Ten years into China's multi-billion dollar investment in health-care reform, the country has made "spectacular" progress on some top public health challenges — including insurance coverage and deaths of children. But it's facing an uphill battle on others, including second-hand smoke and cancer, according to a special China-themed issue on September 28 of the journal The Lancet.
In the collection of nine peer-reviewed studies, commentaries, editorials and reviews of literature, researchers from academic institutions in Beijing and other areas of China, as well as the U.S. and Germany, found the country is making headway in reducing the incidence of infectious diseases like diarrhea and respiratory illnesses among its 1.3 billion citizens. They also found that China has dramatically increased the share of its population receiving insurance coverage for basic health care, up to 96%.
But they also show that the country has a long way to go in encouraging healthy lifestyles and cleaning up pollution to help people avoid cancers and chronic illnesses like heart disease and diabetes. Deaths from these ailments are on the rise.
"China is beginning to look very much like the U.S.," says Dr. Christopher Murray, director of the Institute for Health Metrics and Evaluation at the University of Washington, Seattle.
Still, the country has done well in saving the lives of children, Murray says.
"China is a spectacular success story in reducing child mortality at one of the fastest rates of decline in history," he says. "Their death rate among children under five went down by 9% a year for the past 20 years. That's extraordinary." Murray was an author on one of the Lancet China-themed papers examining causes of illness and death in China since 1990.
A lot of the efforts to reduce infectious disease rates began as early as the 1980s, Murray says. But beginning in 2008, Chinese officials added significant money to their efforts — because, according to Murray, health care was getting increasingly costly, and the government recognized it would need to do something or face a public backlash. China quadrupled health expenditures from 359 billion yuan ($50.2 billion) in 2008 to 1.52 trillion yuan ($212.6 billion) in 2017, says Winnie Yip, professor of international health policy and economics at the Harvard's T.H. Chan School of Public Health.
And they homed in on programs aimed at saving the lives of mothers and children. "They were very deliberate in focusing on reducing maternal and child mortality," says Murray. "They focused on reaching rural areas and ethnic minorities."
The Chinese efforts at saving children and reducing infectious diseases show up in a couple of examples. In a ranking of the number of deaths per 100,000 people, neonatal disorders was the fifth-most common cause in 1990; by 2017, it was down to 27th. And diarrheal diseases dropped from the 20th highest number of deaths per 100,000 in 1990 to the 78th highest cause of deaths in 2017, according to the Lancet study on causes of death and disease.
Worldwide, diarrhea is the second leading cause of death among children under five — responsible for the deaths of more than 2,000 children every day, according to the Centers for Disease Control and Prevention.
Getting the population covered by some level of insurance and tackling infectious diseases are impressive achievements. But China hasn't been as successful at helping its citizens avoid cancer, heart disease, stroke, obesity and diabetes, all of which are increasing.
Those chronic diseases often relate to lifestyle choices. And, says Murray, the government so far doesn't seem to want to get involved in people's personal decisions, like whether to smoke, drink or eat unhealthy foods.
"In the case of tobacco, the government itself is a producer of tobacco, and it's a tremendous source of revenue," he says. Cigarettes are relatively cheap in China — a pack costs the equivalent of about $1.40, according to one of the Lancet papers. In China, 26.6% of adults smoke, compared to 19% around the world, and 14% in the U.S.
At least when they get sick, almost all Chinese citizens have health insurance. "China has two kinds of insurance. One is for the employed population, and the other for everyone else," Yip says. In 2003, only 22% of the population had insurance, and all insurance came through employment. That's when the government began rolling out subsidized insurance for those who didn't get insurance through their workplace. By 2008, 87% of Chinese people were insured. And now, almost everyone is covered.
"They were able to do that in a very short time. It's pretty impressive," Yip says.
But there's a significant hiccup to the high rate of insurance coverage. "The government's principle is to cover basic health care," says Yip. "But in practice there's no explicit list of what is basic care. About the only thing people agree on is that cosmetic surgery is not basic health care."
As in many countries, the escalating cost of health care in China is hard to control, says Yip. China has a very entrepreneurial, unregulated health-care system. For example, the government used to allow hospitals to mark up drug prices without limit. As a result, drug costs in hospitals were out of control, and hospitals were prescribing unusually high amounts of prescription drugs.
Then the government initiated a zero-profit drug policy. "They have to sell the drug at the price they bought it for. It's working in that it has reduced prescriptions in hospitals," she says. But to make up for the lost revenue from drugs, she says, hospitals are now ordering more diagnostic tests than they did before the zero-profit drug policy. To bring in revenue, "rather than giving them drugs, physicians are now sending patients off for lab tests," she says.
Two of the biggest threats to the health of Chinese people are tobacco and environmental pollution. "Smoking is a complicated policy in China because many regions in China rely on the tobacco industry," says Yip.
Rates of exposure to secondhand smoke have gone down from 2010 to 2018, but remain high, according to one article in the China-themed Lancet. For example, 63% of workplaces allowed smoking in 2010, and 51% still did in 2018. In 2010, 39% of China's hospitals and health centers allowed smoking; in 2018, it was 24%. For restaurants, the number dropped from 89% to 73%.
"Recently, in a major government restructuring, tobacco has moved from the Department of Commerce to the Department of Health," Yip says. "It will take time, but I think the health interest will eventually take priority."
And pollution? For decades, China was keen on economic development without much thought of the environment or the effects of pollution on health. One 2015 study by the independent research group Berkeley Earth found that air pollution contributes to 1.6 million deaths per year in China. But now, health is part of the equation when considering future economic development, Yip says.
"It's not easy," she says. "With the magnitude of pollution — air, water soil --that, too, will take time."
Susan Brink is a freelance writer who covers health and medicine. She is the author of The Fourth Trimester and co-author of A Change of Heart.