What can be learned from China's health system?
The Lancet today publishes a themed issue devoted to China to coincide with the third anniversary of the country's 2009 health reform plan, and a conference—Preventing Non-Communicable Diseases (NCDs) in China: national agenda and local commitments—organised by the Shanghai Jiaotong University School of Medicine. Two previous Lancet theme issues, which documented China's progress towards universal health care together with its challenges and development priorities, were launched in Beijing in 2008 and 2010. Why a further theme issue now? The principal reason is that China is experiencing a huge disease burden transition, with unprecedented social and environmental change, that will not only affect the country's future but also shape the pattern of global health. Additionally, The Lancet hopes to act as a bridge for scientific exchange between the rapidly expanding arena of medical science in China and the rest of the world. Again, we acknowledge the valuable assistance of our Editorial Consultant Michael Phillips in preparing this issue.
China's health services used to be described as too difficult to access, too expensive, and too variable in quality. Has the situation changed after 3 years of reform? Winnie Chi-Man Yip and colleagues' most encouraging finding is that China has accomplished near universal coverage in a very short time. This observation receives further support from the work of Qun Meng and colleagues, who use the data from Chinese National Health Services Survey to report that medical insurance coverage has increased from 29·7% in 2003, to 87·9% in 2008, and 95·7% in 2011. However, increased insurance coverage has not yet been effective in reducing patients' financial risks, as both health expenditure and out-of-pocket payments continue to rise rapidly. Reform of public hospitals is essential to control health expenditure because such institutes deliver more than 90% of the country's health services. There are pilot programmes for public hospital reform, but many hospitals remain profit-driven with doctors' bonuses tied to that profit.
In terms of primary care, their gatekeeping and referral roles have not yet been fully established. Health-care reform should benefit not only patients, but also doctors themselves. Yet there have been many reports of tension in doctor—patient relations in China. The reasons are multifactorial. Perhaps, as both papers emphasise, improvements in the quality and efficiency of health services might lead to better relations in the future. Such reform cannot be achieved without more active participation by health professionals. As a nation whose culture and society have long been formed by its farming traditions, China has just passed a landmark: its urban population of more than 680 million people outnumbered its rural residents for the first time in January, 2012. This urban explosion serves as a double-edged sword for public health in China. It not only offers great opportunities in the improvements of health-care access and basic health infrastructure, but also poses substantial risks, including changing diets and lifestyle, air and water pollution, and occupational and traffic hazards. Peng Gong and colleagues review the implications of urbanisation on health, and call for innovative research and health policies to alleviate the adverse health effects of rapid urbanisation.
Growing urbanisation is one of the socioeconomic risks for NCDs, which has already become China's number one health threat. Chronic kidney disease, diabetes, and cardiovascular disease are often closely associated, sharing common risk factors and treatments, and thus they would benefit from a coordinated approach to prevention and control. Luxia Zhang and colleagues estimate the number of patients with chronic kidney disease in China to be about 119·5 million—the largest population in the world. But only 12·5% of these individuals are aware of their condition.
Knowledge exchange is never a one-way street. While China is learning from other countries in health-care delivery and research, it has much to share for reciprocal benefit. China experienced a devastating disaster with the 2008 Wenchuan earthquake, which affected almost 50 million people. Lulu Zhang and colleagues share China's emergency medical rescue experiences from the earthquake.
Health-care reform is not exclusive to one country. How to improve universal coverage, reduce costs, and deal with the mounting challenge of NCDs are truly global problems. China's health-reform process, solutions, and lessons will provide evidence to inform debate and, ultimately, enhance global health-care outcomes.