigns to warn about the harm from excessive salt intake • Increase taxes Harmful alcohol use • Ban advertising • Restrict access • Introduce taxes for unhealthy food Unhealthy diets, physical • Provide subsidies for healthy food inactivity, obesity • Promote labeling • Administer marketing restrictions • Facilitate access to and promote combinations of drugs for individuals at Cardiovascular risk high risk of NCDs Source: Adapted from Beaglehole and others, “Priority actions for the non-communicable disease crisis,� 2011 (53). Initial assessments prepared for this report indicate that smoking in public places. Development of a national salt re- most of the interventions under this group could be imple- duction strategy could be supported to achieve a “quick� public mented in the near term, and their incremental cost would health gain. Some of the proposed interventions for preventing be relatively low, except for some HiAP measures, for which harmful alcohol use could be adopted as well, including en- the costs need to be evaluated. forced legislation to reduce drunk-driving. China has also rati- fied the FCTC, and a ban on smoking in public places became It is highly recommended that the interventions proposed for effective on May 1, 2011, building on the successes of the bans each risk factor be implemented as a package in order to maxi- on tobacco advertisement and smoking in public places during mize the health outcomes. However, building upon existing the 2008 Olympic Games held in Beijing, the 2010 Shanghai political and social acceptance and support, as well as available World Expo, and the 2010 Guangzhou Asian Games. It would funding, a gradual and incremental approach could be adopted be important, therefore, to support the enforcement of the in China, concentrating at the beginning on the reduction of smoking ban in public places, particularly in health facilities, excessive dietary salt intake, harmful alcohol consumption, and and to monitor its effectiveness. Table 6: Tobacco Prices and Taxation in BRICS Countries, 2009 The Russian China Brazil India South Africa Federation Price* US$ 0.73 US$ 1.03 US$ 1.65 US$ 0.51 US$ 2.04 Tax** 36% 58.39% 55% 37% 44.72% Source: WHO Report on the Global Tobacco Epidemic, 2009, available at http://who.int/tobacco. Note: * The price of a pack of 20 cigarettes for most brands (official exchange rate); ** the percentage of the retail price for most brands. Human Development Unit | East Asia and Pacific Region THE WORLD BANK 13 More challenging but more cost-effective actions such as International best practices in using tax policy to reduce to- excise tax increases and the resulting higher retail prices for bacco consumption suggest that (a) there is a trend toward cigarettes merit consideration on the basis of the assessment adoption of specific taxes, particularly if the main goal is and policy deliberation by the Government of China and to discourage the consumption of cigarettes (Australia, In- taking into account international experience in countries dia, Japan, the Republic of Korea, Maldives, New Zealand, such as Australia, Canada and the United States that show the Philippines, and Taiwan, China, have adopted specific that higher excises induce some smokers to quit; reduce con- excises on cigarettes); (b) for countries with specific taxes, sumption by continuing smokers, prevent others from start- there is a trend away from weight-based specific levies to ing, and reduce the number of ex-smokers who resume (54). The adoption of this fiscal measure would be consistent with unit-based levies—that is, specific excises based on the num- the Government’s commitment to the FCTC (55). Com- ber of cigarettes; and (c) specific taxes can and would keep pared to the progress made in other BRICS (Brazil, Russia, pace with inflation if they were automatically adjusted for India, China and South Africa) countries, China has been changes in the consumer price index, as is done in Australia lagging behind mostly in raising the tobacco taxes (Table 6). and New Zealand. Table 7: HiAP for NCD Prevention and Control Sector Opportunities • Subsidy for healthy food production Finance • Increasing prices for tobacco, alcohol, editable oils • Removal of subsidy for products harmful to health, such as tobacco leaf and tobacco products • Production and marketing of healthy food Agriculture, • Salt reduction in (semi)-processed food; reduction of trans fat in food food industry • Maintaining adequate land for agriculture and food systems; crop substitution for tobacco leaves • Globally, a quarter of all preventable illnesses (e.g., cancer, COPDs) are the result of poor environmental conditions where people live. Stricter environment standards and Environment enforcement should be practiced. • Real estate developers can be encouraged or mandated to include physical exercise facilities in their projects. • Optimal planning for road, transport, and housing to reduce environmentally costly Infrastructure, emissions and traffic injuries and to improve accessibility to health services transportation • Better transport, including cycling and walking opportunities, building safer and more livable communities, and accessible facilities for physical activities • Physical activity program among school children • School food and nutrition program Education • Production of an adequate number of health professionals with needed skills for NCD prevention and care • Improved coverage of NCD-related preventive, curative services at the PHC level • Exemption of NCD patients from copayment for selected preventive and curative services Social • Funding the cost for care planning, documentation, and coordination activities for protection integrated care • Adjustment of health financing by disease morbidity/burden • Moving toward a single payer system Legislation • Development and enforcement of pro-health polices and regulations on drunk and law driving,home violence, and a smoke-free environment enforcement • Enforcement of anti-air pollution legislation • Promotion of change in social norms concerning smoking, being sedentary, and alcohol Media abuse and advocating healthy lifestyles • Occupational health and work safety Private sectors • Workplace wellness programs Source: Adopted from Adelaide Statement on Health in All Policies, WHO, Government of South Australia, Adelaide, 2010. 14 Toward a Healthy and Harmonious Life in China In 2009, China adjusted its tobacco tax with the ad valorem China. The concept of employers’ playing a larger role in tax structured at the producer price level but has not passed improving employee fitness and health is not new. The U.S. the adjustment to the retail price level. Had China passed its Government, for example, is encouraging employers to invest 2009 tobacco tax adjustment from the producer price level in workplace health promotion, and about 95 percent of its to the retail price level, the retail price would have increased large employers and a third of its smaller ones offer wellness 3.4 percent, resulting in 700,000 quitters avoiding smok- programs (59). A growing awareness of the substantial costs ing-related illnesses and premature death (56). Alternatively, to employers of ill health and disability linked to NCDs-relat- if China increases the specific tax of 1 yuan per pack (from ed risk factors provides the grounds for advocating workplace- the current level of about 40 percent to about 50 percent of based health promotion initiatives by the Government. the average retail price), with a price elasticity of -0.50, 3.8 million lives would be saved, reducing medical costs by 2.28 Estimated Costs and Effects of NCD Prevention billion yuan and generating a productivity gain of 10.27 bil- Interventions: Halving the NCD Burden lion yuan for the Chinese economy (57). As described in Box 1 and shown in Figure 14, four sets of Other opportunities for HiAP could be considered for NCD population-wide and high-risk, group-based preventive inter- prevention and control (Table 7). It is advisable to set up a ventions are estimated to deliver the greatest value for invest- cross-sectoral taskforce to identify possible areas and interven- ments needed at different levels of available resources in China. tions for dealing with NCDs. A practical first step would be These preventive intervention sets can be implemented sepa- for this task force to prepare a priority list of activities and in- rately; however, combinations of different sets of interventions vestments to implement multisectoral actions in health. Even- lead to economies of scale and more value for money. With tually, the Government could consider adopting HiAP as a full implementation of the combined set of interventions, one national policy, as done by the European Union in 2006 (58). could expect 600–800 million DALYs or lost years averted an- nually over a period of ten years with an expenditure of about The involvement of public and private production and com- $220 per capita per year. This is about 45–60 percent of the mercial enterprises could be of particular importance in estimated total NCD burden of about 1.4 billion in 2010. Box 1: Projected Impact of Priority NCD Prevention Interventions in China • Implementation of tobacco control measures—including higher taxation and prices for cigarettes, and banning smoking in public places and advertisement of tobacco products—would prevent 10 million DALYs lost annually at only a few cents (US) or less than 0.04 yuan per capita per year. • At a doubling of resources, a few additional cents (US) or around 0.07 yuan per capita, a combina- tion of anti-tobacco measures with interventions for controlling alcohol abuse, e.g., increasing tax and banning advertising, would help avert an additional 40 million DALYs lost annually. • At about US$ 13 or 90 yuan per high-risk individual, the combined implementation of anti-smoking and alcohol abuse measures, along with preventive interventions—e.g., screening of and treatment for individuals with elevated blood cholesterol levels—would help prevent about 85 million DALYs lost per year. • US$ 220 or 1500 yuan per high-risk individual annually is required to add a next set of cost-effective interventions, i.e., in high-risk groups, cardiovascular risk assessment and management and preventive treatment with multidrug regimes (statin, aspirin and two or three blood pressure-lowering drugs). The total cost would be over US$ 26.5 billion or 180 billion yuan annually (less than 10 percent of the total health expenditure in 2010), and the total annual DALYs lost averted would be around an additional 500 million. • The first two groups of interventions could be financed through the priority public health programs for NCDs and implemented at the national level. The third and fourth groups can be financed through health insurance schemes. Human Development Unit | East Asia and Pacific Region THE WORLD BANK 15 Figure 14: Proposed Expansion Path for an NCD Prevention Package $ 100,000,000,000 Combined individual risk- $ 10,000,000,000 based interventions Anti-tobacco package + anti- $ 1,000,000,000 Anti-tobacco alcohol package Population-wide package + anti- + cholesterol $ 100,000,000 interventions alcohol package lowering + polypill Costs,US$ + cholesterol intervention $ 10,000,000 lowering $ 1,000,000 Anti-tobacco package anti-alcohol package $ 100,000 10,000,000 100,000,000 1,000,000,000 Health Effects in DALYs $ 1,000,000 $ 750,000 Anti-tobacco Costs, US$ $ 500,000 package + Anti-tobacco anti-alcohol $ 250,000 package package $0 10,650,000 10,700,000 10,750,000 10,800,000 10,850,000 Health Effects in DALYs Source: Authors. Note: Both axes in large figure are in log scale. Interventions for reducing dietary salt intake—which would measures to strengthen the capacity of the health system to lead to lower blood pressure, one of the main risk factors for better respond to the NCD challenge as outlined below. CVDs—could also be highly cost-effective in China, as dem- onstrated by the experience in the United Kingdom, Finland, Improving financial protection in health and Japan. This can be done using a multi-pronged approach, including legislation and regulation, working with the food The Government of China recently committed to support industry, general health promotion campaigns, and the pro- the reduction of OOP payments for health care from the current level of 37 percent of total health expenditure to motion of low-sodium salt substitutes, since in China most 30 percent by 2015 (61). This target is highly relevant to salt is added during cooking. The U.K. salt reduction pro- NCD patients since NCDs are the biggest contributor gram spent just £15 million (about US$ 24 million) but led to escalating individual and household expenditures on to 6000 fewer CVD deaths per year, saving the U.K. economy health care. Between 1985 and 2005, health expenditures about £1.5 billion (about US$ 2.43 billion) per annum (60). associated with CVD alone increased by 17.3 percent an- 6.2.4 Over the Medium Term: Strengthening the nually, while the total health expenditure increased by 11.8 Health System to Address NCDs percent per year. The Government has already adopted some measures—such as reducing the prices of pharma- The explicit priority attached to NCD prevention and control ceuticals, integrating different health insurance schemes, in China over the medium term should drive improvements and increasing government spending on health—in order in the health system. This is required for early detection and to reach the target. Further actions would be needed to treatment of risk factors, and early identification and treat- reduce the OOP burden incurred by NCD patients and ment of conditions such as heart attacks and strokes and the their families. recurrence of these conditions. These interventions occur at the patient level in a health care setting. Building upon ongo- Creating new fiscal space for financing NCDs ing health system reform efforts included under its five health reform pillars, the Government of China may consider adopt- Levying a “sin tax� on tobacco, alcohol, and sugar soft ing additional policy, institutional, and service provision drinks needs to be considered (e.g., on tobacco, as the 16 Toward a Healthy and Harmonious Life in China current price of cigarettes in China is very low compared Moving to a single payer for health services to other G-20 countries). This would not only help reduce Development of a universal basic health insurance scheme their demand and consumption but also has the added in China could be accelerated through integration of various benefit of raising Government revenue (54). Some coun- health insurance schemes as is being done in early stages in tries, such as Australia and the United States, are using Chongqing, Zhejiang and Guagnxi to adopt mechanisms to revenue from these taxes to help fund health promotion fund the NCD prevention and control. Continued coverage programs and insurance schemes. A good example is the by a SINGLE insurer at the provincial level could pool risks, decision in February 2009 by the U.S. Government autho- create improved benefit packages, allow more equitable allo- rizing the renewal and extension of the Children’s Health cations across populations and improve purchaser’s leverage Insurance Program for poor children by using a 62-cent in addressing NCDs more proactively and efficiently, because per-pack increase in the federal taxes of cigarettes to fully the benefits of avoiding severe complications are often only fund the program (62). In addition, taping resources from realized after eight to ten years (64). Such an approach would other sectors through implementation of HiAP could be reduce the administrative costs associated with the operation further considered to mobilize funding for cross-sectoral of thousands of existing insurance schemes, facilitate coordi- health-related interventions. nated care, increase the capacity of the scheme to cushion the financial risks due to NCDs, and better position the payers in Improving central Government financial active purchasing of services from different providers. allocations for health by taking into account the population’s health conditions The financing of NCD-related activities would need to prioritize prevention The central Government in China could consider using dis- ease morbidity as a factor in the formulae used to calcu- Cost-effective, population-wide interventions and those tar- late allocations (per capita) to new rural collective medical geting high-risk groups recommended in the previous section schemes, urban resident basic health insurance schemes, as need to be given the highest priority and be fully financed in well as its NCD-related allocations to the provinces. Such order to achieve the best return for investment. A review of an approach is used in such countries as the Netherlands, the approaches for reducing coronary heart disease (CHD) Belgium, and Germany (63). Similar arrangements have al- in most of developed countries demonstrated that reducing ready been adopted in China for funding HIV/AIDS and total cholesterol level, blood pressure, and tobacco smoking TB prevention and control programs. account for a significant share of the reductions in CHD Figure 15: Effective Approaches to Reducing Mortality from Coronary Heart Disease IMPACT Iceland 1981–2006 24% 74% 2% IMPACT Finland 1982–1997 23% 72% 5% BMJ Finland 1972–1992 24% 76% IMPACT Sweden 1986–2002 36% 55% 9% IMPACT Czech Republic 1985–2007 39% 60% 1% IMPACT Poland 1991–2005 43% 49% 8% IMPACT USA 1980–2000 47% 44% 9% IMPACT England & Wales 1981–2000 38% 53% 11% IMPACT New Zealand 1982–1993 35% 60% 5% IMPACT Scotland 1975–1994 35% 55% 10% Hunink USA 1980–1990 43% 50% 7% Beaglehole New Zealand 1974–1981 40% 60% Goldman USA 1968–1976 40% 54% 6% Treatments Risk factors Unexplained Source: Ford et al., 2007, Explaining the decrease in U.S. deaths from coronary disease, 1980–2000, New England Journal of Medicine, 356: 2388–98, updated by Capewell & Andersen, 2011. Human Development Unit | East Asia and Pacific Region THE WORLD BANK 17 Figure 16: Health Expenditure by Function of Health Care, 2007 100% 5 5 4 7 3 8 3 7 6 6 7 6 3 6 5 9 11 9 12 12 8.6 90% 18 16 13 13 12 18 11 21 17 25 22 80% 21 29 26 20 18 12 28 24 21 8 36 37 70% 13 18 26 18 20 14 1 4 12 12 2 8 16 11 6 13 17 60% 3 0.4 50% 28 23 27 29 31 32 33 40 36 46 26 30 31 29 32 33 37 40% 26 24 33 31 30% 20% 36 36 33 33 32 32 30 30 30 29 29 29 29 29 29 29 28 25 25 24 10% 23 0% Austria France Poland Iceland Czech Republic Norway Finland Luxembourg Denmark OECD Sweden Germany Hungary Switzerland Belgium New Zealand Republic of Korea Portugal (2006) Spain Japan Slovak Republic In-patient* Out-patient** Long-term Care Medical Goods Collective Source: Health at a Glance 2009: OECD indicators. Note: * Curative-rehabilitative care in inpatient and day-care settings; ** home care and ancillary services. mortality (Figure 15) (65). Also, a screening and control pro- about 82 percent of the Government’s and insurance schemes’ gram for early diabetes and hypertension in Mexico demon- spending on CVDs was on inpatient care, and only 18 per- strated that for each U.S. dollar invested in prevention, US$ cent was on outpatient care in 2008 (Figure 17) (69). 85–323 would be saved over a 20-year period (66). To increase the relative importance of PHC services in the health system, health insurance schemes in OECD coun- A shift to primary health care is needed to tackle tries have adopted several measures that may be relevant NCDs effectively for China: Different countries have been shifting emphasis in expend- • Improved coverage of NCD-related preventive and iture toward primary health care to deal with NCDs. OECD curative services at the PHC level and at home and countries on average allocate 31 percent of their total health provision of outpatient drugs (70, 71); expenditure to outpatient care and less than 40 percent to inpatient care (Figure 16). The benefits of this approach are • Exempting NCD patients from copayments for se- well documented. A recent study in Brazil, for example, lected preventive care and curative services that are demonstrated that its strengthened PHC helped prevent necessary for patients who need long-term chronic unnecessary hospitalization (67). care (United States and France, 72); Data from China suggest the opposite: the allocation of total • Funding the cost for care planning, documentation, health expenditure on outpatient care fell from 37.8 percent and coordination activities to incentivize providers to in 2005 to 32.5 percent in 2009 (34). Further evidence in- deliver coordinated and integrated care for NCD pa- dicates health spending by the Government and insurance tients, for example, the “year of care� approach adopted schemes has been skewed toward inpatient care. The recent in the U.K. National Health Services for diabetes con- National Health Service survey showed that in 2008, OOP as trol. The amount of funding for expected care is cal- a share of medical bills, remain significantly higher for outpa- culated using a risk-adjusted capitation formula based tient care compared to inpatient care and reached 84 percent on the likely annual consumption of a range of neces- of monthly per capita income among patients in the poorest sary health services. Service providers are paid through quintile (compared to about 11 percent in the richest quintile) an integrated capitation method (73). Such practices for an average outpatient visit (68). In Tianjin Municipality, are found in Australia, the United States, and parts of 18 Toward a Healthy and Harmonious Life in China Figure 17: Expenditures on CVD Treatment by Treatment Type, Tianjin, 2008 In million yuan Pharmacies Inpatient Outpatient Total 0 50 100 150 200 250 Public Funds Insurance OOP Source: Yang et al., Case Study of NCD Expenditure Analysis in One District of City of Tianjin, 2010. Thailand. Often, GPs act as fund holders, using capita- more efficient care to patients who are affected by two or tion payment funds to purchase inpatient services and/ more chronic conditions. In adopting new approaches, the or specialist services for registered patients. goal is to improve access to and the quality of services and to control health care costs. Before introducing any new model Adopting new health care organization models widely in China, however, it is advisable to pilot it at a small scale to assess its feasibility, adapting it to local conditions, China’s health system will not be able to handle effectively and to evaluate the results. the growing NCD burden alongside the lingering burden of communicable diseases without striving to integrate differ- NCD patients can be categorized according to the intensity ent levels of care to guarantee the continuity of care. and sophistication of care needs (74, 75) and provided with the needed services accordingly. A majority of NCD patients As currently done in other countries (e.g., the United States, need a low level of care since their conditions are reasonably England), the adoption of new health care organization and under control with self-management. Only about 5 percent service delivery approaches may be considered as an option of NCD patients would require complex case management to better manage NCDs in China, particularly for delivering delivered by specialized personnel or through hospital-based Figure 18: “Pyramid of Care� Model Figure 19: “Chronic Care� Model Level 1: Primary care with support/supported Health system self-care (65–80%) of low risk patients Community Organization of health care Resources Self- Delivery Decision Clinical and policies management system support information support design systems Level 2: Care management for high-risk patients (15%) Level 3: Case management Informed Prepared for highly complex activated Productive proactive patient interactions practice team patients (5%) Functional and clinical outcomes Source: Adapted from E. Nolte, M. McKee. Caring for people Source: Adapted from E. Nolte, M. McKee. Caring for people with chronic conditions: A health system perspective, 2008. with chronic conditions: A health system perspective, 2008. Human Development Unit | East Asia and Pacific Region THE WORLD BANK 19 care. In between these two groups are the so-called high-risk pivotal role in the provision of both preventive and patients who need structured care management from spe- curative care for almost all high-risk groups and cialists because their condition is not stable or is deteriorat- most NCD patients (86,87). For NCD care, the ing (Figure 18). PHC system should (a) enable first-contact access for patient needs; (b) provide long-term, patient- The “Chronic Care� model, which has been adopted in sev- centered care; and (c) ensure comprehensive care for eral countries, offers some useful applications for redesign- most health needs and coordinate care, both hori- ing health care organization and service delivery in China zontally and vertically. Experiences in urban areas to improve the quality of care for NCD patients (76; Figure in Shanghai and Beijing, as well as in rural areas 19). The model’s main components are: (a) self-manage- in Shandong Province, show that township health ment support (counseling, education, and information giv- care centers and village clinics in rural China and ing); (b) delivery system design (multidisciplinary teams); community health care centers in urban China have (c) decision support (evidence-based guidelines and training been able to fulfill such tasks when they are well of health workers); and (d) clinical information systems (pa- equipped and staffed with trained and motivated tients’ records, clinical audit, and feedback). At the core of personnel. Currently, however, the health system in this model are the productive interactions between service China is still hospital-centered, which is less cost- providers and patients in assessment, self-management sup- effective for the Government and provides less fi- port, optimization of therapy, and follow-up. nancial protection for patients and their families. Disease management program (DMP), another model that • Self-management of NCDs: Patients and their may be relevant for organizing the provision of NCD-relat- families are informed and motivated for self-man- ed health care services in China, is now widely used in the agement by either PHC providers or peer patients United States, Germany, and other OECD countries (77). to adhere to treatment regimes, monitor their con- The decision to include any NCDs as part of DMPs is guided ditions, and adopt and maintain healthy behaviors. by selection criteria, such as a high number of patients, high expenditure, potential for quality improvement, existence of • Effective coordination between PHC, hospitals, evidence-based guidelines, need for coordinated care at dif- and other service providers: Coordination is need- ferent levels of the system and potential for improvement ed to ensure continuity of care for NCD patients through patients’ initiatives (78). NCD patients and service at different levels of the system, enabled by well providers can be encouraged to join the appropriate DMP defined referral procedures and contractual arrange- with appropriate incentives, such as risk structure compen- ments, and information systems and technology. sation and a reduced or even waived copayment by enrolled patients. A recent review confirmed that after four years of Developing synergies between NCD programs follow-up, overall mortality and drug and hospital costs and other health programs were all significantly lower for patients who participated in Given co-morbidities among NCD patients (88), taking the program compared to other insured patients with simi- a disease-inclusive approach at the service delivery level is lar health profiles who did not participate (79). critical. As part of health care organization reforms, there Telemedicine (e-health, m-health) is also being increasingly is opportunity to develop synergies among different health used for NCD care and has been proven effective for the programs to show benefits for their own work and for tack- treatment of diabetes, heart disease, and COPD, as well ling NCD so that different health programs (a) share exist- as for promoting smoking cessation and physical activity, ing facilities, resources, information systems and (b) target a with good results as measured in terms of improved service “common� population, as follows: utilization and treatment compliance, reduced hospital ad- • Maternal and child health and NCDs: Lifestyle mission, increased patient satisfaction, and improved health modification and behavioral interventions—such as outcomes (80,81,82,83,84,85). tobacco and alcohol control and adequate and ap- Effective NCD health care models point to three important propriate nutrition during pregnancy—could lead to healthier mothers and babies and lower infant lessons that may be relevant to China: mortality. Tackling medical conditions arising dur- • Emphasis on PHC: The PHC system plays a ing pregnancy (hypertension, gestational diabetes) 20 Toward a Healthy and Harmonious Life in China Table 8: Life Course Approach for NCD Prevention and Control Stages of Life Opportunities • Maternal diet/nutrition Fetal development and • Regular check-ups for intra-uterine growth and control of hypertension and maternal environment high blood sugar • Subsidy for healthy food or targeted nutritional intervention for children from Infancy and early child- families with low socio-economic status hood • Promotion of breast feeding • School-healthy lunch/dinner program • Regulating food advertising to children Adolescence • Reducing time for television viewing and fostering sports and hobbies • Banning tobacco sales to minors • Risk factor modifications, such as prevention of tobacco smoking, smoking cessation, prevention of alcohol drinking • Development of parental and food preparation/cooking skills Adulthood • Wellness programs at workplaces • Early detection and treatment for elevated blood pressure, serum cholesterol level, and hyper-insulanemia • Risk factor modifications: prevention of tobacco smoking and excessive alco- Aging and older people hol drinking, smoking cessation • Establishment of expert patient groups or patient self-support groups • Five servings of fruits and vegetables per day • 30 minutes of physical activity per day • Preventing tobacco smoking and the harm of second-hand smoke All stages • Effective and equitable primary health care • Changing social norms to make healthy choices easier • Promoting community safety Source: Hill, D., Nishida, C., James, W. P. T. 2004. A life course approach to diet, nutrition and the prevention of chronic diseases. Public Health Nutrition 7 (1A): 101–121. could reduce maternal mortality and impact on the of occupational health legislation could help to re- longer term health of mothers. Maternal and child duce the prevalence of COPD and cancers. health programs could also be used to raise aware- ness of and detect early signs and symptoms of cer- Life course approach for NCD prevention and vical and breast cancer (89). control • Communicable diseases and NCDs: A TB control Major biological risk factors may emerge and begin hav- program provides an opportunity for NCD preven- ing effects in early life and continue to have a negative tion and control since TB patients may also have impact throughout life and even into the next generation. diabetes and/or COPD and may smoke (90). TB control programs could be also leveraged to pro- Lifestyle modification at all stages of life can reduce the mote smoking cessation. Cervical cancer is vaccine risk of progression to NCDs. A life course approach is preventable, so prevention of this cancer could be recommended for adaptation in China to seize opportu- built into existing immunization programs. Screen- nities at different stages in life for NCD prevention and ing for hypertension and elevated blood sugar levels control (Table 8) (91). Government policy has an essen- can be administered among people diagnosed with tial role in facilitating a conducive economic and legal HIV infection. environment to reduce risk factors at the population level • Environmental health and NCDs: Smoke-free en- and to facilitate making health changes easier, more effec- vironments or air pollution control and enforcement tive, and sustainable. Human Development Unit | East Asia and Pacific Region THE WORLD BANK 21 Establishing new institutions and adopting new example is the U.K. Every Contact Counts initiative, which roles aims to have every provider-patient contact include health promotion and disease prevention interventions (e.g., coun- New institutional bodies would need to be set up to selling, screening, smoking cessation advice). strengthen the capacity of the health system to deal with NCDs. For example, China’s MOH, with the support of the Developing new roles and searching for more flexibility in U.K. National Institute of Health and Clinical Excellence using existing staff require an assessment of the existing en- (NICE), has established a new agency in charge of conduct- vironment (policy and legal, structural and procedural, and ing routine technology assessments and screening new drugs financial mechanisms) that influence institutions’ or health to guide resource allocation decisions and improve the cost- care workers’ proposed new roles. To support these arrange- effectiveness of services provision. The capacity of this insti- ments, additional changes may be needed so that (a) adequate tution needs to be developed and strengthened to fulfill its incentives for various health care professions and stakeholders critical role. are provided for the delivery of required care to patients, and (b) collaboration and teamwork are enhanced. Some existing institutions may require further strengthening to take on new roles or perform their current duties and re- sponsibilities more effectively. For instance, local CDCs may Developing a capable and motivated workforce function as technical hubs to support a strengthened NCD The rising NCD epidemic necessitates a comprehensive hu- prevention and control effort, bringing together and coordi- man resources development plan. To this end, the following nating different initiatives and actions. At the service delivery considerations should be taken into account in China: level, new organizational arrangements may be developed as well. PHC providers have a role to play as gatekeepers to pre- • Skill mix for NCDs: Expertise in some areas—such as how to define a health insurance benefit package vent unnecessary hospital admissions. In turn, hospitals may based on cost-effectiveness analysis; how to regu- rely on technical advisory teams comprised of specialists in late price, volume, availability, and payment of new different disciplines for handling complicated cases and pro- market entry pharmaceuticals related to NCD and viding technical assistance to PHC providers. Indeed, there other diseases; how to plan, organize, and provide is now an opportunity to reorient the entire health system patient-centered care; partnership development; towards health promotion and disease prevention. A good information and communication technology; and Table 9: Examples of Financial Incentives for NCD Services Focus Financial Incentives (Country of Practice) Demand side • Reduce health insurance premiums if enrollees meet health improvement targets (e.g., quit smoking or reduce weight) (United States) • Reduce/waive copayment by enrollees for joining DMPs (Germany) Structure • Cover additional services for patients in DMPs Supply side • Implement DMPs and enroll patients in DMPs (Germany, United States) • Put in place a “package of care� that crosses institutional/ sectoral boundaries (Australia); • Risk structure compensation (Germany) Demand side • Keep patients in DMPs for a set period (Germany) Supply side Process • Pay for performance: Ensure the care protocols specified in DMPs are followed; reach pre- defined targets on process measures (Germany, United Kingdom, Australia); offer quality improvement grants (Australia) Supply side Outcome • Pay for performance: Reach predefined targets, health outcomes. and patient satisfaction or reward the top X% of providers on an indicator(s) (United Kingdom) Source: Adopted from E. Nolte and M. McKee. Caring for People with Chronic Conditions: A Health System Perspective. 2008. Sour. 22 Toward a Healthy and Harmonious Life in China behavior sciences and public health—should be de- community resources—such as patient-self sup- veloped. Global experiences suggest GPs are key to port groups; retired health workers; and NGOs, facilitating integrated care for NCD patients if they such as associations for hypertension and diabe- are trained to meet patients’ multiple and complex tes prevention and control—could be explored as needs. By the end of 2010, there were only 60,000 NCD service extenders, as has been practiced for GPs in China, 3.5 percent of all licensed physi- HIV/AIDS and TB care in China. Trained and cians, far lower than the 30–60 percent observed in equipped with adequate skills and knowledge, they OECD countries. can take on functions traditionally assigned to staff in medical facilities. • Staff mix for NCDs: China may assess the need to train more nurses and to enlarge their roles • Quantity and distribution: The number of health in NCD management. In addition, enlisting worker per 1000 population in China is lower than Box 2: Quality and Outcome Framework in the United Kingdom Providers must fulfill a range of quality requirements in order to be contracted with the National Health Service (e.g., having a practice information leaflet for patients and a system to enable quality assur- ance). The contract includes a system of financial incentives for clinical and organizational quality. The Quality and Outcomes Framework (QOF) rewards practices for the provision of ‘quality care’ and helps to standardize improvements in the delivery of clinical care. Quality rewards are a substantial part of the funding (typically 25% of a GP’s income) in addition to capitation and infrastructure payments. To link payments to the achievement of quality standards, a system of points was developed, with an original maximum of 1000. The maximum number of points achievable for each indicator is related to its associated workload: 87 clinical indicators account for 66% of the total number of points achiev- able by a practice. The most points are available for diabetes (92 points), hypertension (79 points), and coronary heart disease (76 points) and smoking cessation (60 points). Points for clinical indicators are awarded on a simple linear basis between a minimum and maximum. For example, for controlling blood pressure, a maximum of 57 points can be earned. No points are earned until 40% of patients have achieved a targeted blood pressure level; the maximum practically achievable has been set at 70%. If a practice achieves the blood pressure target in 70% of covered population, it will receive 57 points for this indicator. If the target is achieved in only 60% of the targeted population, the practice will earn for this indicator only 38 points [=57*(50%–40%) / (70%–40%)]. Domain Sample Indicator % of patients with hypertension whose last blood pressure measure- ment is 150/90 or less Clinical management % of patients with diabetes whose the last blood pressure measure- ment is 140/80 or less The practice has up to date clinical summaries in at least 60% of Organization patient records The practice engages with the development of and follows 3 agreed Quality & productivity care pathways in the management and treatment of patients to avoid emergency admission and produces a report of the action taken. The length of routine booked appointments with the doctor is not less Patient experience than 10 minutes % of female patients whose notes record that a cervical screening test Additional services has been performed in the proceeding 5 years Source: Adapted from British Medical Association. Quality and Outcomes Framework Guidance for GMS Contract 2011/12. 2011. Human Development Unit | East Asia and Pacific Region THE WORLD BANK 23 that in OECD countries (92,93) and concentrat- percent of reimbursement payments can be withheld for a ed in the economically developed eastern region. quality reward. They can be allocated to service providers in Less than 36 percent of physicians are working at the full amount or partially on the basis of compliance with the PHC level, such as at village clinics, township agreed service delivery targets; (b) a bonus of 5–20 percent health centers, and urban community health cen- of total reimbursement can be paid to top-rated providers; ters. Alternative options could be assessed to reverse (c) quality grants can be set up for specific quality improve- this situation and improve the distribution of hu- ment activities to providers who meet quality improvement man resources in the health system. targets; and (d) to get started, health insurance authorities can link at least 10 percent of compensation to performance Improving health service delivery to promote change in practices and improvement in service Different approaches that may be relevant for China exist quality. The percentage should be then increased gradually. to improve health services delivery for NCD patients, with To discourage practices that discriminate against older and larger effect when measures are combined. sicker patients and facilitate the provision of services to NCD patients along a care continuum, physicians could be contract- Financial incentives ed on a risk-adjusted capitation basis (taking into account age, gender, health status, and quality indicators). A combination Financial incentives can be applied at different levels and of different payment methods is recommended to be used to to different stakeholders to encourage behavior modifica- pay hospitals. While a diagnostic-related groups (DRGs) re- tion among the patients and improve the delivery of NCD imbursement method, coupled with good quality assurance services (Table 9). systems such as pre-admission certification, can help improve Pay for performance (P4P): Payment to health care providers technical efficiency, the allocation of global budgets can dis- could be conditioned on the achievement of specific program- courage unnecessary hospital admissions and promote service matic targets measured in terms of volume, price, type of ser- delivery at the primary and specialized outpatient levels of vice delivered, and quality. P4P could be particularly useful for care. In addition, incentives for patients can be introduced: the prevention and control of certain NCDs, such as diabetes NCD patients can be encouraged to join NCD management and hypertension, because (a) the quality and outcome of these programs through reductions in and/or exemptions from co- NCDs are easy to measure, for example, blood glucose test for payments and by lowering the health insurance premiums of diabetes patients and blood pressure measurements for hyper- patients who enroll in such programs and achieve individual tensive patients (94), and (b) they have clearly defined treat- health targets (e.g., smoking cessation, weight reduction). ment protocols that can be used to define care norms based on Regulatory tools evidence. In addition, international experiences suggest that it is important that the design of a P4P mechanism (a) not penalize To contribute to the improvement of quality of care in China, providers who serve populations with high morbidity or that are the adaptation of some additional regulatory tools and service hard to reach and (b) minimize distorting aspects of P4P in rela- delivery arrangements could be explored, as follows: tion to other services not included in the scheme (95). Licensing and accreditation: These mechanisms could General practitioners (GPs) in the United Kingdom, for in- be used to prequalify potential service providers under the stance, are rewarded for delivering care (processes) exhibiting DMP approach for NCDs. Structural and equipment re- particular features assumed to be associated with clinical and quirements, use of standardized clinical guidelines and pro- organizational quality and health outcomes of the registered tocols to guide the process of care, as well as data collection patients (96). The Quality and Outcome Framework in that and reporting requirements can be established for service country structures and facilitates contractual arrangements providers and facilities that want to be licensed/ accredited. and conditions for providers (Box 2). Some models of P4P have been introduced in China; e.g., in Shanghai and Henan Selective contracting: Contracting with pre-selected pro- Province. The accumulated experiences in these provinces viders is done, for example, in the United States, Austria, should be evaluated before replication in other provinces. and the Netherlands. Selective contracting allows health insurers to channel their members to providers who of- Different ways to implement P4P could be assessed for ad- fer favorable terms, fostering competition among provid- aptation in China: (a) global experience suggests that 5–25 ers on the basis of price, quality, scope of services and 24 Toward a Healthy and Harmonious Life in China amenities. Selective contracting does not necessarily re- and evaluation arrangements that underpin and accompany strict access to any provider. Seeing a noncontract provider policy development, target setting, and program implemen- could just require lower reimbursement rates for provid- tation. The systematic collection and assessment of data and ers by the insurance companies and higher copayments for information are necessary to better understand the changing patients (97,98). nature and characteristics of the population’s health condi- tions and to measure and document the impact of policy Gatekeeping: GPs and their assistants have been used as the decisions and interventions that are implemented to address first contact for managing health problems in Australia and NCDs at different levels of the system. Many of the recom- the United Kingdom (99,100). Specialists can be seen only mended options and actions in China have been either not upon referral from a GP or GP’s assistant. PHC providers implemented or not properly evaluated. willing to be a gatekeeper have to fulfill certain criteria, such as: (a) follow evidence-based clinical guidelines, (b) attend China would also need to be cautious when extracting les- mandatory training on patient-oriented communication and sons from other countries’ experiences, because its health basic diagnosis and treatment of common NCDs, and (c) run delivery system is organized differently and operates in a dif- an in-house quality management program in their practice. ferent socio-economic context than those in other countries. Similarly, the Chinese people have different sets of cultural Development and enforcement of evidence-based guide- values and expectations that influence demand and utiliza- lines: Practice guidelines for chronic disease management tion of health services. need to be updated on the basis of reviews of available clini- cal evidence and technological developments and adapted at Scaling up and strengthening the epidemiological surveil- the different levels of the health system in accordance with lance systems for NCDs and related risk factors and creat- the institutional and financial reality of China’s provinces. ing a strong empirical research capacity in the health sec- Standard operating procedures or criteria need to be devel- tor are critical to generate valid, reliable, and timely data oped on NCD patient referral between health providers at and assessments on what works for NCD prevention and different levels. control in the country. While full-fledged NCD surveil- lance surveys should be implemented every five years, risk Building a continuous quality assurance culture behavior surveillance surveys are recommended every two years. Besides, province representative data on NCDs and In China, the adoption of processes and tools for continuous related risk behaviors need to be developed and used to as- monitoring and assessment of the performance of service sess local NCD response. providers could be explored so that the results can be used to identify areas for improvement. Patient satisfaction surveys At the service delivery level, the development of electronic can also be used to identify areas for health care improve- health record (EHR) systems has the potential to improve ment, to induce physicians and other care givers to modify NCD care by (a) facilitating coordinated and integrated care: service delivery practices in accordance with feedback pro- health providers at different levels and different location could vided by patients. In order to build a continuous quality as- have all the necessary information on any given patient in a surance culture in the health system, the National Center for timely manner; (b) tracking and monitoring patients’ status Cancer Research, National Center for CVD Research of the and sending out health maintenance alerts (101); (c) docu- Chinese Academy of Medicine, China CDC, and the China menting the performance of different service providers (102); National Health Development Research Center would need and (d) reducing laboratory and medication errors. to work together to develop clinical guidance and standards Many countries are investing heavily in EHR systems (103). of care for the management of NCDs at the service delivery China’s MOH has started an initiative to health sector “in- level, as well as processes and tools to monitor and assess formatization,� and different EHR systems have been de- their uptake by providers and the impact of these measures veloped at the provincial level. It is of utmost importance, on the quality of care delivered and health outcomes. therefore, to ensure the standardization of demographic, 6.3 Addressing Information Gaps health and service data across the health system through the use of a common patient identifier (e.g., civil registry In developing new policy and implementing institutional number), as well as internationally accepted diagnosis and reforms in China’s health system, proper attention would procedures coding systems, and recording and reporting need to be placed on (a) establishing robust monitoring forms, including health insurance claim forms. These Human Development Unit | East Asia and Pacific Region THE WORLD BANK 25 measures would facilitate the coordinated flow of informa- As the “platform for action� for effectively addressing NCDs tion among service providers, and between service provid- in China is a medium-term effort, its implementation could ers, health insurance schemes and public health authorities. build on and be accelerated by the full and immediate im- The development of EHR at the provincial level in China plementation of the FCTC that the Chinese Government should be closely monitored and evaluated to draw lessons has ratified, including adoption and enforcement of smoke- about design, cost, implementation requirements, and re- free public spaces and workplaces to reduce the risks of sults achieved to inform scale up to other provinces. second-hand smoking, tobacco advertising, and increases in excise taxes on tobacco products, enhanced regulation of the 7 THE WAY FORWARD salt, fat, and sugar content of processed foods; and the scal- China’s NCD epidemic will continue to explode over the ing up of health care organization and financial reforms to next 20 years if not addressed effectively. This has the poten- facilitate access to essential treatments for the most common tial to undermine the Government’s agenda for harmonious NCDs. At the same time, making the achievement of good and human-centered development, particularly by aggravat- health outcomes a key social objective under China’s 12th ing health inequities. It may also raise the odds of a future Five-year Plan (2011–2015) would help to raise the political slowdown in economic growth due to a reduced ratio of commitment to promote health improvement contributions healthy workers to a growing number of sicker dependents. by other sectors, such as education, employment, transport, Too low a ratio may pose a significant social challenge that and urban and rural development. could undermine China’s economic prosperity. With reduced unhealthy behaviors, improved socioeconomic Much of China’s NCD burden can be avoided and the re- environments conducive to health, and expanded access to mainder managed with the adoption and adaptation to lo- quality health services, not only do people live longer, but their cal conditions of good practices that have been proven ef- quality of life is also improved by the reduction of sickness and fective internationally. Indeed, as outlined in this report, disability at the end of life. Data from successful efforts in de- cost-effective policy options exist for a comprehensive veloped countries reveal that health improvements occurs in a multisectoral response to the NCD epidemic. With im- shorter time frame than people commonly believe—within a proved political commitment at the highest levels of Gov- year or a few years rather than decades—after the elimination of ernment, many of the key challenges for implementing the exposure to risk factors (104,105). 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Human Development Unit | East Asia and Pacific Region THE WORLD BANK 31 Human Development Unit | East Asia and Pacific Region THE WORLD BANK 33 Toward a Healthy and Harmonious Life in China: Stemming the Rising Tide of Non-Communicable Diseases discusses why priority attention to non-communicable diseases (NCDs) is now required in China, articulates what would constitute an effective NCD response, and proposes how to operationalize the response over the medium and longer terms. It is expected that the findings and recommendations of this report can inform and promote a broad dialogue toward the development of a multisectoral response to effectively address the growing burden of NCDs in China, including a better alignment of the health system with the population’s health needs. An effective response by China to address the NCD challenge in the years to come could be a powerful example that would significantly influence the rest of the world. Toward a Healthy and Harmonious Life in China: Stemming the Rising Tide of Non-Communicable Diseases will be of interest to political and business leaders, policy makers and managers who focus on economic and social development challenges and options to address them. Within the health sector, this report will be of particular interest to ministry of health and health insurance officials, university researchers, health services providers, and others working to improve health conditions in China and in other countries around the world. A healthier and more productive population is a critical factor for ensuring sustainable economic growth and harmonious social development over the medium and longer term.