Progress and challenges in NCD prevention and control in China

Abstract

A BMJ collection highlights the need for an integrated population tailored approach

Non-communicable diseases (NCDs), such as cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes, account for 91% of all deaths in China.¹ China accounted for 17.9% of the world population in 2021, but 25.9% of global deaths from NCDs.¹² The burden of most NCDs has continued to rise over the past two decades,³⁴⁵ driven mainly by population ageing⁶ and a failure to fully and effectively tackle major risk factors for NCDs, including use of tobacco and alcohol, physical inactivity, unhealthy diets, and air pollution. A new collection of articles in The BMJ (www.bmj.com/collections/chronic-diseases-in-china) attempts to shed light on the current state and challenges of NCD prevention and control in the context of China’s population ageing, as well as to discuss strategies and approaches to deal with these issues.

Over the past two decades, China has implemented several NCD prevention and control programmes, such as morbidity and mortality surveillance, public health intervention programmes,⁷ and screening for major chronic diseases, primarily through the national basic and major public health service programmes. Among several national health policies, laws, and regulations introduced to improve public health is the prominent Healthy China 2030 Outline, which introduced more proactive approaches to NCD prevention and control that align with the World Health Organization’s (WHO) global strategy. The global strategy explicitly acknowledges the primary role and responsibility of governments in responding to NCD challenges and the need for multisectoral engagement, emphasising health in all policies, addressing modifiable risk factors by creating health promoting environments, taking a life course approach to health, and making efforts to improve health equity.

Although China has made considerable progress in its national strategy for NCD prevention and control, challenges remain, as the collection lays out. First, there is insufficient emphasis on evidence in making policies, strategies, and practices for NCD prevention, diagnosis, treatment, and management. For example, because of insufficient studies and effectiveness trials in Chinese populations, good evidence for determining optimal thresholds for the diagnosis and treatment of hypertension, diabetes, and even cancer for the Chinese population is largely lacking.⁸ As a result, Chinese NCD policies often follow those of western countries, even though the cost effectiveness of interventions, available resources, and values of people differ hugely in China. This has resulted in poor compliance with NCD policies.⁸

Another challenge pertains to healthcare access and health equity. The implementation of national policies and programmes varies greatly by region, reflecting differences in the local economic development level, culture, healthcare system capacity, and priorities of local governments, including health and non-health sectors. As part of the collection, Lu and colleagues discuss how individual variations in socioeconomic position also result in inequalities in lifestyle factors, exposure to air pollutants, other disease risk factors, and the effectiveness of interventions on risk factor control and disease outcomes.⁹ Other articles argue that without a strong effort to address the social determinants of health, even effective policies and programmes, such as digital health solutions to disease prevention and management,¹⁰¹¹ may exacerbate health inequities.

Importance of leadership

Although the health in all policies approach has been highlighted as a strategy in national and global policy documents, its implementation is also a challenge for China. Strong leadership from the central and local government is critical for successful implementation of policies and programmes that can truly improve health. For example, the Chinese government has issued national action plans to improve air quality since 2013, implementing comprehensive multisectoral actions that resulted in a significant reduction in PM_2.5 concentrations between 2014 and 2022.¹² In contrast, after 15 years of implementing the WHO Framework Convention on Tobacco Control in China, the best performing of the six recommended tobacco control measures are the monitoring of tobacco use and prevention policies and anti-tobacco mass media campaigns, both of which are primarily led by the health sector.¹³¹⁴ Gaps remain in the implementation of other measures that need national or non-health sector’s leadership, such as national smoke-free law, health warnings on tobacco packaging, and tobacco tax increases.

NCDs and infectious diseases are not entirely distinct disease categories; rather, they share similar features and also have common interactions.¹⁵ For example, major NCDs increase the risk of severe or fatal outcomes of covid-19, and covid-19 can also lead to long covid, a chronic health condition. Experiences with covid-19 also show that it is important to prevent people with chronic diseases from having infections, particularly during a communicable disease outbreak.¹⁶ Three decades ago, the management of the prevention and control of infectious diseases and NCDs in China was merged into one department, the Department of Disease Control and Prevention of the former Ministry of Health. In May 2021, China inaugurated a new agency under the National Health Commission called the National Disease Control and Prevention Administration, with primary responsibilities for infectious disease prevention and control and public health supervision. However, this new agency is not in charge of NCD prevention and control, which was taken over by the Department of Medical Emergency Response.

The BMJ collection contributes to a growing understanding of NCD prevention and control, not least by showing that successful national prevention and control will depend on strong leadership from the central and local governments, on the integration and collaboration of both health and non-health sectors, and on policies made based on evidence relevant to the Chinese population. It will also require a shift from health in all policies to a health for all policies approach—that is, moving from focusing on wins for the health sector to emphasising co-benefits for all sectors.¹⁷

Footnote

Competing interests: We have read and understood BMJ policy on declaration of interests and have no interests to declare.

Provenance and peer review: Commissioned; not externally peer reviewed.

¹ Liu H Yin P Qi J Zhou M. Burden of non-communicable diseases in China and its provinces, 1990-2021: Results from the Global Burden of Disease Study 2021. Chin Med J (Engl) 2024. 10.1097/CM9.0000000000003270   39193717

² World Health Organization. Noncommunicable diseases. 2023. https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases

³ Ma Q Li R Wang L. Temporal trend and attributable risk factors of stroke burden in China, 1990-2019: an analysis for the Global Burden of Disease Study 2019. Lancet Public Health 2021; 6: e897 - 906. 10.1016/S2468-2667(21)00228-0   34838196

⁴ Qi J Li M Wang L. National and subnational trends in cancer burden in China, 2005-20: an analysis of national mortality surveillance data. Lancet Public Health 2023; 8: e943 - 55. 10.1016/S2468-2667(23)00211-6   38000889

⁵ Han B Zheng R Zeng H. Cancer incidence and mortality in China, 2022. J Natl Cancer Cent 2024; 4: 47 - 53. 10.1016/j.jncc.2024.01.006   39036382

⁶ Lv Y Fan L Zhou J. Burden of non-communicable diseases due to population aging in China: challenges to healthcare delivery and long term care services. BMJ 2024; 387: e076529. 10.1136/bmj-2023-e076529

⁷ Wu J Gao X Yang Z. Shen H. Non-pharmacological interventions for prevention and treatment of non-communicable diseases with experiences from China. BMJ 2024; 387: e076764. 10.1136/bmj-2023-e076764

⁸ Yang Z Tang JL. Definitions of chronic disease need to be more patient centred. BMJ 2024; 387: q1858. 10.1136/bmj.q1858

⁹ Lu J Xu Y Bi Y. Ning G. Reducing inequity through tackling social determinants of cardiovascular diseases in China. BMJ 2024; 387: e079197. 10.1136/BMJ-2024-079197

¹⁰ Gong E Wang H Zhu W. Shao R. Bridging the digital divide to promote prevention and control of non-communicable diseases for all in China and beyond. BMJ 2024; 387: e076768. 10.1136/bmj-2023-076768

¹¹ Tong X Zu J Gone E. Frailty as a breakthrough point for multimorbidity management among older adults: challenges and opportunities in China. BMJ 2024; 387: e076767. 10.1136/bmj-2023-076767

¹² Zheng H Kong S Seo J. Achievements and challenges in improving air quality in China: Analysis of the long-term trends from 2014 to 2022. Environ Int 2024; 183: 108361. 10.1016/j.envint.2023.108361   38091821

¹³ Sun D Pang Y Lyu J Li L. Current progress and challenges to tobacco control in China. China CDC Wkly 2022; 4: 101 - 5. 10.46234/ccdcw2022.020   35186379

¹⁴ World Health Organization. WHO report on the global tobacco epidemic 2021: addressing new and emerging products. WHO, 2021.

¹⁵ Remais JV Zeng G Li G Tian L Engelgau MM. Convergence of non-communicable and infectious diseases in low- and middle-income countries. Int J Epidemiol 2013; 42: 221 - 7. 10.1093/ije/dys135   23064501

¹⁶ Li Y Tong X Jiang M. Chronic disease and infection: lessons from the covid-19 pandemic. BMJ 2024; 378: q2000.

¹⁷ Greer SL Falkenbach M Siciliani L McKee M Wismar M Figueras J. From health in all policies to health for all policies. Lancet Public Health 2022; 7: e718 - 20. 10.1016/S2468-2667(22)00155-4   35907422