Reducing inequity through tackling social determinants of cardiovascular diseases in China
BMJ 2024; 387 doi: https://doi.org/10.1136/bmj-2024-079197 (Published 18 October 2024) Cite this as: BMJ 2024;387:e079197Read the collection: Unmet needs for chronic diseases in China
- Jieli Lu, professor1 2,
- Yu Xu, professor1,
- Yufang Bi, professor1 2,
- Tiange Wang, professor2,
- Ruizhi Zheng, senior research fellow2,
- Weiqing Wang, professor1 2,
- Guang Ning, professor1 2
- 1Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- 2National Clinical Research Center for Metabolic Diseases (Shanghai), Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, National Research Center for Translational Medicine, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Correspondence to: G Ning gning{at}sibs.ac.cn
Cardiovascular disease (CVD) has become a great health challenge worldwide, contributing appreciably to morbidity and mortality.1 Rapid urbanisation, sedentary lifestyles, dietary changes, and population ageing in China have considerably increased the prevalence of CVD, including ischaemic heart disease and stroke. Social determinants of health have been increasingly recognised as an important contributor to health outcomes, given their association with about half of all-cause mortality.2
However, as in many other economically less developed countries, China’s current health policies have only recently started to recognise and tackle the importance of social determinants, particularly the urban-rural inequality in health.3 This analysis examines the achievements and challenges related to social determinants of health and associated inequity in CVD prevention and management in China over the past two decades, with a particular focus on socioeconomic status, healthcare accessibility, and affordability (fig 1).
Social determinants of cardiovascular health
Socioeconomic status and cardiovascular health
Socioeconomic status generally refers to an individual’s position in a hierarchical social structure. At an individual level, socioeconomic status is determined mainly by a person’s education, income, and occupation.4 Evidence from the United States and Europe showed wide variations in social determinants of health,56 and suggested that socioeconomic inequity might be equally important, if not more, as a contributor to human health than biomedical interventions.2 Although education, occupation, and income are inter-related, because education has more potential for intervention and can motivate subjects, it is commonly believed that education affects occupation and income, subsequently determining one’s lifestyle. In Europeans, educational attainment, rather than income and occupation, is the main socioeconomic indicator of longevity and CVD risk.7 The important effect of education on CVD risk and mortality was also explored in two nationwide prospective cohort studies in China: the China Cardiometabolic Disease and Cancer Cohort (4C) Study and the China Health Evaluation And risk Reduction through nationwide Teamwork (ChinaHEART).89 The 4C study of 193 846 adults found that education attainment below high school (versus high school or further education) accounted for roughly 14% of population attributable risk for CVD mortality.8 The ChinaHEART study of 1 283 774 adults reported that compared with college or above educational attainment, educational attainment at primary school or below was associated with a 44% to 101% increased risk of mortality across generations born between 1940 and 1979 in China, independent of income, health insurance, and occupation.9
Educational attainment is associated with a number of lifestyle behaviours (eg, cigarette smoking, alcohol use, physical activity, and diet) and diseases or disorders (eg, obesity, diabetes, hypertension, and dyslipidemia), which in turn increase the risk of CVD or CVD related mortality.710 A good example is the relation between education and obesity. Data from the China Chronic Disease and Risk Factors Surveillance of six nationally representative surveys between 2004 and 2018 showed that women with higher educational attainment had lower body mass indexes compared with women with lower education levels, while the inverse was true among men.11 Data from the China Health and Nutrition Survey (1991-2011) of 21 133 adults indicated that lower socioeconomic status, as determined by individual (education, income, and occupation) and area level (urbanisation index) was associated with higher mortality and shorter life expectancy; this was slightly mediated by lifestyle, including smoking, physical activity, diet, and bodyweight.12 This evidence suggests that the entire chain encompassing socioeconomic status and its associated lifestyle behaviours is critical for the prevention of CVD.
In recent decades, China has adopted a range of interventions to improve health literacy, including developing national basic public health services, health education and promotion, tobacco control, continuous health literacy monitoring, and holding special revenue funds. Health literacy of the population increased from 6.48% in 2008 to 23.15% in 2020.13 Notably, education was closely associated with health literacy, as the proportion with college or higher educational attainment gradually increased in China from 3.6% in women and 5.8% in men in 2000 to 18.2% in women and 19.0% in men in 2020.14 Future investigations are warranted to quantify the subsequent improvement in cardiovascular health in the Chinese population.
Besides universal social determinants, China has unique socioeconomic determinants of the CVD burden. Use of solid fuel is an important one, which is less well studied. As a common source of household energy in China and many other low and middle income countries, solid fuel is a family or community level indicator of socioeconomic status, reflecting the cooking and heating style closely related to the economic development and energy source. One nationwide prospective cohort study which recruited 271 217 participants from five rural areas across China found that using solid fuel for cooking and heating was associated with an increased risk of cardiovascular and all-cause mortality in rural China.15 Other evidence from the China Kadoorie Biobank showed that in urban China, the excess risks of all-cause and cardiopulmonary mortality from use of solid cooking fuels decreased by more than 60% five years after cessation, and good ventilation could also reduce CVD mortality even among people who persistently use clean fuels.16 Notably, the associations between solid fuel use on CVD and mortality were independent of traditional risk factors, including lifestyle, socioeconomic indicators, and stove ventilation.1516
Healthcare system and cardiovascular health
Aside from the socioeconomic status of an individual, a healthcare system that promotes delivery of efficient and high quality healthcare and optimises healthcare accessibility and affordability is of crucial importance in achieving population cardiovascular health.
Healthcare accessibility
Healthcare accessibility, namely the convenience and opportunity for individuals or communities to access and use healthcare services, is an important social determinant. Understanding the intricate relation between accessibility and health is crucial, considering its profound impact on the wellbeing of a population.17
Accessibility is influenced mainly by the structure of the healthcare system in a country or region. The publicly funded National Health Service in the United Kingdom since 1948 exemplifies a model of universal healthcare coverage, efficiently tackling nearly 95% of healthcare needs with 10% of the national gross domestic product (GDP). In contrast, the United States has a market driven healthcare model, incorporating both private and public insurance, allocating over 18% of GDP to healthcare but facing persisting inequalities, especially for racial and ethnic minorities. China’s healthcare system has undergone radical transformation over the past decades aimed at improving quality, accessibility, and equality, yet challenges persist, notably in inequalities in access to healthcare resources in rural and urban areas (fig 2).
Numbers of hospital beds, healthcare staff, practising physicians, and registered nurses per 1000 people from 2004 to 2021 in urban and rural China.14 Note, the downturn in medical resources within urban areas from 2020 to 2021 is linked to national directives regulating hospital scale, the covid-19 pandemic, and the widespread adoption of internet based healthcare facilities
Firstly, substantial inequalities in the availability of medical and healthcare resources were evident in 1999, with urban areas having 3.49 hospital beds per 1000 people compared with only 0.8 beds per 1000 people in rural areas —a nearly fivefold difference. Similarly, the number of healthcare staff per 1000 people was 5.17 in urban areas and 1.45 in rural areas, resulting in a nearly 3.6-fold difference.14 By 2021, the number of hospital beds had increased overall to 6.70 per 1000 people, with urban areas having 7.47 beds and rural areas 6.01 beds per 1000 people.14 Additionally, the number of healthcare staff improved overall to 7.97 per 1000 people, with 9.87 in urban areas and 6.27 in rural areas.14 This indicates a considerable narrowing of the urban-rural gap in healthcare resources in China. Since 2017, the annual growth of hospital beds has slowed, mainly the result of national policies controlling hospital development.
Secondly, urban-rural inequalities persist in timely healthcare access, crucial for tackling CVD. In 2008, 4.2% of households took over 30 minutes to reach medical facilities: 0.7% of households in urban areas compared with 5.7% in rural areas. An estimated 59.76 million people in China lack timely medical access, largely in rural areas (70%, or 44.35 million people). Efforts to improve accessibility have shown progress, with the proportion of households taking over 30 minutes in 2018 reduced to 1.3% (0.6% in urban households compared with 2.1% in rural areas).18
Thirdly, accessibility of quality care is what matters. In China, the historical dual economic structure and the policy in favour of urban areas have resulted in substantial inequality in allocation of healthcare resources. In the 1950s, the famous barefoot doctor programme was initiated to tackle rural healthcare needs by training paramedics. Economic growth during the 1980s spurred increased healthcare expenditure and a gradual phasing out of the barefoot doctor programme. Subsequent initiatives, such as the family doctor system in the 1980s to 1990s and the 2009 proposal for a tiered healthcare system sought to promote a more rational development of the healthcare system.19 Management led by non-physician, community healthcare providers has also been effective in reducing CVD and deaths.20 While these systems have had some success in improving primary healthcare, chronic disease management, and the efficient use of medical resources, more effort is needed for better resource allocation, enhancing doctor training, and improving the quality of medical services.
Guided by the National Health Commission, the establishment of national chest pain centres and stroke centres, aligned with the Healthy China Action Plan 2030, signals a new round of extra initiatives. Following accreditation of the chest pain centre, there was a 22% decrease in major adverse cardiovascular events and a 29% reduction in all-cause mortality among patients with acute myocardial infarction.21 Stroke centre certification resulted in a doubling of thrombolysis rates, with a 50% decrease in complications in hospital and a 30% reduction in the three month disability rate.22 The metabolic management centre has considerably improved control of glycated haemoglobin A1c levels, indicating a positive impact on diabetes management and the potential to enhance overall cardiometabolic healthcare quality in the future.23 Financial constraints, workforce shortages, and infrastructure limitations are big challenges that need to be tackled to ensure the long term success and impact of these initiatives, particularly in rural and underserved areas.
Healthcare affordability
Healthcare affordability refers to the ability with which a person or organisation can afford or pay for the costs of healthcare services.24 Total health expenditure in China, including government, social, and out-of-pocket health expenditure as a percentage of total GDP increased from 5.03% in 2009 to 6.43% in 2018,14 although it is still below the world average.25
As part of social health expenditure, comprehensive healthcare insurance is important in achieving wide affordability in healthcare. By 2011, China achieved near universal medical insurance coverage for its 1.4 billion population. To safeguard equal healthcare, in 2016 the New Rural Cooperative Medical Scheme merged with the Urban Resident Basic Medical Insurance to improve equity in health insurance benefits between rural and urban areas. The China Health and Retirement Longitudinal Study reported that the merging has considerably improved benefits such as the amount of compensation and reimbursement ratio for rural residents, particularly those in western China.26 In addition, during the latest round of healthcare reform, China’s government health expenditure has more than tripled, increasing from ¥482bn (£52bn; $67bn; €61bn) in 2009 to ¥1640bn in 2018, and the percentage of out-of-pocket expenditure accounting for total health expenditure dropped from 37.5% in 2009 to 28.6% in 2018.14
For CVD, the total expenditure in China in 2018 was ¥597.6bn, accounting for 16.92% of all disease expenditure. The basic medical insurance covered ¥331.2bn for the treatment of CVD, ranking top among all disease types. Out-of-pocket expenditure accounted for 23.95% of the total expenditure for CVD management.27 These numbers highlight the enormous burden management of CVD places on the healthcare system. Therefore, aside from increasing government and social financial investment, other methods are needed to improve healthcare affordability for CVD in China, such as primary healthcare and CVD prevention.
Notably, less than 11% of CVD medical expenditure occurred in primary healthcare settings in China.27 Even for diseases such as hypertension, one of the commonest conditions for people to consult a primary care physician about, only a quarter of medical expenditure for treatment occurred in primary healthcare institutions. Barriers may include insufficient and underqualified primary healthcare personnel and equipment and patients’ low trust. Improving the primary healthcare system is essential for building an affordable healthcare system. The Chinese government has substantially increased funding for primary healthcare as part of the new healthcare reforms, but many challenges still lie ahead—for example, the suboptimal training of primary healthcare providers and their preference for testing and treatment over prevention. These challenges call for fundamental reforms to improve continued education and training, and to build a system incentivising high quality and high value preventive care.28
CVD prevention achieved largely by population methods, such as health education and promotion and creation of a healthy environment and agriculture, could benefit people unselectively. For example, studies of hypertension show that it may cost ¥125m a year to fill the awareness gaps in Chinese adults aged 35-75 years, but achieving that goal, by health education and population screening and so on, could save ¥486m annually from treating cardiovascular diseases and increase productivity worth ¥2691m a year.28 Meanwhile, nutrition is an important driver of cardiovascular risk. The successful implementation of the national salt reduction programme has considerably reduced cooking salt intake, leading to a decreased prevalence of hypertension in Chinese adults since 2010.29 In particular, efforts are needed to increase the awareness and control of cardiovascular risk factors in people in rural areas or minority ethnicity, and in people without employment.30
Other social determinants and cardiovascular health
Emerging evidence from the US has shown that factors such as neighbourhood environmental burden31 as well as social and community determinants of health, such as community engagement, social support, and cultural beliefs and related behaviours,32 also showed significant associations with health outcomes, including CVD. Although the characteristics of these social determinants may vary between the US and China, these investigations underline the need to elucidate these relations in China.
Furthermore, it is important to note the influence of industry on health outcomes, which constitutes an often overlooked but crucial aspect of social determinants independent of socioeconomic status. For example, the tobacco and alcohol industries have considerable economic influence and benefit from low tax rates and ineffective package warnings in China. Additionally, public awareness and institutional mechanisms have not yet fully tackled the impact of the food industry (eg, sugar sweetened drinks and ultra-processed food) on food safety and healthy food governance.33 Effective policies are required to tackle the adverse influence of industry, including implementing taxes for tobacco and alcohol, improving hazard warnings on tobacco and alcohol labels, refining food nutrition labels, and restricting the marketing of unhealthy foods to vulnerable populations, which warrant the involvement of nearly all sectors well beyond health.
Conclusions and recommendations
More than half of cardiovascular health is determined by social factors. China has made considerable efforts to tackle the social determinants of CVD over the past two decades through various means, including enhancing socioeconomic status, healthcare systems, and so on. However, there remains substantial room for improvement, and prioritising social determinants on the national agenda is crucial. This necessitates implementing comprehensive strategies dealing with immediate health concerns and the underlying social determinants. Initiatives should focus on reducing urban-rural inequalities, enhancing healthcare access in underserved areas, and tackling socioeconomic inequalities related to cardiovascular risk factors. By wisely mapping our efforts and resources, we can establish a more equitable and inclusive healthcare system that empowers individuals, promotes preventive measures, and ensures timely and affordable access to cardiovascular care for all.
Key messages
Socioeconomic status influences CVD in China through complex pathways, including educational inequalities, regional variations, and lifestyle determinants such as solid fuel use
Rural-urban inequalities in allocation of healthcare resources, including hospital bed capacity, healthcare personnel, and timely medical accessibility, persist but have gradually decreased
Establishing national standardised cardiometabolic disease centres has effectively enhanced medical capabilities and raised the overall quality of cardiometabolic healthcare
Near-universal medical insurance coverage highlights the considerable progress made towards health equity in China, although geographic gaps in healthcare affordability may continue to impact cardiovascular health inequalities, emphasising the need for ongoing reform
Footnotes
Contributors and sources: GN had the idea for the article; JL, YX, YB, TW, and RZ did the literature searches. All authors contributed to the writing of this manuscript and have reviewed and approved the final version. JL, YX, and YB contributed equally and are joint first authors.
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; externally peer reviewed.
This article is part of a collection on chronic diseases in China funded by the Chinese Center for Disease Control and Prevention, Beijing Hospital, and the authors and their institutions. The BMJ commissioned, peer reviewed, edited, and made the decisions to publish these articles. The lead editors for The BMJ were Jin-Ling Tang and Di Wang..
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