Toward a Healthy and Harmonious Life in China: Stemming the Rising Tide of Non-Communicable...

7/29/2019 Toward a Healthy and Harmonious Life in China: Stemming the Rising Tide of Non-Communicable Diseases

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HUMAN DEVELOPMENT UNIT

East Asia and Pacifc Region

Toward a Healthy andHarmonious Li e in China:

Stemming the Rising Tide of Non-Communicable Diseases


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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 orde ense training and health benefts. Photo taken by Mr. Chunsheng Bai, Beijing, China, June 2, 2011.


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HUMAN DEVELOPMENT UNIT

East Asia and Pacifc Region

Toward a Healthy andHarmonious Li e in China:

Stemming the Rising Tideof Non-Communicable Diseases


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Contents

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2 Why This Report? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

3 Chinas Rising NCD Epidemic: 20102030 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3.1 Explosive Increase in the Number o People with at Least One NCD 2

3.2 Morbidity Makes Up the Bulk o the Burden Attributable to NCDs and about 50 Percent o Tat Burden Occurs in People under 65 3

3.3 NCD Mortality Is Higher in China Tan in Other Leading G-20 Countries 3

4 Socioeconomic Determinants and Health Risk Factorsor NCDs and Consequences In China . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

4.1 Growing Urbanization and Changes in Behavioral and Biological Factors 4

4.2 Over 50 Percent o the Increased NCD Burden Is Preventable by Modi ying Behavioral Risks 4

4.3 Rapid Population Aging May Increase Chinas NCD Burden by at Least 40 Percent by 2030 I the NCD Epidemic Is Not Controlled 5

4.4 NCDs Contribute to Inequalities in Health 6

4.5 Economic Impact o the NCD Burden 7

5 Role or Government on NCDs Prevention and Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

5.1 Economic Rationale Justi ying Government Actions on NCDs 8

5.2 Con ronting NCDs E ectively: A Litmus est o Chinas Health Sector Re orm 8

6 Launching a Multisectoral Strategy or NCD Prevention and Control . . . . . . . . . . . . . . . . 10

6.1 Suggestions or Comprehensive and E ective NCD Strategies in China 10

6.2 What Actions to ake? From Governmental Policy to Program Implementation 11

6.3 Addressing In ormation Gaps 25

7 The Way Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Re erences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Map IBRD 33387 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33


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iv Toward a Healthy and Harmonious Li e in China

FIGURES

Figure 1: Distribution o Disease Burden in China 1

Figure 2: Projected Number o NCD Cases (People Aged 40 Years or Over) 2

Figure 3: otal Years Lost due to NCD Morbidity per 1000 Population 3

Figure 4: otal Years o Li e Lost rom Death per 1000 Population 3

Figure 5: Mortality (per 100,000) rom Major NCDs in China and Selected Countries 3

Figure 6: Number o Adults above 40 Years Old with at Least One Risk Factor, 2010 5Figure 7: Population Growth and Share o Population Aged 65+ and 80+ in China, 20102050 5

Figure 8: Te E ect o Aging on the Future Number o People with at Least One NCD by Gender 6

Figure 9: Tree Scenarios o the CVD Working-age Mortality Rate, 20102040 7

Figure 10: Simulated per Capita GDP Path 7

Figure 11: Diabetes Acute Complications Admission Rates, 2007 9

Figure 12: Coverage o NCD Programs at County Level in China 9

Figure 13: Preventing and Controlling the NCD ide 11

Figure 14: Proposed Expansion Path or an NCD Prevention Package 16

Figure 15: E ective Approaches to Reducing Mortality rom Coronary Heart Disease 17

Figure 16: Health Expenditure by ype o Health Care Service, 2007 18

Figure 17: Expenditures on CVD reatment by reatment ype, ianjin, 2008 19

Figure 18: Pyramid o Care Model 19

Figure 19: Chronic Care Model 19

TABLES

able 1: NCDs and Care-seeking Behavior among Low-income Groups,2008 7

able 2: Impact o a Change in Sel -assessed Health on Hours Worked and Income in China 8

able 3: Characteristics o NCDs 9

able 4: Examples o Inter-Institutional Coordination Mechanisms or Health-Related Activities in China 12able 5: Priority Interventions or NCDs 13

able 6: obacco Prices and axation in BRICS Countries, 2009 13

able 7: HiAP or NCD Prevention and Control 14

able 8: Li e Course Approach or NCD Prevention and Control 21

able 9: Examples o Financial Incentives or NCD Services 22

BOXES

Box 1: Projected Impact o Priority NCD Prevention Interventions in China 15

Box 2: Quality and Outcome Framework in the United Kingdom 23


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v Human Development Unit | East Asia and Pacifc Region THE WORLD BANK

Abbreviations

BMI Body mass index

BP Blood pressure

BRICS Brazil, Russia, India, China and South A rica

CDC China Center or Disease Prevention and Control

COPD Chronic obstructive pulmonary disease

CHD Coronary heart disease

CVD Cardiovascular diseases

DALY Disability-adjusted li e year

DM Diabetes mellitus

DMP Disease management program

DRG Diagnostic-related groups

EHR Electronic heath records

EU European Union

FC C Framework Convention on obacco Control

GDP Gross domestic product

GP General practitioner

HALE Healthy li e expectancy

HIP Health Impact Assessment

H Hypertension

MI Myocardial in arction

MOF Ministry o Finance

MOH Ministry o Health

NCD Non-communicable diseaseNICE National Institute o Health and Clinical Excellence

NPFPC National Population and Family PlanningCommission

OECD Organization or Economic Cooperationand Development

OOP Out o pocket expenditures

P4P Pay or per ormance

PPP Purchasing power parity

PHC Primary health care

QOF Quality and outcome ramework

RF Risk actor

UNDP United Nations Development Program

VSL Value o a statistical li e

WHO World Health Organization

W P Willingness-to-pay


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viiHuman Development Unit | East Asia and Pacifc Region THE WORLD BANK

In the late 1980s, Chinas Ministry o Health started to o-

cus on the transition in the countrys demographic and dis-ease pattern. Te Disease Prevention Project, launched in1997, ormalized the collaboration between the Governmento China and the World Bank in ghting the rising tide o non-communicable diseases (NCDs). Te project introduced

or the rst time innovative behavior risk actor surveillancesurveys and health promotion or NCD disease preventionand control in China. Despite having achieved encouragingresults in reducing the prevalence o smoking among the lo-cal population and improved institutional capacity in sevenproject cities and one province, these early successes could not

be sustained, mainly because the health system was geared tocombat only acute and in ectious diseases and insu ciently prepared to tackle chronic diseases, including NCDs.

Te new round o health sector re orm in China presentsan opportunity or a revitalized ocus on NCDs that havebecome the most prominent threat to peoples health in thecountry. Mutual bene ts will likely derive rom addressingNCDs and implementing health sector re orm.

Te Ministry o Health and the World Bank have jointly ad-opted a three-step approach with the aim o placing NCDsat the top o the Governments agenda. Step one is to raiseawareness about NCDs among policy makers, particularly those outside the health sector, through a number o high-level con erences, seminars, and workshops. Step two is toimplement urther analytical studies to address key questionsthe Government has raised, particularly: (a) what should theGovernment do in response to the escalating NCD burden;

that is, what interventions should be included in NCD pre-vention and control programs, taking into account coste -

ectiveness, equity, local relevance, and political and otherprede ned criteria? and (b) how can the proposed NCDprevention and control interventions be implemented? Stepthree is to put the proposals rom Steps one and two intopractice by developing and implementing a National Program

or NCD Prevention and Control in China.

Te present report is part o Step two. Te evidence pre-sented in the report strongly suggests that the coming 10years are a critical time or China to prevent and controlthe threat posed to the countrys prosperity by the growingNCD burden. Te challenge ahead is signi cant, but withpolitical commitment and support at the highest levels o government, both at the central and provincial levels, an e -

ective multisectoral response could be developed, includingthe adoption o critical changes in the current health systembuilding on ongoing health care organization, nancing,and service delivery re orms in China. And, as noted in thisreport, a combination o population-based interventionsand treatment targeted at NCD-related, high-risk groups,

would reduce the NCD burden by 50 percent when imple-mented at ull-scale. It is our sincere hope that this report

will provide a use ul re erence to policy makers or movingorward a multisectoral agenda or NCD prevention and

control over the short and medium term.

Klaus Rohland

Country Director, China World Bank O ce, Beijing

Foreword

Te scientifc concept o development means putting people frst and aiming at comprehensive, coordinated and sustainable development o put people frst, we should take peoples interests as

the starting point and oothold o all o our works, make continuous e orts to meet various needs o the people, and promote an overall development o the people

17th National Congress of theCommunis t Party of China, 2007


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ixHuman Development Unit | East Asia and Pacifc Region THE WORLD BANK

AcknowledgementsTis report was prepared over December 2010April 2011by a World Bank team comprising:

Mr. Shiyong Wang (East As ia and Paci ic Region,EASHD),

Mr. Patricio Marquez (Europe and Central Asia Region,ECSHD), and

Mr. John Langenbrunner (EASHD).

Contributions or preparing this report were providedby Pro essor Louis Niessen rom Johns Hopkins Univer-sity Bloomberg School o Public Health; Pro essor MarcSuhrcke and Dr. Fujian Song rom the University o East

Anglia (UEA), United Kingdom; and Pro essor WenhuaZhao, Dr. Yong Jiang, Dr. Yichong Li, Dr. Nan Hu, Dr.Zhuoqun Wang, Dr. Xiaoming Shi and Dr. Xiaoyan Li rom

China Center or Disease Prevention and Control.

Background in ormation or this report originated roman analytical and advisory activity (AAA) on non-com-municable diseases (NCDs) in China carried out in 2009and 2010 as a collective e ort by a team comprising Pro-

essor Suhrcke, Dr. Song, Ms. Xia Wang, Ms. PhilomenaBacon, and Mr. Peter Mo att rom the University o East

Anglia (UEA), United Kingdom; Pro essor Niessen andMr. Andrew Mirelman rom the Johns Hopkins University Bloomberg School o Public Health; Mr. Lorenzo Rocco

rom the University o Padova, Italy; and Mr. Shiyong Wang, Ms. Huihui Wang, and Mr. John Langenbrunner

rom EASHD/World Bank.

Many World Health Organization (WHO) colleagues worked closely with the Ministry o Health (MOH) inChina and the World Bank. Valuable advice was providedby Dr. Ala Alwan rom WHO Geneva; Dr. Hans roedssonand Dr. Cherian Varghese rom WHOs Western Paci c Re-gional O ce; and Dr. Sarah Barber, WHO O ce, Beijing.

Te Government o China collaborated in many ways. Te World Bank is particularly grate ul or the overall guidanceprovided by Dr. Lingzhi Kong, Deputy Director General,Bureau or Disease Prevention and Control, MOH. Specialthanks go to Dr. Zhenglong Lei, Dr. Guanglin Li, Liangyou

Wu and Dr. Jia Fei rom the NCD Division, Bureau orDisease Control, MOH, or their coordination with di -

erent technical agencies and provinces or data collectionneeded or the analysis and or organizing workshops ordisseminating interim reports. Advice and comments were

also received rom Madame Zhijun Sun and Mr. QichaoSong rom the Ministry o Finance (MOF), Mr. Wei Ren,Mr. Heyu Zhou, and Ms. Chun ang Li rom the NationalDevelopment and Re orm Commission and Ms. Fanglin

Wang and Ms. Xiaoli ang rom the Ministry o HumanResources and Social Security. Without the support o Mr.

Yanning Wang and his colleague, Mr. Wei eng Yang, Mr.

Jiangnan Qian rom MoF, Mr. Yong Feng rom MOH, thisreport, would not have happened.

Te work was carried out under the supervision o Mr.Klaus Rohland (World Bank Country Director, China),Madame Hsiao-Yun Elaine Sun (Country Manager, China),Mr. Emanuel Jimenez (Director, EASHD), Mr. Juan PabloUribe (Sector Manager, Health, Nutrition and Popula-tion Unit, EASHD), Mr. Ardo Hansson (Lead Economist,China, World Bank), and Ms. Fadia Saadah ( ormer SectorManager, Health, Nutrition and Population Unit, EASHD).Guidance and support were also provided by Philip OKee e(Lead Economist, EASHD).

Tis report was reviewed by Pro essor Vivian Lin rom Larobe University, Australia; Ms. Jill Farrington, ormer

NCD Coordinator at the WHO Regional O ce or Eu-rope; Mr. Louis Kuijs (Poverty Reduction and EconomicManagement Unit, World Bank); and Ms. MontserratMeiro-Lorenzo (Human Development Network, WorldBank), and Mr. Juan Pablo Uribe. Te quality o this reportbene ted greatly rom their valuable comments.

Excellent administrative support was provided by Ms. LisaRowe o the University o East Anglia; Ms. Lansong Zhang,Ms. ao Su, and Ms. Limei Sun o the World Bank Country O ce in Beijing; and Ms. Imani Rasheedah Haidara romEASHD, World Bank.

During the nal consultation mission held in Beijing on April 1115, 2011 by a World Bank team comprising Mr.Shiyong Wang, Mr. Patricio Marquez, Mr. John Langen-brunner, and Mr. Philip OKee e, comments on a dra treport were received rom and discussed with the ollow-ing Chinese O cials: Mr. Heyu Zhou, Ms. Chun ang Li,National Development and Re orm Commission; Dr. SenGong, Development Research Center o State Council;Dr. Lingzhi Kong, Dr. Liangyou Wu, MOH; Ms. Fanglin

Wang, Ms. Xiaoli ang, Ms. Li Dong, Ms. Xin Zhao, Min-istry o Human Resource and Social Security; Mr. Dezhi

Yu, Dr. Yanhua Chi, and Dr. Maowei Liu, Center or Proj-ect Supervision and Management, MOH; Pro essor Dong-

eng Gu, Fuwai CVD Hospital; Pro essor Yang eng Wu,George Institute China; Dr. Wanqing Chen, Institute o


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x Toward a Healthy and Harmonious Li e in China

Cancer Research, China Academy o Medicine; and Pro-essor Kun Zhao, China National Health Development

and Research Center.

Additional comments and suggestions were provided dur-ing the mission by: Dr. Michael OLeary, Dr. Pillay Mu-kundan, Dr. Sarah England, Dr. Yanwei Wu, Dr. Jing He,and Dr. Pingping Zhang rom the WHO O ce Beijing; Dr.

Je rey McFarland and Ms. Alison Kelly, as well as Dr. Michael Engelgau rom the U.S. Centers or Disease Controand Prevention; Dr. Felix Li, Health Canada; as well as romMr. Geo Bowan and Ms. Linna Cai rom the Australian

Agency or International Development.

Te co-authors would like to document their appreciation toMs. Elizabeth Goodrich or her meticulous editing service.


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1Human Development Unit | East Asia and Pacifc Region THE WORLD BANK

1 INTRODUCTION

Chinas 12th Five-year Plan (20112015) aims to promoteinclusive, equitable growth and development by placing anincreased emphasis on human development (1).

Good health is an important component o human develop-ment, not only because it makes peoples lives better, but also

because having a healthy and long li e enhances their ability to learn, acquire skills, and contribute to society (2). Indeed,good health is a undamental right o every human being (3).Good health among a population can also enhance economicper ormance by improving labor productivity and reducingeconomic losses that arise rom illnesses (4,5,6,7).

While China has had an enviable economic growth and de-velopment per ormance or more than 30 years, its humandevelopment has lagged behind the most advanced econo-mies. China ranked 89th in the 2010 human development

index prepared by the United Nations Development Program(UNDP) (8). Te Chinese populations healthy li e expec-tancy (HALE) at birth is about 10 years shorter than in someo the leading G-20 countries (9). China could narrow thesegaps in human development vis--vis these countries by iden-ti ying the priority health issues a ecting its population, mus-tering political support to overcome them, and implementingappropriate interventions, as described below.

China has made impressive gains in recent decades to con-trol communicable diseases, ushering in an opportunity to

con ront non-communicable diseases (NCDs), its leading

cause o ill health, premature mortality, and disability. ak-ing advantage o this opportunity would enhance the healthand wel are o Chinas population. Challenges abound, but

with a care ully laid-out approach, China can lead the way globally in tackling NCDs and advance its social and eco-nomic development in the decades ahead.

2 WHY THIS REPORT?

NCDs1 are Chinas number one health threat. Tey accountor over 80 percent o its 10.3 million annual deaths (10)

and Figure 1 shows that they contribute to 68.6 percent o the total disease burden (11). Te main NCDs in Chinaare cardiovascular diseases (CVDs), diabetes mellitus (DM),chronic obstructive pulmonary diseases (COPDs), and lungcancer. Tese conditions account or a signi cant shareo the total NCD burden in China and share common,amendable behavioral and biological risk actors.

In 2010 and again in 2011, the World Economic Forumsingled out NCDs as a leading risk to the global economy (12) due to their high likelihood o occurrence and theirhuge potential to cause severe economic loss. Te Forumrecommended that governments mount a serious policy and programmatic response to this economic and socialdevelopment risk.

1 NCDs are a set o chronic diseases, including cardiovascular disease,cancers, chronic respiratory diseases, and diabetes, characterized by a long

latency period, prolonged clinical course and debilitating mani estations.

Figure 1: Distribution o Disease Burden in China

17.90%

9.30%

2.10%

17.60%

9.80%

12.40%

7.60%

3.10%

1.20%

3.30%

1.40% 13.40%

Communicable, maternal,perinatal and nutritionalconditions

Malignant neoplasms

Diabetes mellitus and otherendocrine disorders

Neuropsychiatric conditions

Sense organ diseases

Cardiovascular diseases

Respiratory diseases

Digestive diseases

Genitourinarydiseases

Musculoskeletaldiseases

Congenital diseases

Injuries

Source: WHO, Burden o Disease Study, 2009.


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2 Toward a Healthy and Harmonious Li e in China

Figure 2: Projected Number o NCD Cases (People Aged 40 Years or Over)

10,000,000

20,000,000

30,000,000

40,000,000

50,000,000

60,000,000

70,000,000

2010 2012 2014 2016 2018 2020 2022 2024 2026 2028 2030

Total MI Pop Total Stroke Pop Total COPD PopTotal Lung Ca Pop Total DM Pop

Estimated Number o Cases 2010 2020 2030

Myocardial in arction 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

As is discussed herein, there is a substantialavoidable economic burden associated with NCDs. For example,estimates or China done or this report indicate that theeconomic bene t o reducing CVD mortality by 1 per-cent per year over a 30-year period (20102040) couldgenerate an economic value equivalent to 68 percent o Chinas real gross domestic product (GDP) in 2010, more

than US$ 10.7 trillion (valued in purchasing powerparity terms-PPP). However, i an e ective response is notmounted in China to deal with NCDs, the disease burdenposed by these conditions will aggravate the economic andsocial impact o the expected population explosion o oldercitizens and smaller work orce in China. And, a reducedratio o healthy workers to sicker, older dependents, willcertainly increase the odds o a utureeconomic slowdownand pose a signifcant social challenge in China.

Tis report, prepared on the basis o assessments conductedby the World Bank in 20082010, outlines why the Govern-ment o China should pay priority attention to NCDs, artic-ulateswhat would constitute an e ective NCD response, andproposeshow to operationalize the response over the medium

and longer terms. Te ndings and recommendations can in-orm and promote a broad dialogue toward the development

o a multisectoral response to e ectively address the growinburden o NCDs, including a better alignment o the healthsystem with the populations health needs. Te report also ad-vocates implementing Health in All policies and actions oa multisectoral response to NCDs in China to help achieve

the ultimate goal o harmonious development and growth.

3 CHINAS RISING NCDEPIDEMIC: 20102030

3.1 Explosive Increase in the Number ofPeople with at Least One NCD

Te number o NCD cases (CVDs [myocardial in arctionand stroke], COPDs, DM, and lung cancer) among Chi-nese people over 40 will double or even triple over the nextwo decades, most o it during the next 10 years (Figure 2)Diabetes cases will be the most prevalent disease, while luncancer cases will increase ve old.


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3.2 Morbidity Makes Up the Bulk of theBurden Attributable to NCDs andabout 50 Percent of That BurdenOccurs in People under 65

Te burden o the our leading causes o ill healthMI,stroke, diabetes, and COPDis expected to increase over

20102030 by almost 50 percent. More than 50 percent o the disease burden will be caused by CVDs (MI and stroke)

(Figure 3); stroke has the largest health and well-being im-pact on an individual. Te burden due to deaths rom theseNCDs will increase by more than 80 percent (Figure 4).NCD-related morbidity accounts or more than 90 percento the total NCD burden. About hal o Chinas disease bur-den rom NCDs occurs in people under 65. Te growingNCD burden is ominous or the country as disability will

likely be substantial in the years to come, including a signi -cant and growing burden to the health system.

Figure 3: Total Years Lost due to NCD Morbidity Figure 4: Total Years o Li e Lost rom Deathper 1000 Population per 1000 Population

0

500

1,000

1,500

2010 2020 2030

MI Stroke COPD Lung Ca DM Injury

0

50

100

150

200

2010 2020 2030

MI Stroke COPD Lung Ca DM Injury

Source: Death Cause Surveillance rom China Disease Surveillance Points, 2005, and China Nutrition and Health Survey, 2002,and China National NCD Risk Factor Surveillance, 2007.

Figure 5: Mortality (per 100,000) rom Major NCDs in China and Selected Countries

0.0

50.0100.0

150.0

200.0

250.0

300.0

CVD Stroke COPD Cancers Diabetes Infectiousparasite

China Japan USA UK France Australia

Source: Data and Statistics, World Health Organization (2004).Note: Standardized according to worlds population age structure in 2000.

3.3 NCD Mortality Is Higher in ChinaThan in Other Leading G-20 Countries

China has very high mortality rates due to the major NCDs(Figure 5). Its mortality rate or stroke is our to six times

higher than that in Japan, the United States, and France; orCOPD it is about 30 times as high as in Japan; and its rates

or cancers are also slightly higher than comparators. Chinas

mortality rate or diabetes is lower than that in the UnitedStates, but higher than in Japan and the United Kingdom.


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4 SOCIOECONOMICDETERMINANTS AND HEALTHRISK FACTORS FOR NCDs ANDCONSEQUENCES IN CHINA

Chinas shi ting disease pro le is deeply rooted in the so-cial, economic, and environmental changes the country has

experienced in recent decades, particularly changes in ex-posure to and the magnitude o di erent health risk actorsand, as will be discussed in the later sections o this report,limitations in the access to, use o , and e ectiveness o pub-lic health and medical care services.

4.1 Growing Urbanization and Changes inBehavioral and Biological Factors

Internal migration, particularly to big cities, is alteringthe spatial distribution o Chinas population. Te UNDPestimates that there will be more than 900 million peo-ple60 percent o the total populationliving in citiesby 2030 (13). More than 250 million o the increased 350million will be migrants. At least six out o the eight mega-citiesthe countrys economic engines, Shanghai, Bei-

jing, ianjin, Shenzhen, Wuhan, Chongqing, Chengdu,and Guangzhouare each projected to have a population

well above 10 million.

While rising incomes, an improved ood supply, and avariety o ood products contributed to the signi cantreduction in malnutrition and improved health status in

China over the past 20 years, changes in dietary patterns,unhealthy behaviors, and pollution associated with urban-ization are now involved in the rapid increase o NCD-related risk actors, particularly among low-income groupsand migrants (14,15).

Excessive salt intake, by ar the most prevalent modi ablerisk actor or NCDs in China, is greater than 12 g per day per person, twice the maximum intake recommended by

WHO. Chinas high level o consumption has not changedor a decade.

At 54 percent, the prevalence o tobacco smoking amongmen aged 1569 is among the highest in the world.

Among daily smokers aged 2034 years, 52.7 percentstarted smoking daily be ore age 20. Although the over-all smoking level among emales is relatively low at 2.1percent, it has been increasing among young emales. Tehighest rates o smoking are among males with lower edu-cation levels (63.2 percent or those with a secondary edu-cation versus 44 percent or those with college or above

education); among rural males (56.1 percent versus 49.2percent among urban males); and among males in the

western regions (60.1 percent versus 50.1 percent amongmales in the east region) (16).

Te prevalence o hypertension, high blood glucose, overweight/obesity, and high blood cholesterol, which are re-lated to dietary intake (e.g., high intake o saturated at andsalt and low intake o vegetables, ruits, and vegetable an

sh oils) is lower than those in Organization o EconomicCo-operation and Development (OECD) countries but hasbeen increasing rapidly. Te estimated prevalence o hyper-tension among adults over 18 increased rom 7.5 percenin 1979 to 18.1 percent in 2004 (17). Te prevalence o diabetes has increased alarmingly: rom 0.67 percent in th1980s, 2.5 percent in 1994, 5.5 percent in 2001, to 9.7 per-cent in 2007/08 (18).

Te overall prevalence o overweight and obesity increasedrom 1992 to 2002, by 38 percent and 81 percent, respec-

tively, and reached 22.8 percent and 7.1 percent, respec-tively, in 2002 (19). It is estimated that about 200 millionpeople in China are overweight or obese. Also, obesity andoverweight have been increasing at an alarming rate amongadolescents. Te prevalence o overweight plus obesity inchildren/ adolescents aged 7 to 18 years old rom urbancenters reached 32.5 percent or boys and 17.6 percent ogirls in the northern coastal cities: this rate is the same oreven higher than that or the same groups in developedcountries (20,21).

Te undamental drivers o the obesity epidemic in Chinahave been reduced daily energy expenditure due to increasedphysical inactivity in cities and at intake, particularly romgrowing consumption o ast oods and sugar-rich sodrinks, both o which have a high energy density. While traditional Chinese diets had only 15 percent at and negligiblesugar, between 1982 and 2002 average at consumption inurban areas rose rom 25 percent to 35 percent and rom14.3 percent to 27.7 percent in rural areas (22).

4.2 Over 50 Percent of the Increased NCDBurden Is Preventable by ModifyingBehavioral Risks

At least 580 million Chinese were estimated to have at leasone modi able NCD-related risk actor in 2010 (Figure6). Between 70 and 85 percent o these people were undeage 65. By 2030, those risk actorsbehavioral and nutritionalcould contribute to a 50 percent increase in ChinasNCD burden i not controlled.


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Figure 7: Population Growth and Share o Population Aged 65+and 80+ in China, 20102050

0

5

10

15

20

25

2010 2015 2020 2025 2030 2035 2040 2045 2050Population growth rate (%)Percentage aged 65 or over (%)Percentage aged 80 or over (%)

Source: Population Division o the Department o Economic and Social A airs o the United Nations Secretariat,World Population Prospects: The 2008 Revision, http://esa.un.org/unpp.

4.3 Rapid Population Aging May IncreaseChinas NCD Burden by at Least 40Percent by 2030 If the NCD Epidemic IsNot Controlled

Te aging o a populationwhere the absolute number o adults and elderly growsinevitably leads to a shi t in theburden o disease rom younger to older age groups and to-

ward NCDs. Te changes in the age structure o Chinaspopulation have the ollowing important eatures that sug-gest the potential geographic oci or mounting an e ectiveresponse to NCDs in China:

1. Te low ertility rate in the past several decadesis the demographic driver shaping Chinas uturepopulation pro le (23). By 2040, it is anticipatedthat China will have ewer people under the ageo 50 and many more elderly in their 60s to 80s(24) (Figure 7). Te cohort o the oldest-old (aged80 plus) is orecast to increase rom 12 million in2000 to over 40 million in 2030. Tis populationexplosion o older citizens will result in about 240million people 65 or older by 2030, up rom 115million today.

Figure 6: Number o Adults above 40 Years Old with at Least One Risk Factor, 2010

0

100,000,000

200,000,000

300,000,000

400,000,000

500,000,000

600,000,000

At least oneRF

Excessivesalt

Smoking BP Inactivity BMI Highcholesterol

Age group: 4064 Age group: 6580 Age group: 80+

Source: China Nutrition and Health Survey, 2002, and China National NCD Risk Factor Surveillance, 2007.Note: RF means risk actor.


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Figure 8: The E ect o Aging on the Future Number o Peoplewith at Least One NCD by Gender

45

3,500,000 2,500,000 1,500,000 500,000 500,000 1,500,000 2,500,000 3,500,000

50

55

60

65

2010

70

75

80

85

90

95

100

a g e

women men

2020 2030

Source: Authors.

2. Chinas rural areas are aging more rapidly than itscities, largely due to rural-to-urban migration. In2008, the aged proportion (60 years old and above)

was 9.4 percent in rural areas and 6.9 percent in ur-ban areas, a gap o 2.4 percentage points. By 2030,the aged proportions in rural and urban areas willbe 21.8 percent and 14.8 percent, respectively, a gap

o 7.09 percentage points (25).3 . Chongqing , S i chuan, Anhu i , Hunan, and

Hubei have a relatively higher level o populationaging in relation to their level o economic develop-ment (26).

4. Most o Chinas mega-cities (Shanghai, Beijing,ianjin, Shenzhen, Wuhan, Chongqing, Chengdu,

and Guangzhou) already have people 65 and olderexceeding more than 10 percent o their popula-tions, while the national average or this age group

is 8.5 percent (27).

Chinas rapid population aging is estimated to increase theNCD burden by at least 40 percent by 2030 (Figure 8). Teexpected population explosion o older citizens and reducedsize o the labor orce (people aged 1564 years) will placesevere economic and social pressures as the country strives tomeet the needs o the elderly, particularly o a growing cohorto people with chronic ailments that last years or even a li e-time (28). Furthermore, a reduced ratio o healthy workers tosicker dependents will certainly increase the odds o a uture

economic slowdown and pose a signi cant social challenge

in China. While aging is not avoidable, premature death canbe prevented, disability due to NCDs can be postponed, andhealthy aging can be achieved as demonstrated in leadingG-20 and European Union (EU) countries (29, 30, 31).

4.4 NCDs Contribute to Inequalities inHealth

Te socioeconomically and otherwise disadvantaged popula-tions in China are o ten hit harder by NCDs than the a uentmembers o society since (a) chronic diseases and at least somo the risk actors leading to NCDs, e.g., hypertension, tend tobe more prevalent among the poor; (b) the poor are o ten lack-ing in or have limited access to quality health care when theydevelop an NCD; and (c) the adverse impact o chronic diseaseon income and overall amily wel are is proportionally larger the poor. NCDs also contribute to high out-o -pocket (OOP)payments or health services and drugs and exacerbate inequitin both health status and access to health care. While low-incomegroups in China experience a similar or even higher prevalence oNCDs than the rest o the population, their lower hospitalizationrates suggest that they are less likely to seek health care ( able 1Te incidence o catastrophic health spending tends to be higheramong low-income groups as well (32). Even in cities, 37.6 percent o low-income patients reported not being hospitalized, despite advice to do so, because a majority o them (89.1%) ace

nancial constraints. A recent study also showed that because ohigh health care expenditure, rural patients with chronic condi-tions were more than twice as likely to drop out o treatment o

nancial reasons, as were patients in urban areas (33).


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4.5 Economic Impact of the NCDBurden

Recent estimates indicate that Chinas overall economic bur-den rom NCDs could be very high. In the absence o ascaled-up Government response, CVDs, stroke, and diabe-tes alone are expected to result in a loss o US$ 550 billionin China between 2005 and 2015 (34). An analysis by the

World Bank calls attention to the ollowing potential gainsstemming rom e ective NCD policies:

At the micro-economic level: A change in adulthealth status can result in a 16 percent gain inhours worked and a 20 percent increase in indi-vidual income.2 ackling NCDs, on top o being avaluable health investment, may thus be seen as an

2 Surveys typically ask respondents to assess their health on a ve-pointscale ranging rom very poor to excellent. Te change means a one-step improvement along the range, such as rom poor to air.

investment into peoples productivity and hencetheir earnings potential ( able 2).

At the macro-economic level: reducing CVD mortal-ity by 1 percent per year over a 30-year period (20102040) could generate an economic value equivalentto 68 percent o Chinas real GDP in 2010, morethan PPP US$ 10.7 trillion (Figures 10 and 11).

Te society wide economic costs o NCDs areeven larger i the value people attribute to healthis captured.3 Reducing CVD mortality by 1 per-cent per year producesi the intrinsic value that is

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 or speci cmarket goods or which a price exists. Willingness-to-pay (W P) studiesundertake this measurement. A large number o W P studies make itpossible to calculate a value o a statistical li e (VSL), which can beused to value changes in mortality. W P can also be in erred rom risk premiums in the job market: Jobs that entail health risks, such as mining,pay more in the orm o a risk premium.

Table 1: NCDs and Care-seeking Behavior among Low-income Groups, 2008

Accessibility to Inpatient CareNational Average Low-Income Group

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 reasonor not being hospitalized 67.5% 71.4% 89.1% 81.5%

Prevalence o catastrophic health expenditure 5.9% 10.2%

Source: Ministry o Health (MOH), National Health Services Survey in China, 2008.

Figure 9: Three Scenarios o the CVD Working-age Figure 10: Simulated per Capita GDP PathMortality Rate, 20102040

0102030405060708090

2 0 1 0

2 0 1 2

2 0 1 4

2 0 1 6

2 0 1 8

2 0 2 0

2 0 2 2

2 0 2 4

2 0 2 6

2 0 2 8

2 0 3 0

2 0 3 2

2 0 3 4

2 0 3 6

2 0 3 8

2 0 4 0 C

V D m o r t a

l i t y r a t e a g e

1 5 - 6

4

( p e r

1 0 0 , 0 0 0 )

Status quo (no change)Scenario 2 (3%-reduction p.a.)

Scenario 1 (1%-reduction p.a.)

11000

12000

13000

14000

15000

16000

17000

18000

2 0 1 0

2 0 1 2

2 0 1 4

2 0 1 6

2 0 1 8

2 0 2 0

2 0 2 2

2 0 2 4

2 0 2 6

2 0 2 8

2 0 3 0

2 0 3 2

2 0 3 4

2 0 3 6

2 0 3 8

2 0 4 0

P e r c a p

i t a

G D P ( P P P U S $ )

Status quo Scenario 1 Scenario 2

Source: Authors, 2010.Note: Assuming 2005 CVD mortality rate according to Abegunde et al. (36).


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attributed to li e is measuredan annual bene t o about 15 percent o Chinas 2010 GDP (PPP US$2.34 trillion), while a 3 percent reduction wouldamount to an annual bene t o 34 percent (PPPUS$ 5.40 trillion).

Te combination o exceptionally ast population aging inChina and a low ertility rate will strain Chinas labor orceparticipation rate by 34 percentage points by 2030 (35).Te increase in NCDs, i not addressed e ectively as a topgovernmental priority in the years to come, would not only exacerbate the expected labor orce shortages, but also com-promise the quality o human capital because more than 50percent o the NCD burden currently alls on the economi-cally active population (aged 1564).

Table 2: Impact o a Change in Sel -assessedHealth on Hours Worked and Income in China

Hours Worked IncomeOverall 16.0% 20%Urban 21.0% 5.2%Rural 12.0% 14.6%

Source: Authors.

o optimize labor productivity as the population ages, inter-ventions to improve the quality and skill mix o the existinglabor orce and extend the retirement age could only pro-vide a short-term solution. Te success o these interven-tions in the medium and longer terms would depend on the

working-age populations staying healthy. Indeed, the rise o the epidemic o NCDs, i not addressed, will dilute andhinder the expected positive e ects o these policy measures.

Inertia in response to NCDs and the resulting aggravationo health inequalities and economic growth slowdown havethe potential to exacerbate social tensions in China.

5 ROLE FOR GOVERNMENTON NCDs PREVENTIONAND CONTROL

5.1 Economic Rationale JustifyingGovernment Actions on NCDs

From an economic perspective, government intervention is justi ed as a means to achieve a net improvement in social wel are. Tat is, it is justi ed when private markets ail to

unction e ciently or when the social objectives o equi-ty in access to health services are otherwise unlikely to be

attained. Global evidence suggests at least three sources omarket ailure that could justi y government interventio

or tackling the risk actors that give rise to NCDs:

Externalities:Tere are substantial external costsresulting rom second-hand smoke and alcohol-in-duced road tra c injuries and atalities. NCDs alsoimpose costs on health care and the social insurancesystem and hence on third parties.

Imper ect in ormation:People are not always ullyaware o the health (and other) consequences ounhealthy li estyle choices such as smoking, alcohoabuse, physical inactivity, and poor diet. Tey may also be misled by deliberately distorted in ormationpromoted by the ood, alcohol, and tobacco indus-tries. Government intervention in the orm o theprovision (and production) o NCD-related healthin ormation (such as the health consequences osmoking) provides a public good that generally isundersupplied compared to the social optimum.Tis also includes the role or a government to en-gage in research about the health consequences ounhealthy behavior.

Non-rational behavior:Children and adolescents(and even adults) tend not to take into account the

uture consequences o their current choices, irrespective o whether they are in ormed about themTeir current choices may well confict with theirlong-term best interests. Tis provides, in principle,a justi cation or government to support interven-tions to prevent people rom harming themselves

when they do not ully appreciate the consequenceo behaviors that pose health risks.

5.2 Confronting NCDs Effectively:A Litmus Test of Chinas HealthSector Reform

Te chronic nature o NCDs, their chronicity, poses a ma-

jor challenge to health systems worldwide because with thonset o NCDs people o ten spend substantial parts o thelives in less than per ect health and in need o medical ca(37). Well designed and sustained prevention and treatmentinterventions, which are mutually rein orcing, are requiredto reduce the burden o NCDs and control their potentially enormous pressure on the health system.

Te Government o China, there ore, will need to tackle themain risk actors o NCDs ollowing a multisectoral approac


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Table 3: Characteristics o NCDs

Characteristics o NCDs Needs o NCD Care

Etiology, behavior risk actors,pollutants, viruses

Behavioral interventions

Duration: long-term and repeti-tive, acute episodes

Continuous, long-term care, particularly at the primary care levelCare planned in advance and pro activelyPatients trained in goal setting, problem solving, sel -management andactively involved in decision making and treatment planning, since thecomposition o services will change i the condition deteriorates or per-sonal priorities changeRegular interaction between health pro essionals and patients

Frequent co-morbidities Multi-disciplinary teamsCoordination between di erent service providers

Frequent disability Involvement o patients themselves and their amily membersOther orms o social services

Source: Adopted rom E. Nolte and M. McKee. Caring or People with Chronic Conditions: A Health System Perspective. 2008.

Figure 11: Diabetes Acute ComplicationsAdmission Rates, 2007

Age-sex Standardized Rates per 100,000 Aged 15 and Over

0 20 40 60 80 100 120 140 160

New ZealandNetherlands (2005)

IcelandItaly (2006)

Switzerland (2006)Germany

Republic of KoreaSpan

SwedenDenmark

NorwayOECD

Austria (2006)Belgium (2006)

Canada

Poland (2006)FinlandUnited Kingdom

IrelandUnited States (2006)

China (2008)

Source: Health at a Glance 2009. Chinas datapoint is anestimate based on the 2008 national household health surveys.

Figure 12: Coverage o NCD Programs at CountyLevel in China

0%

10%

20%

30%

40%

50%

60%

70%

80%

No institutionNo staff No surveillance

No budget No intervention

Source: China CDC, Capacity or NCD Prevention and Control o the Center or Disease Control System in China, 2009.

to prevent their onset in the rst place, while at the same time

redesigning and improving the per ormance o the health sys-tem to deal with NCDs that do occur in spite o preventione orts (e.g., heart attacks, strokes) ( able 3).

Chinas health system is not currently responding e ective-ly to the needs and demands o its population. Te highermortality rates or major NCDs (such as CVDs, COPD, andcancers) and the higher hospital admission rates or acute

complications o diabetes in China relative to the rates in

OECD comparators4

provide strong evidence o the poorper ormance o the Chinese health system (Figures 5 and 11).

Additional evidence o the organizational and operationalde ciencies in the Chinese health system is provided by the

ndings o a recent survey on institutional capacity or NCDprevention and control in the country. Te survey ndings re-vealed that more than 55 percent o counties had no specialized

4 Te variations in hospital admission rates across countries can only be partially explained by the di erences in prevalence rates (R 2=0.17). oa great extent, this variation refects e ectiveness and e ciency o eachcountrys health system in addressing NCDs.


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institutions or NCDs, and around 15 percent had no sta work-ing on NCDs at the local level (38). In terms o work per ormed,less than 45 percent o county-level Centers or Disease Control(CDCs) carried out any orm o NCD-related surveillance activi-ties, and only about 30 percent o them implemented any NCD-related interventions in the year be ore the survey (Figure 12).

Te surging NCD epidemic, i not checked, may pose a severechallenge or containing the escalation o health expenditures inChina. Globally, e ective containment o health care costs andexpenditures has proven very di cult. For instance, in the past10 years, health expenditures in OECD countries have increasedby 50 percent in real terms (39). In China, health expenditurestripled between 2000 and 2009, with the most rapid increase in2008 and 2009, reaching, respectively, more than 16 percent and20 percent o total health expenditures.It is estimated that total health expenditure might urther grow by almost 50 percent in the next fve years (40). Such a skyrocketing increase would not only constrain government budgets, but also those o the Chinesepopulation, particularly the rural poor, since OOP payments orhealth represent 37 percent o total health expenditures (41). Tissituation would signi cantly undermine Chinas e ort to expandhealth insurance coverage in the ace o growing health care costs;it could also increase the odds o impoverishment among vul-nerable populations due to catastrophic health events that wouldrequire high OOP expenditures to cover the cost o needed drugsand medical care services.

6 LAUNCHING A MULTISECTORALSTRATEGY FOR NCDPREVENTION AND CONTROL

While NCDs cannot be totally eliminated, preventing themand managing those cases that remain through a continuumo care can make a substantial di erence in minimizing pre-mature mortality, ill health, and disability, as con rmed by the experience in developed countries, such as Finland, Eng-land, Canada, France, and Germany. Many preventive NCDinterventions can be highly cost-e ective (42), such as theinterventions recommended under the Framework Conven-tion on obacco Control (FC C, 43) and multidrug therapy administered to individuals at high risk o developing CVDs(44). And, improvements occur in a shorter time rame thanpeople commonly believeindeed, recent evidence romEngland indicates that reducing direct and second-hand ex-posure to tobacco smoke has immediate health and economicbene ts, as the burden o CVD is reduced along with relatedhealth care expenditures within one year. Finlands long-documented experience also shows that health improvements

occur within twoseven years a ter the elimination o the exposure to risk actors, and they are bene cial even or peopin older age groups (45, 46, 47).

6.1 Suggestions for Comprehensiveand Effective NCD Strategiesin China

At the international level there is agreement on what con-stitutes an e ective set o policy options and intervention

or tackling NCDs e ectively (48,49). As this consensus ibased on accumulated evidence rom di erent countries, theGovernment o China may consider adopting the ollowinpolicy options or the short and medium terms:

Health in All Policies (HiAP)5: HiAP seeks to im-prove health and contribute to the well-being and

wealth o nations through structures, mechanismsand actions planned and managed mainly by sectors

other than health, because improved health status othe population has, in turn, important e ects on therealization o social and economic objectives.

Fiscal and regulatory measures: Tese measures in-clude pricing policies; marketing o healthy products such as ruits and vegetables; and increasing thsocial and economic costs o unhealthy products(e.g., cigarettes, alcohol, and ast ood or children

Health sector actions: Te health sector needs to berestructured to adopt novel care organization and

nancial models with a strong primary health care(PHC) system that is structured or delivery o wellde ned, integrated NCD care and that creates anenabling environment or individuals to assumegreater responsibility or their own health by making in ormed, healthier choices.

Community actions: In OECD countries, tnessprograms are subsidized by employers, who canalso provide tobacco- ree workplaces. Health promotion activities are implemented by communi-

ties. Indeed, companies, as employers, can have astrong infuence on the behavior o their sta and

5 Te two most important instruments to practice HiAP are the healthimpact assessment (HIA) and health lens projects. HIA is de ned as acombination o procedures, methods and tools by which a policy, pro-gram, or project may be judged as to its potential e ects on the health o a population, and the distribution o those e ects within the population.Designed and implemented by non-health sectors, health lens projectsmainly aim to accomplish a sectoral development agenda but also includesome activities or components to mitigate the negative impacts or enhancethe positive impacts on a populations health.


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can make them aware o health risks in ways notopen to a government. As shown by the experiencein the United States, these types o programs havevery good returns: a recent study documentedthat medical costs ell by about US$ 3.27 or ev-ery dollar spent on wellness programs with similarreturns achieved rom reduced absenteeism (50).

Chinas experience in Daqing and Beijing demon-strated that community-based NCD interventions were not only e ective but also had long-lasting im-pacts on health improvement (51,52).

Figure 13 illustrates the linkage between the above-proposedpolicy options (including the intervention packages) andthe expected outcomes. Te population in China can be di-vided into two groups: the population without any knownNCD-related risk actor (the blue bar) and the population

with at least one NCD-related risk actor (the yellow bar).

Implementing population-wide interventions, such as HiAPand other measures, including scal and regulatory mea-sures, community actions, and a health sector responsesuch as screening and treating individuals or/with NCD-related biological risk actor(s)will result in a reductionin the share o the population with at least one NCD risk

actor (compared to the no-intervention scenario). Tese re-

sults are also observed among NCD patients: some o themhave been diagnosed and identi ed (the brown bar), butconcurrently a signi cant number o them are not; amongthose who have been diagnosed, again, only some are un-der medical care (the pink bar). Lastly, among those undermedical care, only some achieve improved health outcomes(the green bar). An e ective health system response wouldensure that more NCD patients are being diagnosed as early as possible and managed properly; over time, a greater shareo NCD patients will have improved outcomes.

Figure 13: Preventing and Controlling the NCD Tide

Whole population

Population with specic NCD risks

NCD patients

Diagnosed NCD patients

NCD patients managed

NCD patients with improved outcomes

Individual-based interventions primary health ca re for NCDs patient-center ed NCD

management models behavior change interventions improved quality of ca re

High-risk group interventions scr eening & tr eating individual biological risk factors workplace- & school- based interventions

Population-wide interventions health in all policies healthy city initiativ e

tobacco, alcohol contr ol workplace- & school-based interventions

Source: Authors.

6.2 What Actions to Take? FromGovernmental Policy to ProgramImplementation

6.2.1 Improving the Governments Commitmentand Response to NCDs

Improving the populations health should be among the pri-ority social objectives to be pursued under the programs,activities, and investments required to implement Chinas12th Development Plan over 20112015. As argued be ore,this would require improved Government commitment totackle NCDs e ectively in the medium term.

o that end, the Chinese Government may consider sup-porting the ollowing actions in the short term:

A mid- and long-term multisectoral national plan orNCDs should be prepared with clear, time-boundobjectives and targets and a ully costed action planto guide related budgetary and investment decisions.Such plan could serve as a ramework or developing

required laws, regulations, and en orcement mecha-nisms, as well as policies and programs, assigning in-tersectoral responsibilities and accountability or theresults at the central, provincial, and local levels, andcoordinating international cooperation.

Epidemiological surveillance systems and other datacollection mechanisms should be strengthened tomonitor regularly the achievement o time-boundtargets, and well-structured strategic communication


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activities should be supported to communicate theresults achieved to policy makers, program managersand the population as a whole.

Large-scale (province-wide) demonstrational NCDprevention and control pilots in collaboration withinternational organizations should be designed andimplemented. Such projects would: (a) mobilize inter-national technical assistance to support project prepa-ration and implementation, based on global best prac-tices, and (b) generate evidence about new approachesbe ore scaling up to the rest o the country.

6.2.2 Putting in Place an E ective MultisectoralCoordination Mechanism

Te Government could consolidate, streamline, andstrengthen the coordination o health actions and invest-ments or health-related activities, including those or tackling NCDs, by establishing an overarching multisectoralNational Health Committee ( able 4). Tis committeeshould be chaired by at least a Vice Prime Minister-level o

cial to raise the political importance o the NCD e ort andinvolve representatives rom di erent sectoral ministries another stakeholders.

Table 4: Examples o Inter-Institutional Coordination Mechanisms or Health-Related Activities in China

Name Institutional Characteristics

National Food Sa ety Committee A Vice Premier is the leader o this long-term institution.

The State Council Leading Group or Strength-

ening Health System Re orm

A Vice Premier is the leader o this temporary institution,

with equivalent structures at the local level.National Population and Family PlanningCommission (NPFPC)

Minister o NPFPC, a long-term institution having localbranches.

Inter-ministerial Coordination Mechanism orFramework Convention on Tobacco Control(FCTC) implementation in China

Minister o Industry and In ormation is the leader, holdingirregular meetings.

Inter-ministerial Meeting Mechanism or MentalHealth

The Vice Minister o Health is the leader, holding irregularmeetings.

Source: Prepared by authors on the basis o available Government in ormation.

o strengthen coordination and a multisectoral response

to NCDs, China can introduce di erent nancial mecha-nisms, such as establishing a start-up grants mechanismto support the development o the new approaches, as donein such countries as Australia, Denmark, England, France,Germany, and Canada.

6.2.3 An Initial Focus on Four Major NCDs be oreExpanding to Cover All NCDs

An e ective NCD response in China can begin with avert-ing and delaying as much as possible the onset o our majorNCDs: namely, CVDs (heart attacks and stroke), diabetes

mellitus, COPDs, and lung cancer, along with alcohol-relatedinjuries. A sustained e ort is required to reduce the prevalenceo our major behavioral risk actors: smoking, unhealthy diet,physical inactivity, and alcohol abuse. Tis in turn would con-tribute to the reduction o the our major related biologicalrisk actors at the population level: hypertension, high choles-terol, high blood sugar, and overweight/obesity.

Tis proposed initial ocus is justi ed by the ollowing con-siderations: (a) a signi cant share o total NCD burden

stems rom the onset and prevalence o these diseases an

conditions; (b) these diseases share common risk actorand, hence, common interventions; and (c) equity and ea-sibility criteria or China support a ocus on these diseases

6.2.4 The Priority or Immediate Action:Adopting Population-Wide Preventionand Targeted Treatmentto High-Risk Individuals

Accumulated evidence at the international level indicatesthat population-wide prevention, which aims to change dis-ease-related risk behaviors, environmental actors, and theisocial and economic determinants or NCDs in an entirepopulation, are the most e ective or NCD prevention andcontrol, along with those that target treatment to people athigh risk o NCDs ( able 5). It should be clear howeverthat international experiences cannot be simply transplant-ed into China. urning this evidence into actionable policiesand practices in China will require care ul assessment andadaptation that takes into account particular cultural, so-cioeconomic, and institutional actors that infuence policy decisions and program development.


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Initial assessments prepared or this report indicate thatmost o the interventions under this group could be imple-mented in the near term, and their incremental cost wouldbe relatively low, except or some HiAP measures, or whichthe costs need to be evaluated.

It is highly recommended that the interventions proposed oreach risk actor be implemented as a package in order to maxi-mize the health outcomes. However, building upon existingpolitical and social acceptance and support, as well as available

unding, a gradual and incremental approach could be adoptedin China, concentrating at the beginning on the reduction o excessive dietary salt intake, harm ul alcohol consumption, and

smoking in public places. Development o a national salt re-duction strategy could be supported to achieve a quick publichealth gain. Some o the proposed interventions or preventingharm ul alcohol use could be adopted as well, including en-

orced legislation to reduce drunk-driving. China has also rati-

ed the FC C, and a ban on smoking in public places becamee ective on May 1, 2011, building on the successes o the banson tobacco advertisement and smoking in public places duringthe 2008 Olympic Games held in Beijing, the 2010 Shanghai

World Expo, and the 2010 Guangzhou Asian Games. It wouldbe important, there ore, to support the en orcement o thesmoking ban in public places, particularly in health acilities,and to monitor its e ectiveness.

Table 5: Priority Interventions or NCDs

Risk Factor Intervention

Tobacco use

Accelerate implementation o the Framework Convention on Tobacco Control: Raise taxes on tobacco En orce bans on tobacco advertising, promotion, and sponsorship Ban smoking in public places and protect people rom tobacco smoke O er help to quit tobacco use and warn about the dangers o tobacco use

Excessive dietary saltintake

Regulate salt concentration limits in processed and semi-processed oods Reduce dietary salt levels through voluntary action by ood industry Promote low-sodium salt substitutes Implement in ormation and education campaigns to warn about the harm

rom excessive salt intake

Harm ul alcohol use Increase taxes Ban advertising Restrict access

Unhealthy diets, physicalinactivity, obesity

Introduce taxes or unhealthy ood Provide subsidies or healthy ood Promote labeling Administer marketing restrictions

Cardiovascular risk Facilitate access to and promote combinations o drugs or individuals at

high risk o NCDs

Source: Adapted rom Beaglehole and others, Priority actions or the non-communicable disease crisis, 2011 (53).

Table 6: Tobacco Prices and Taxation in BRICS Countries, 2009

China Brazil India The RussianFederation South A rica

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 o a pack o 20 cigarettes or most brands (o fcial exchange rate);** the percentage o the retail price or most brands.


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More challenging but more cost-e ective actions such asexcise tax increases and the resulting higher retail prices orcigarettes merit consideration on the basis o the assessmentand policy deliberation by the Government o China andtaking into account international experience in countriessuch as Australia, Canada and the United States that show that higher excises induce some smokers to quit; reduce con-

sumption by continuing smokers, prevent others rom start-ing, and reduce the number o ex-smokers who resume (54).Te adoption o this scal measure would be consistent withthe Governments commitment to the FC C (55). Com-pared to the progress made in other BRICS (Brazil, Russia,India, China and South A rica) countries, China has beenlagging behind mostly in raising the tobacco taxes ( able 6).

International best practices in using tax policy to reduce to-bacco consumption suggest that (a) there is a trend towardadoption o speci c taxes, particularly i the main goal to discourage the consumption o cigarettes (Australia, India, Japan, the Republic o Korea, Maldives, New Zealandthe Philippines, and aiwan, China, have adopted speci cexcises on cigarettes); (b) or countries with speci c taxe

there is a trend away rom weight-based speci c levies unit-based leviesthat is, speci c excises based on the number o cigarettes; and (c) speci c taxes can and would keepace with infation i they were automatically adjusted ochanges in the consumer price index, as is done in Australiaand New Zealand.

Table 7: HiAP or NCD Prevention and Control

Sector Opportunities

Finance

Subsidy or healthy ood production Increasing prices or tobacco, alcohol, editable oils Removal o subsidy or products harm ul to health, such as tobacco lea and tobacco products

Agriculture,ood industry

Production and marketing o healthy ood Salt reduction in (semi)-processed ood; reduction o trans at in ood Maintaining adequate land or agriculture and ood systems; crop substitution or

tobacco leaves

Environment

Globally, a quarter o all preventable illnesses (e.g., cancer, COPDs) are the result opoor environmental conditions where people live. Stricter environment standards anden orcement should be practiced.

Real estate developers can be encouraged or mandated to include physical exerciseacilities in their projects.

In rastructure,transportation

Optimal planning or road, transport, and housing to reduce environmentally costlyemissions and tra c injuries and to improve accessibility to health services Better transport, including cycling and walking opportunities, building sa er and more

livable communities, and accessible acilities or physical activities

Education

Physical activity program among school children School ood and nutrition program Production o an adequate number o health pro essionals with needed skills or NCD

prevention and care

Socialprotection

Improved coverage o NCD-related preventive, curative services at the PHC level Exemption o NCD patients rom copayment or selected preventive and curative services Funding the cost or care planning, documentation, and coordination activities or

integrated care

Adjustment o health nancing by disease morbidity/burden Moving toward a single payer systemLegislationand lawen orcement

Development and en orcement o pro-health polices and regulations on drunkdriving,home violence, and a smoke- ree environment

En orcement o anti-air pollution legislation

Media Promotion o change in social norms concerning smoking, being sedentary, and alcohol

abuse and advocating healthy li estyles

Private sectors Occupational health and work sa ety Workplace wellness programs

Source: Adopted rom Adelaide Statement on Health in All Policies, WHO, Government o South Australia, Adelaide, 2010.


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In 2009, China adjusted its tobacco tax with the ad valoremtax structured at the producer price level but has not passedthe adjustment to the retail price level. Had China passed its2009 tobacco tax adjustment rom the producer price levelto the retail price level, the retail price would have increased3.4 percent, resulting in 700,000 quitters avoiding smok-ing-related illnesses and premature death (56). Alternatively,

i China increases the speci c tax o 1 yuan per pack ( romthe current level o about 40 percent to about 50 percent o the average retail price), with a price elasticity o -0.50, 3.8million lives would be saved, reducing medical costs by 2.28billion yuan and generating a productivity gain o 10.27 bil-lion yuan or the Chinese economy (57).

Other opportunities or HiAP could be considered or NCDprevention and control ( able 7). It is advisable to set up across-sectoral task orce to identi y possible areas and interven-tions or dealing with NCDs. A practical rst step would be

or this task orce to prepare a priority list o activities and in-vestments to implement multisectoral actions in health. Even-tually, the Government could consider adopting HiAP as anational policy, as done by the European Union in 2006 (58).

Te involvement o public and private production and com-mercial enterprises could be o particular importance in

China. Te concept o employers playing a larger role inimproving employee tness and health is not new. Te U.S.Government, or example, is encouraging employers to investin workplace health promotion, and about 95 percent o itslarge employers and a third o its smaller ones o er wellnessprograms (59). A growing awareness o the substantial coststo employers o ill health and disability linked to NCDs-relat-

ed risk actors provides the grounds or advocating workplace-based health promotion initiatives by the Government.

Estimated Costs and E ects o NCD PreventionInterventions: Halving the NCD Burden

As described in Box 1 and shown in Figure 14, our sets o population-wide and high-risk, group-based preventive inter-ventions are estimated to deliver the greatest value or invest-ments needed at di erent levels o available resources in China.Tese preventive intervention sets can be implemented sepa-rately; however, combinations o di erentsets o interventions lead to economies o scale and more value or money. With

ull implementation o the combined set o interventions, onecould expect 600800 million DALYs or lost years averted an-nually over a period o ten years with an expenditure o about$220 per capita per year. Tis is about 4560 percent o theestimated total NCD burden o about 1.4 billion in 2010.

Box 1: Projected Impact o Priority NCD Prevention Interventions in China

Implementation o tobacco control measuresincluding higher taxation and prices or cigarettes, andbanning smoking in public places and advertisement o tobacco productswould prevent 10 millionDALYs lost annually at only a ew cents (US) or less than 0.04 yuan per capita per year.

At a doubling o resources, a ew additional cents (US) or around 0.07 yuan per capita, a combina-tion o anti-tobacco measures with interventions or controlling alcohol abuse, e.g., increasing tax andbanning 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 o anti-smokingand alcohol abuse measures, along with preventive interventionse.g., screening o and treatment

or individuals with elevated blood cholesterol levelswould help prevent about 85 million DALYs lostper year.

US$ 220 or 1500 yuan per high-risk individual annually is required to add a next set o cost-e ectiveinterventions, 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 othe total health expenditure in 2010), and the total annual DALYs lost averted would be around anadditional 500 million.

The rst two groups o interventions could be nanced through the priority public health programsor NCDs and implemented at the national level. The third and ourth groups can be nanced through

health insurance schemes.


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Interventions or reducing dietary salt intake which wouldlead to lower blood pressure, one o the main risk actors orCVDscould also be highly cost-e ective in China, as dem-onstrated by the experience in the United Kingdom, Finland,and Japan. Tis can be done using a multi-pronged approach,

including legislation and regulation, working with the oodindustry, general health promotion campaigns, and the pro-motion o low-sodium salt substitutes, since in China mostsalt is added during cooking. Te U.K. salt reduction pro-gram spent just 15 million (about US$ 24 million) but ledto 6000 ewer CVD deaths per year, saving the U.K. economy about 1.5 billion (about US$ 2.43 billion) per annum (60).

6.2.4 Over the Medium Term: Strengthening theHealth System to Address NCDs

Te explicit priority attached to NCD prevention and controlin China over the medium term should drive improvementsin the health system. Tis is required or early detection andtreatment o risk actors, and early identi cation and treat-ment o conditions such as heart attacks and strokes and therecurrence o these conditions. Tese interventions occur atthe patient level in a health care setting. Building upon ongo-ing health system re orm e orts included under its ve healthre orm pillars, the Government o China may consider adopt-ing additional policy, institutional, and service provision

measures to strengthen the capacity o the health system tobetter respond to the NCD challenge as outlined below.

Improving fnancial protection in health

Te Government o China recently committed to supportthe reduction o OOP payments or health care rom thcurrent level o 37 percent o total health expenditure to30 percent by 2015 (61). Tis target is highly relevant toNCD patients since NCDs are the biggest contributorto escalating individual and household expenditures onhealth care. Between 1985 and 2005, health expendituresassociated with CVD alone increased by 17.3 percent an-nually, while the total health expenditure increased by 11.8percent per year. Te Government has already adoptedsome measuressuch as reducing the prices o pharma

ceuticals, integrating di erent health insurance schemesand increasing government spending on healthin orderto reach the target. Further actions would be needed toreduce the OOP burden incurred by NCD patients andtheir amilies.

Creating new fscal space or fnancing NCDs

Levying a sin tax on tobacco, alcohol, and sugar sodrinks needs to be considered (e.g., on tobacco, as the

Figure 14: Proposed Expansion Path or an NCD Prevention Package

Anti-tobaccopackage + anti-alcohol package

+ cholesterol

lowering

Anti-tobaccopackage + anti-alcohol package

+ cholesterollowering + polypill

intervention

$ 100,000

$ 1,000,000

$ 10,000,000

$ 100,000,000

$ 1,000,000,000

$ 10,000,000,000

$ 100,000,000,000

000,000,000,1000,000,001000,000,01

C o s

t s , U

S $

Health Effects in DALYs

Anti-tobaccopackage

Anti-tobaccopackage +

anti-alcoholpackage

$ 0

$ 250,000

$ 500,000

$ 750,000

$ 1,000,000

10,650,000 10,700,000 10,750,000 10,800,000 10,850,000

C o s

t s ,

U S $

Health Effects in DALYs

Population-wideinterventions

Combined individual risk-based interventions

Anti-tobacco packageanti-alcohol package

Source: Authors.Note: Both axes in large fgure are in log scale.


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current price o cigarettes in China is very low comparedto other G-20 countries). Tis would not only help reducetheir demand and consumption but also has the addedbene t o raising Government revenue (54). Some coun-tries, such as Australia and the United States, are usingrevenue rom these taxes to help und health promotionprograms and insurance schemes. A good example is the

decision in February 2009 by the U.S. Government autho-rizing the renewal and extension o the Childrens HealthInsurance Program or poor children by using a 62-centper-pack increase in the ederal taxes o cigarettes to ully

und the program (62). In addition, taping resources romother sectors through implementation o HiAP could be

urther considered to mobilize unding or cross-sectoralhealth-related interventions.

Improving central Government fnancial allocations or health by taking into account the populations health conditions

Te central Government in China could consider using dis-ease morbidity as a actor in the ormulae used to calcu-late allocations (per capita) to new rural collective medicalschemes, urban resident basic health insurance schemes, as

well as its NCD-related allocations to the provinces. Suchan approach is used in such countries as the Netherlands,Belgium, and Germany (63). Similar arrangements have al-ready been adopted in China or unding HIV/AIDS and

B prevention and control programs.

Moving to a single payer or health services

Development o a universal basic health insurance schemein China could be accelerated through integration o varioushealth insurance schemes as is being done in early stages inChongqing, Zhejiang and Guagnxi to adopt mechanisms to

und the NCD prevention and control. Continued coverageby a SINGLE insurer at the provincial level could pool risks,create improved bene t packages, allow more equitable allo-cations across populations and improve purchasers leveragein addressing NCDs more proactively and e ciently, becausethe bene ts o avoiding severe complications are o ten only realized a ter eight to ten years (64). Such an approach wouldreduce the administrative costs associated with the operationo thousands o existing insurance schemes, acilitate coordi-nated care, increase the capacity o the scheme to cushion the

nancial risks due to NCDs, and better position the payers inactive purchasing o services rom di erent providers.

The fnancing o NCD-related activities would need to prioritize prevention

Cost-e ective, population-wide interventions and those tar-geting high-risk groups recommended in the previous sectionneed to be given the highest priority and be ully nanced inorder to achieve the best return or investment. A review o the approaches or reducing coronary heart disease (CHD)in most o developed countries demonstrated that reducingtotal cholesterol level, blood pressure, and tobacco smokingaccount or a signi cant share o the reductions in CHD

Figure 15: E ective Approaches to Reducing Mortality rom Coronary Heart Disease

40%

40%

43%

35%

35% 38%

47%

43%

39%

36%

24%

23%

24%

54%

60%

50%

55%

60% 53%

44%

49%

60%

55%

76%

72%

74%

6%

7%

10%

5% 11%

9%

8%

1%

9%

5%

2%

Goldman USA 19681976Beaglehole New Zealand 19741981

Hunink USA 19801990IMPACT Scotland 19751994

IMPACT New Zealand 19821993IMPACT England & Wales 19812000

IMPACT USA 19802000IMPACT Poland 19912005

IMPACT Czech Republic 19852007IMPACT Sweden 19862002

BMJ Finland 19721992IMPACT Finland 19821997

IMPACT Iceland 19812006

Treatments Risk factors Unexplained

Source: Ford et al., 2007, Explaining the decrease in U.S. deaths rom coronary disease, 19802000, New England Journal o Medicine, 356: 238898, updated by Capewell & Andersen, 2011.


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mortality (Figure 15) (65). Also, a screening and control pro-gram or early diabetes and hypertension in Mexico demon-strated that or each U.S. dollar invested in prevention, US$85323 would be saved over a 20-year period (66).

A shi t to primary health care is needed to tackleNCDs e ectively

Di erent countries have been shi ting emphasis in expend-iture toward primary health care to deal with NCDs. OECDcountries on average allocate 31 percent o their total healthexpenditure to outpatient care and less than 40 percent toinpatient care (Figure 16). Te bene ts o this approach are

well documented. A recent study in Brazil, or example,demonstrated that its strengthened PHC helped preventunnecessary hospitalization (67).

Data rom China suggest the opposite: the allocation o totalhealth expenditure on outpatient care ell rom 37.8 percentin 2005 to 32.5 percent in 2009 (34). Further evidence in-dicates health spending by the Government and insuranceschemes has been skewed toward inpatient care. Te recentNational Health Service survey showed that in 2008, OOP asa share o medical bills, remain signi cantly higher or outpa-tient care compared to inpatient care and reached 84 percento monthly per capita income among patients in the poorestquintile (compared to about 11 percent in the richest quintile)

or an average outpatient visit (68). In ianjin Municipality,

about 82 percent o the Governments and insurance schemesspending on CVDs was on inpatient care, and only 18 per-cent was on outpatient care in 2008 (Figure 17) (69).

o increase the relative importance o PHC services in thehealth system, health insurance schemes in OECD coun-tries have adopted several measures that may be relevan

or China:

Improved coverage o NCD-related preventive andcurative services at the PHC level and at home andprovision o outpatient drugs (70, 71);

Exempting NCD patients rom copayments or selected preventive care and curative services that arenecessary or patients who need long-term chroniccare (United States and France, 72);

Funding the cost or care planning, documentation,and coordination activities to incentivize providers todeliver coordinated and integrated care or NCD pa-tients, or example, the year o care approach adoptein the U.K. National Health Services or diabetes con-trol. Te amount o unding or expected care is cal-culated using a risk-adjusted capitation ormula basedon the likely annual consumption o a range o necessary health services. Service providers are paid throughan integrated capitation method (73). Such practicesare ound in Australia, the United States, and parts o

Figure 16: Health Expenditure by Function o Health Care, 2007

36 36 33 33 32 32 30 30 30 29 29 29 29 29 29 29 28 25 25 24 23

28 23 27 29 31 26 32 30 33 3140

29 2632

24 33 36 46 37 33

31

1311 6

184

26 12 1821

128

13

3

20 17

14 2 1

8 16 0.4

1821 29

16

26

1318 11

13

21 17 2036

12 18 12 28

25 24 22 37

5 9 5 4 7 3 8 113 7 6 9 6 7 12 12

6 3 6 5 8.6

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

A u s t r i a

F r a n c e

P o

l a n

d

I c e l a n

d

C z e c h

R e p u

b l i c

N o r w a y

F i n

l a n

d

L u x e m

b o u r g

D e n m a r

k

O E C D

S w e d e n

G e r m a n y

H u n g a r y

S w i t z e r l a n

d

B e

l g i u m

N e w

Z e a l a n

d

R e p u

b l i c o

f K o r e a

P o r t u g a

l ( 2 0 0 6 )

S p a i n

J a p a n

S l o v a k

R e p u

b l i c

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.


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Tailand. O ten, GPs act as und holders, using capita-tion payment unds to purchase inpatient services and/

or specialist services or registered patients.

Adopting new health care organization models

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