the economic development & public health challenge in china

The Economic Development & The Economic Development & Public Health Challenge Public Health Challenge

inin ChinaChina

LimingLiming LeeLee M.D., M.P.H

Professor, School of Public Health, Peking University

Introduction of Health Enterprises in ChinaIntroduction of Health Enterprises in China

Public Health Challenge in ChinaPublic Health Challenge in China

Future strategy for the challengeFuture strategy for the challenge

Outline

Introduction of Health Enterprises in ChinaIntroduction of Health Enterprises in China

Public Health Challenge in China

Future strategy for the challenge

Outline

General InformationGeneral Information The Characteristics of China The Characteristics of China

Health EnterprisesHealth Enterprises Health Policy in ChinaHealth Policy in China Health Care System in ChinaHealth Care System in China

☼ Area: 9.6 million km2

☼ Total population: 1.27 billion (2000)

☼ Population in rural areas: 63.8％☼ Administrative: 31 provinces

☼ GDP: 8940.4 billion RMB

☼ Number of health agencies: 330 thousand

☼ Number of health workers: 5.568 million

☼ Number of school of public health: 36

General Information The Characteristics of China Health

Enterprises Health Policy in China Health Care System in China

Source: 《 China Statistical Yearbook 》 2001

General Information The Characteristics of China Health

Enterprises Health Policy in China Health Care System in China

General Information The Characteristics of China Health

Enterprises Health Policy in China Health Care System in China

1949-1977 Welfare enterprises for the whole

population (Government paid health services)

1978-1996 Public welfare enterprises

(Government & hospital paid health services)

1996-now Welfare public enterprises

(Government, Collective & individual paid health

services)

General Information

The Characteristics of China Health

Enterprises Health Policy in China Health Care System in China

Dec.1996 the health meeting of China Center Gov.

♪ Stress the health work in the rural areas♪ Put the prevention first♪ Lay equal stress in the Western and Chinese

traditional medicine ♪ Rely on the science and education ♪ Mobilize the participation of the whole society

General Information The Characteristics of China Health

Enterprises

Health Policy in China Health Care System in China

The organization structure of Chinese health system

State Department

Specialized HospitalLocal CDCMCH Hospital (Clinic)Drug Inspection StationMedical college or university

Specialized hospitalAnti-epidemic stationMCH Hospital (Clinic)Drug Inspection Station

Township hospital (clinic)District health center(outpatient clinic)MCH care center

General Public HospitalAnti-epidemic StationEndemic Disease Prevention StationMCH Care Center (Clinic)Secondary Health School

Township government, Sub-district Office

Villagers’ committee, Neighborhood residents’ committee Village health station

Red Cross health station

Three tiered prevention and

health care system

Government of Municipal, County, District

The Board (department) of Health

The Board of Health Regional Administrative Office

Government of Provincial, Municipal, Autonomous Region

The Ministry of Health

The Bureau of Health

CAMSChina CDC FDAPUMC

Introduction of Health Enterprises in China

Public Health Challenge in ChinaPublic Health Challenge in China

Future strategy for the challenge

Outline

Population DynamicsPopulation Dynamics Double Burdens of Diseases Urbanization and

Industrialization Behavioral Risk Factors Unreasonable of Resource

Allocation

The proportion of senile population (≥60 years old)The proportion of senile population (≥60 years old)

1999China 126 million

Asia 314 millionWorld 593 million

2050China 410 million

Asia 1.24 billionWorld 1.97 billion

0

2

4

6

8

10

12

14

16

18

1953 1964 1982 1990 1995 2000 2015

Trend of Population and Aging Trend of Population and Aging (0.1 Billion)

2050

1949Total 0.058 billion

Aging 8% 2000Total 0.126 billion

Aging 10%

2050Aging 25%

2015Aging 14%

Most of the aging population is living Most of the aging population is living in the rural areain the rural area

The proportion of aging population living in therural and urban area in developing countries

urban34%

rural66%

The family support system is weakThe family support system is weak

4

2

1

4-2-1 syndrome

Introduction of Health Enterprises in China

Public Health Challenge in ChinaPublic Health Challenge in China

Future strategy for the challenge

Outline

Population Dynamics Double Burdens of DiseasesDouble Burdens of Diseases Urbanization and Industrialization Behavioral Risk Factors Unreasonable of Resource

Allocation

Increasingly serious threats from…

Communicable diseasesCommunicable diseases

Re-emerging: TB, STD, plague, cholera…

Emerging: AIDS, SARS…

Non-communicable diseases Non-communicable diseases (NCD)

Stroke, cancer, CHD, diabetes, chronic obstructive

pulmonary diseases (COPD), mental diseases…

0

2000

4000

6000

8000

1965 1975 1985 1995

7061/100 thus.

195/100 thus.

Incidence Rate（1/100,000）

Main communicable diseasesMain communicable diseasesThe Incidence Rate of Communicable Diseases in China,

1965~1998

The Proportion of Different Communicable Diseases by Etiology in China, 1950’s-2002’s (%)

0 10 20 30 40 50 60 70 80 90 100

1950-

1960-

1970-

1980-

1990-

1995

2000

2002

Ye

ar

(%)

1.Communicable Diseases

Transmitted by sex or

blood

Gastrointestinal

Vector-borne and natural endemic

RespiratoryRespiratory

The first 10 communicable diseases, 2003

Main communicable diseasesMain communicable diseases

0

100

200

300

400

500

600

700

800

900

1954 1957 1963 1975 1980 1985 1990 1995 1998

CD

R（

1/1

00

,00

0）

Tendency of Death Pattern, China, 1954-1998

OtherOtherss

Injuries & Injuries & poisoning poisoning

Non-communicable Non-communicable diseasesdiseases

CommunicablCommunicable,e,

maternal and maternal and child child

diseasesdiseases

Mortality rate of Leading Causes of Death in China(2003)

95.68

89.89

70.86

45.53

21.54

134.54

105.40

77.29

76.23

32.55

0 20 40 60 80 100 120 140 160

Malignant neoplasms

Cerebrovasculardisease

Diseases of theRespiratory System

Heart disease

Injury & Poisoning

(1/100,000)

Urban

Rural

2.Non-communicable diseases

Introduction of Health Enterprises in China

Public Health Challenge in ChinaPublic Health Challenge in China

Future strategy for the challenge

Outline

Population dynamics Double burdens of diseases Urbanization and Urbanization and

industrializationindustrialization Behavioral risk factors Unreasonable of resource

allocation

China China 55 55 AnniversaryAnniversary

The overall capacityThe overall capacity

Annual average growth rate of…

GDP 9.3%

GDP per capita 8.2%

Year 2003…

GDP RMB 11669 billion

GDP per capita $1000

Foreign exchange reserve $403 billion

China China 55 55 AnniversaryAnniversary

Industry rapidly developingIndustry rapidly developing

% of GDP: 44.4% (Year 2002)

Value added of industry: RMB 5361.2 billion

(12.6%) (Year 2003)

Natural Environment Destroy

Pollution from waste water, waste gas, waste residue

Devastation of forest vegetative cover and the loss of soil and water

Eutrophication of the water bodies

Energy production (Year 2002)Energy production (Year 2002)

Total energy production:

139000 (10,000 tons of SCE)

Coal 70.7%

Crude oil 17.2%

Natural gas 3.2%

Hydro-power 8.9%

China China 55 55 AnniversaryAnniversary

Occupational Health Issues

Occupational diseases

Occupational accidents

TransportationTransportation

Newly built railways 1210 km

Newly built double-Tracking Length 1443 km

Length of Railways in Operation 72 thousand km

Length of highways 1.77 million km

Expressway 25 thousand km

Private cars in urban 7.7 million units

China China 55 55 AnniversaryAnniversary

Traffic Accidents

Number of major durable consumer goods owned Number of major durable consumer goods owned

per 100 urban households at the Year 2002-endper 100 urban households at the Year 2002-end

Refrigerator (set) 87.38

Color Television Set (set) 126.38

Video-recorder (set) 18.43

Air conditioner (unit) 51.10

Oven (unit) 30.91

Mobile telephone (unit) 62.89

Personal computer (set) 20.63

China China 5555 Anniversary Anniversary

Living Environment Pollution

Building decoration materials pollution

Electromagnetic pollution

Light pollution

China China 55 55 AnniversaryAnniversary

Peasant Out-Migration increasing

Number of

laborer in rural:

485 million

Number of

peasant out-

migration: 9999

millionmillion

Health issues of floating population

Unsanitary living environment

Poor immunization protection

Unhealthy behavior

Be difficult to manage

Introduction of Health Enterprises in China

Public Health Challenge in ChinaPublic Health Challenge in China

Future strategy for the challenge

Outline

Population Dynamics Double Burdens of Diseases Urbanization and Industrialization Behavioral Risk FactorsBehavioral Risk Factors Unreasonable of resource

allocation

Tobacco Epidemic in ChinaTobacco Epidemic in China

Approximately 320 million smokers in China. (1996)

The prevalence of smoking among 15 years old and

above was 35.10%.

60% smokers have never contemplated quitting.

The majority of the population is involuntarily

exposed to tobacco smoke (53.5%).

Smoking

61% of adults believed that tobacco use was o

f a little or no harm to their health.

The average age at which smoking starts is 2

0 years old.

Smoking already causing about 750,000 deat

hs a year and predicting that this will rise to thr

ee million a year.

Tobacco Epidemic in ChinaTobacco Epidemic in China

Smoking

The smoking behavior comparison of Chinese aged 15+ between 1984 and 1996

1984 1996Average number of cigarettes smoked per day(piece) 13 15The average age at which smoking starts(years) 23 20General smoking rate(%) 33.88 35.10Male smoking rate(%) 60.01 63.00Female smoking rate(%) 7.04 3.80

Smoking

Economics of tobacco in ChinaEconomics of tobacco in China

China is the world’s leading producer of tobacco.

Cigarette tax revenue in China was 31.0 billion RMB

in 1992, 65.0 billion RMB in 1997, average

representing 10.0% of total government revenue.

Smoking

0

500

1000

1500

2000

2500

3000

3500

4000

Production

Marketing

Production and Marketing of tobacco in China

Source:The Report of Tobacco in China

Smoking

Trend of Tobacco Sales & Mortality in Chinese Pop, 1996

1981 1986 1991 1996

Year

0

500

1000

1500

2000

2500Volume of Sales£¨Billion£©

0

10

20

30

40

50Mortality(1/100,000)

Lung Cancer

Volume of Sales

Smoking

Drinking

Source: 《 China Statistical Yearbook 》 2003

The frequency of drinkingThe frequency of drinking

Female

Male

≤ 1/month 2-4/month 2-3/week 4-5/week ≥ 1/day

Drinking

The Drinking TypeThe Drinking Type

MaleMale

High degree white spiritHigh degree white spirit BeerBeer

FemaleFemale

WineWine BeerBeer

Low degree white spiritLow degree white spirit

Drinking

12.5%

87.5%

Heavy drinkers(≥ 50ml/day)

Moderate drinkers(<50ml/day)

The proportion of heavy drinkers to the whole drinking population

Drinking

3.22.2 2.5

0.0

3.0

6.0

9.0

12.0

15.0

18.0

21.0

24.0

Ho

urs

City Rural Total

The average sedentary time per day during free time

Physical Exercise

25.7 23.3 24.5

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

(%)

Male Female Total

The proportion of persons taking exercises

Physical Exercise

The long-term trend of the prevalence of overweight and obesity in China

12.8

17.5

3.1

5.7

0

2

4

6

8

10

12

14

16

18

Pre

vale

nce

(%)

Overweight Obesity

1992

2002

Overweight & Obesity

83.9%

36.7%

The prevalence of Chinese overweight and obesity by age in 2002

3.42.0

4.5

2.1

22.8

7.1

17.5

5.7

0

5

10

15

20

25

pre

va

len

ce

(%

)

0- 7- 18 Total

Age (Years)

Overweight

Obesity

Diagnostic criteria:

<7 years old: (WHO Z score reference) 2<WHZ≤3 overweight, WHZ>3 obesity

7-17 years old : BMI≥p85 overweight, BMI≥p95 obesity

≥18 years old : 24 BMI<28 overweight, BMI≥28≦ obesity

Overweight & Obesity

The comparisons among 4 times of National Hypertension Survey

• 与 1991年相比，患病率的相对增长量为 30.9%，患病人数的绝对增长量为 9千万人。

5.11

7.73

13.58

17.65

7.5

9.4

12.3

0

2

4

6

8

10

12

14

16

18

20

1959 1979 1991 2002

Pre

va

len

ce

(%

)

: Nominal prevalence with different diagnostic criteria.

: Age-adjusted standardized prevalence. The diagnostic criteria was unified with SBP≥141mmHg and/or DBP≥91mmHg regardless of whether taking medication within 2 weeks (the criterion in 1979).

Hypertension

The rates of awareness, treatment and control of hypertension between 1991 and 2002

26.6

12.2

2.9

30.2

24.7

6.1

0

5

10

15

20

25

30

35

Awareness Treatment Control

Ra

te (

%)

1991

2000

Hypertension

In Chinese aged 18 or above years old:

Prevalence of…

Diabetes: 2.6%

Impaired fasting glucose: 1.9%

Number of patients…

Diabetes: 23 million

Impaired fasting glucose: 17 million

Diabetes

The prevalence of diabetes by areas in 2002

Diagnostic criterion: (1) FBG≥7.0 mmol/l; or (2) OGTT≥11.1 mmol/l; or(3) ever been diagnosed by county or above level hospital and receive treatment then.

6.35 6.19

4.10

3.43

1.982.42

1.721.92

2.182.49

0.84 0.85

0

1

2

3

4

5

6

7

Pre

vale

nce (

%)

Large cities Medium andsmall cities

1st classrural areas

2nd classrural areas

3rd classrural areas

4th classrural areas

Male

Female

Diabetes

Introduction of Health Enterprises in China

Public Health Challenge in ChinaPublic Health Challenge in China

Future strategy for the challenge

Outline

Population Dynamics Double Burdens of Diseases Urbanization and Industrialization Behavioral Risk Factors Unreasonable of Resource Unreasonable of Resource

AllocationAllocation

Unreasonable Health Resource AllocationUnreasonable Health Resource Allocation

Urban

Rural

Population%

26 .4

73.6

29.9

70.1

Population%

1991 1997Distribution of

Resource%

80.7

19.3 46.7

53.5

Distribution of Resource%

27.4

14.8

10.3

42.5

29.6

22.5

0

5

10

15

20

25

30

35

40

45

Mo

rta

lity

ra

te o

f c

om

mu

nic

ab

led

ise

as

es

(1

/10

0,0

00

)

City Rural

West Middle East

Unbalanced development of health enterprisesUnbalanced development of health enterprises

22

1412

46

23

17

0

5

10

15

20

25

30

35

40

45

50

Infa

nt

mo

rta

lity

(1

/1,0

00

)

City Rural

West Middle East

World Health Report 2000 Selected Indicators World Health Report 2000 Selected Indicators

Attainment of Goals Performance

Health level DALY

ResponsivenessFairness in

financial contribution

On level of health

Overall health system

USA 24 1 54-55 72 37

Sweden 4 10 12-15 21 23

Japan 1 6 8-11 9 10

China 82 88-89 188 61 144

Thailand 100 33 128-130 102 47

Introduction of Health Enterprises in China

Public Health Challenge in ChinaPublic Health Challenge in China

Future strategy for the challenge

Outline

Public Health New Concept Development of Future Public

Health

1.Public health new concept

Public policy

Government leadership and support

Law & regulation development

Public health

Multi-sectoral collaboration

Full social involvement

2.Development of future public health

Capacity building

Bridging the gap between clinic medicien and public health

Construction of public health information system

Evidence based decision making

Health education

Thank Thank you!you!