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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
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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
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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
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☼ 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
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General Information The Characteristics of China Health
Enterprises Health Policy in China Health Care System in China
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General Information The Characteristics of China Health
Enterprises Health Policy in China Health Care System in China
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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
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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
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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
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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
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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
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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%
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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%
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The family support system is weakThe family support system is weak
4
2
1
4-2-1 syndrome
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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
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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…
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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
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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
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The first 10 communicable diseases, 2003
Main communicable diseasesMain communicable diseases
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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
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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
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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
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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
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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)
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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
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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
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Occupational Health Issues
Occupational diseases
Occupational accidents
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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
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Traffic Accidents
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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
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Living Environment Pollution
Building decoration materials pollution
Electromagnetic pollution
Light pollution
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China China 55 55 AnniversaryAnniversary
Peasant Out-Migration increasing
Number of
laborer in rural:
485 million
Number of
peasant out-
migration: 9999
millionmillion
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Health issues of floating population
Unsanitary living environment
Poor immunization protection
Unhealthy behavior
Be difficult to manage
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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
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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
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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
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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
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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
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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
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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
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Drinking
Source: 《 China Statistical Yearbook 》 2003
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The frequency of drinkingThe frequency of drinking
Female
Male
≤ 1/month 2-4/month 2-3/week 4-5/week ≥ 1/day
Drinking
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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
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12.5%
87.5%
Heavy drinkers(≥ 50ml/day)
Moderate drinkers(<50ml/day)
The proportion of heavy drinkers to the whole drinking population
Drinking
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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
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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
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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%
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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
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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
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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
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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
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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
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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
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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%
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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
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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
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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
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1.Public health new concept
Public policy
Government leadership and support
Law & regulation development
Public health
Multi-sectoral collaboration
Full social involvement
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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
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Thank Thank you!you!