As legend goes, in the 1980s Chinese leader Deng Xiaoping said: “to get rich is glorious”. This was very much the aspiration of a poor country that hoped to become rich. What should we make of this same country that, some 30 years later, no longer aspires to be rich, but to be healthy instead? The Chinese government’s Healthy China 2030 plan is big on health goals and sweeping in its view of how the country needs to fundamentally re-imagine what it means to be healthy.
Yet, in its need to formalize a goal for a healthy nation, the planning document acknowledges how much ground must be covered for China to meet its many fundamental challenges and reach the self-imposed deadline. The World Health Organization (WHO)’s own review of this plan pointed out that “this document is the first medium to long-term strategic plan in the health sector developed at the national level since the founding of China in 1949”. Even for a country with a strong history of setting and reaching impressive goals, this represents one of its most symbolically potent aspirations yet. Certainly, the leaders in Beijing who crafted this policy document understand that the mere act of acknowledging the need for a healthy country, coupled to this particular set of aggressive goals, carries with it risks should China come up short.
The plan acknowledges problems that everyone in China lives with on a daily basis: polluted water, air and food supplies; rising rates of cardiovascular and neurovascular diseases; and heightened rates of the most insidious forms of cancer. The country’s rapid modernization prioritized economic gains with the belief that public health outcomes would follow. Few would argue with the way China sequenced these aspirations. What many question, however, is how long it took the government to address the problems that have persisted. The environmental impact of China’s economic growth already begs the question of what the ultimate trade-off will be for both the government and individuals. Into this uncertainty steps the Healthy China 2030 plan.
However, there are five factors that could limit China’s ability to achieve the goal it sets out in the plan:
Goals such as the per-capita increase in the number of physicians, a decrease in out-of-pocket payments and aggregate public and private sector spending will only be possible if China’s economic growth continues, and if the government continues to be able to direct limited tax monies towards social and health services. It can’t afford to continue propping up inefficient state-owned enterprises or various other bad-debt-related concerns if the country is going to continue to make significant new investments across China’s healthcare system.
However, one theme running through the plan that can address this is that China’s public policy apparatus will consider – and ideally put at the center – healthcare concerns when making decisions as disparate as city and building design, activity programs for children in school, or simple government-led dietary recommendations.
As geopolitical analyst Tom Barnett has written, “no country in the history of mankind will get as rich, or as old, as fast as China will”. Getting old is a demographic certainty, but getting rich or healthy is not. China’s rapid aging is complicating its economic goals because it’s happening precisely as the country enters the middle-income trap.
The impact of these trends can be assuaged by the plan’s promotion of more preventive medicine and the goal of driving operational efficiencies from within the state-run portion of China’s healthcare system.
Driving growth from health
China must get healthcare inputs – clinics, hospitals, medical devices, biotech and healthcare information technology (HIT) – to become meaningful drivers of economic growth rather than costs that add further headwinds to the 2030 health goals. Its regional economic competitors – South Korea and Japan specifically – have struggled with how to best adjust their approach to innovation around healthcare inputs without driving up public expenditure to unsustainable levels. In these two countries’ recent experience, past policies that emphasized healthcare, biotech and HIT innovation have been forced to come to terms with economic reality, as evidenced by changes to pricing and reimbursement policies and IP practices that attempt to accelerate the public’s ability to access and afford specific types of innovation.
The Healthy China 2030 plan does, though, look to accelerate reforms that relate to access, affordability, quality, and innovation. The continued opening of healthcare to the private sector, as well as creating, channeling and consolidating healthcare date in order to help make public policy decisions, will be crucial to making the health sector part of China’s economic powerhouse.
A recent study suggested that northern Chinese would live, on average, five years fewer than their counterparts further south, largely because of cardiovascular and oncology risks. What this demonstrates is that China’s 2030 healthy goals need to do more than work at the edges of an increasingly well-off society that wants better healthcare services, more innovative offerings, and a higher quality of life. This sort of life expectancy difference reinforces that China’s healthcare system is going to rapidly encounter a specific, and expensive, set of chronic diseases and types of cancer. The latter represents a major cost driver that will occur at disproportionate rates versus those of other economies.
The plan acknowledges this, and the drive to close the urban-rural divide is one of its main themes. It will continue to expand health services outside of cities and improve rural environments.
Many of the changes reflected in the 2030 health goals reflect pervasive institutional reforms that touch on “deep culture”. Matters such as the role of physicians in society, the social contract between government and the individual, the “red envelopes” (monetary gifts) that persist in the physician to patient encounter, and the perception that quality care is only accessible in Tier 1 cities are all much easier to define in a planning document than they are to remedy in real life.
A year since the plan was announced, it is difficult to gauge progress. The mere fact that the Chinese government has put forward a strategy that redefines what national success means, emphasizing not just economics but public health as well, can only be a good thing. The focus on prevention and the education of children and families about the value of a healthy work-life balance, physical activity or diet will only begin to pay off over the long term. However, the integration of health goals into the public policy agenda and the focus on rural health should see shorter-term changes and, as China’s various critics have learned the hard way, underestimating the country’s ability to set big goals and achieve them has not been a smart bet.