Executive summary
Over the past four decades, rapid urbanisation in China has brought unprecedented
health benefits to its urban population, but has also created new challenges for protection
of and promotion of health in cities. With the shift from rural to urban living, more
people than ever enjoy the health advantages that cities can provide, such as better
access to health services and improved sanitation. For example, the average life expectancy
of male urban residents in 2010 was estimated to be 7·09 years longer than that of
of their counterparts in rural China; urban females lived 6·64 years longer.
1
Other changes associated with rapid urbanisation–including large-scale migration,
ageing, pollution, shifts in diet and lifestyle, and social inequality–have created
new health challenges.
2
For example, about 52% of people over 60 years old lived in urban areas in 2015 compared
with 34% in 2000,
3
thus increasing the burden of senior care in Chinese cities. Non-communicable diseases
have replaced infectious diseases as the leading cause of death among urban residents;
the percentage of years of life lost because of such diseases as a fraction of all-cause
years of life lost increased from 50·0% (95% CI 48·5–53·0) in 1990 to 77·3% (76·5–78·1)
in 2015.
4
Health inequality also increased in urban areas.
5
China has acted to address urban health challenges by passing strict environmental
regulations and investing heavily in urban infrastructure. Major reforms have been
passed to increase the transparency of environmental governance to control pollution
over the short term, while moving to reform whole industries and thus provide long-term
solutions. Programmes like the Hygienic Cities movement have invested heavily in urban
infrastructure to promote health, including major improvements in urban sanitation.
6
China has also increased coverage of and accessibility to health services in urban
areas. In 2016, around 93·8% of the urban population was covered by urban medical
insurance programmes, a substantial increase from 4·1% in 1998 when the programmes
started.7, 8
Meanwhile, cities in China are also testing new strategies for urban health management,
such as China's pilot Healthy Cities project.
9
Management of chronic diseases and mental disorders in cities has improved dramatically
and major progress has been made regarding access to preventive and primary health
services. All these efforts have contributed to the reduction of exposure to health
risks and health improvement in urban China. However, despite these successes, major
gaps remain, including but not limited to an over-reliance on a top-down-approach
to environmental management, a narrow focus on health care in urban health management,
and a scarcity of intersectoral action.
Given that the urbanisation rate in China is predicted to reach 71% by 2030,
10
urban health challenges will continue to emerge and expand. If innovative strategies
are not used to address these issues, they will become major obstacles to the achievement
of improved health and development for millions of people. It has also become clear
that the health sector alone, with its traditional piecemeal approach, cannot effectively
resolve the modern challenges to urban health in China. The country is now in a transitional
period in which the pursuit of economic growth at any cost is being replaced by sustainable
development. In 2013, President Xi Jinping declared China's intention to develop a
so-called ecological civilisation (ecocivilisation), the core principles of which
involve balancing the relationship between humanity and nature. During this transition,
health is recognised as the centrepiece of sustainable development in China, as highlighted
in the Healthy China 2030 plan that was adopted in 2016.
11
As a result, people-centred and health-oriented urban development will hopefully prevail
in China; however, major efforts, political will, and investments will be needed to
put this vision into practice.
The Tsinghua–Lancet Commission on Healthy Cities in China aimed to characterise, understand,
and address urban health challenges in the unique context of China's rapid and dynamic
urban development. Experts from a wide range of disciplines examined environmental
and social determinants of health, identified key stakeholders, and assessed actions
for the prevention, management, and control of adverse health outcomes associated
with the country's urban experience. We conclude that key efforts are needed to combat
urban health challenges in China and these should be unified with the Healthy Cities
movement, which uses a systems approach to urban health management and provides a
clear path to the realisation of the Healthy China 2030 plan.
Actions taken to build healthy cities in China have contributed to global knowledge
on the development of healthy cities in other parts of the world. China's strategic,
simultaneous rollout of diverse trials in different cities—in areas such as health
education and promotion—and its rapid adoption of effective approaches at the national
scale is a valuable lesson for other countries facing rapid urbanisation. Despite
such successes, we believe that there is room for substantial improvement and make
the following five key recommendations.
Integrate health into all policies
China should take advantage of new, human-centred urbanisation strategies. For example,
cities should integrate health into urban planning and design as a first step towards
the integration of health into all policies.
Increase participation
Cities should increase participation by residents, the private sector, non-governmental
organisations (NGOs), and community groups in health management. This increase can
be achieved through investment in community capacity building and engagement with
the private sector.
Promote intersectoral action
To motivate and sustain intersectoral action in the design, building, and management
of healthy cities, cities should develop ways to assess the health effects of urban
management by use of measures that span multiple and diverse sectors.
Set local goals for 2030 and assess progress periodically
Cities should view the health goals specified in the Healthy China 2030 plan as long-term
goals that are achieved through the building of healthy cities. Indicator systems
should be put in place to assess progress and inform the public.
Enhance research and education on healthy cities
To develop new theories and practical solutions, cities should increase investment
and form partnerships with universities, research institutes, and the private sector
to support research and education on the best ways to create healthy cities.
Introduction
Health, defined as “a state of wellbeing emergent from conductive interactions between
individual's potentials, life's demands, and social and environmental determinants,”
12
is a fundamental right of every human being.
13
Good health and wellbeing has been adopted as a key Sustainable Development Goal by
the international community,
14
and although recognition of the importance of health is universal, it is particularly
important in China because the quest for health is deeply embedded in Chinese culture.
The earliest recorded discussion on healthy living is attributed to Zhuangzi (around
369–286 BCE), who stated that to stay healthy one should “conform to nature”. In other
words, health is the result of a lifestyle in which human beings and nature are in
harmony.
15
This philosophy underpins the basic principles of traditional Chinese medicine, which
takes a systems view of health. In traditional chinese medicine, human health is seen
as the consequence of harmonisation between human beings and their environments and
between the various parts of the human body and the focus is on disease prevention
rather than treatment.
16
Concepts from traditional Chinese medicine, such as the maintenance of regular daily
activities (rest, diet, and exercise) and avoidance of negative health effects from
environmental factors (eg, Fengshui) have become essential parts of Chinese culture.
These concepts have much in common with the guidelines for healthy lifestyles promoted
by WHO.
17
Health is increasingly at the centre of China's approach to sustainable development.
Policy makers in China have started to acknowledge that health is not only a fundamental
right but is also the cornerstone for economic growth and development. Economic growth
is not always accompanied by prosperity and can create serious challenges and threats
to the health and welfare of populations;
18
therefore, overlooking the importance of health during development will yield heavy
future costs. For example, the environmental pollution associated with rapid economic
growth has already taken a massive economic toll in China. In 2007 alone, particulate
matter with a diameter of less than 2·5 μm (PM2·5) affected the productivity of about
72 million workers in 30 Chinese provinces, causing an estimated economic loss of
¥346·3 billion (US$44·4 billion, about 1·1% of the national gross domestic product
[GDP]).
19
Total economic losses attributed to the public health effects of pollution from particulate
matter with a diameter of less than 10 μm (PM10) and sulphur dioxide (SO2) pollution
in 74 cities were estimated to be as high as ¥439·8 billion ($70·9 billion, about
2·3% of these cities' GDP) in the first half of 2015.
20
China will also have a massive future burden of non-communicable diseases—most of
which will affect urban areas—that will strain future health systems and limit economic
growth in the country. Total annual premature deaths from such diseases are expected
to increase from 3·11 million in 2013 to 3·52 million in 2030.
21
Between 2012 and 2030, economic losses attributable to five key non-communicable diseases–ischaemic
heart disease, cerebrovascular disease, diabetes, breast cancer, and chronic obstructive
pulmonary disease–will total $23·03 trillion USD,
22
which is more than twice of China's total GDP in 2015 ($11·07 trillion). If urgent
actions are not taken, this epidemic will affect China's capacity to achieve its other
goals for sustainable development.
At the same time, a better educated Chinese urban population has become more health
conscious over the past few decades and has become increasingly concerned about environmental
pollution and health care. The China Urban Life Quality Indicator Survey, which has
been done annually among residents of 38 cities since 2000, found that environmental
issues were one of the top six issues of concern between 2000 and 2006; health care
was among the top six issues for 11 consecutive years.
23
Concerns about environmental pollution and associated health risks over the past decade
mirrored increases in severe PM2·5 pollution. A survey of perceived health risks from
air pollution in Shanghai, Wuhan, and Nanchang found that more than 57% of respondents
were not satisfied with current air quality; 46% of participants expressed anxiety
about exposure to polluted air.
24
Through social media, urban citizens in China are increasingly speaking out on issues
that they believe are affecting their health and wellbeing. Environmental petitions
and complaints have increased by more than 20% annually in recent years and mass protests
for environmental issues are occurring across China.
25
These new trends show a willingness on the part of the Chinese people to break away
from the norm of focusing on economic growth and avoid politics. In response to these
challenges, the central government has proposed the formation of a so-called ecologically
civilised society that actively and structurally addresses these concerns. Local leaders
in China are increasingly under pressure from the central government and the public
to shift from growth-centred development to sustainable development policies that
protect environmental quality and health.
26
The Healthy China 2030 plan released by the State Council of China in 2016 acknowledges
the confluence of health challenges, trends, and the public's health concerns. The
plan lays the foundations for health policy in China over the next 15 years and is
a dramatic departure from traditional strategies (panel 1
). In the past, health was just one of various goals for societal advancement and
the central focus of health management was on the improvement of the health-care system.
27
By contrast, the new plan presents health as the foundation for all socioeconomic
development, calls for the integration of health into all policies, and emphasises
the importance of addressing the environmental and social determinants of health.
Panel 1
Healthy China 2030
The Healthy China 2030 plan was released by the State Council of China on Oct 25,
2016. It specifies that health management in China will focus on the promotion of
healthy lifestyles, optimisation of health services, improvements in health care coverage,
provision and protection of a healthy environment, and development of service industries
in health care.
Health will be highly prioritised in the development of public policy and incorporated
into all stages of policy making. All actions will be guided by four principles: health
first, reform and innovation, science-guided development, and equity.
Health inequality between urban and rural areas and among different regions and population
segments will be addressed through equal access to basic health services. Ultimately,
the goal is to achieve health for all citizens. To achieve this aim, all citizens
will need access to services and health issues at different stages of the life course
will need to be addressed. The plan also identifies specific goals, such as to increase
the average life expectancy of Chinese people to 79 years by 2030 (appendix). Action
items for each focus area, such as to improve health literacy and to strength health
education, are also included.
The successful implementation of this plan will be determined by various political
and socioeconomic factors. Given their large and increasing share of population and
dominance in the political and economic systems, cities are key to the realisation
of a healthy China. Healthy cities will be crucial to the achievement of the ambitious
goals of the plan, as directly acknowledged in the document: “Building healthy cities,
towns and villages is the key to a healthy China”.
11
And yet, because the plan is intended only to provide broad guidelines, these now
need be translated to detailed strategies and specific actions to yield the desired
results.
In this Commission, we examine the challenges and opportunities cities face in building
a healthy China and make specific policy recommendations. In section 1, we detail
why cities are the key to a healthy China. In section 2, we examine major health challenges
and modifiable risk factors in urban China. In section 3, we analyse current practices
for dealing with health challenges in urban China, with a particular focus on the
health outcomes arising from these practices and on remaining gaps. In section 4,
we discuss principles and specific actions that cities in China can adopt to address
these gaps. China is not the only country facing substantial urban health challenges—many
cities in developing countries and emerging economies, particularly rapidly developing
ones, have similar problems. Lessons learned from China could, therefore, benefit
cities in other parts of the world.
Section 1. Cities are key to health management in China
Since the launch of economic reform in 1978, rapid urbanisation has changed China
from an agrarian society into an urbanised society. Because of their dominant role
in Chinese society and the large urban population, cities hold the key to health management
in China.
Urbanisation in China: current status and projections
When China began major economic reforms under the leadership of Deng Xiaoping in 1978,
the country was primarily an agrarian society, with the largest rural population in
the world (about 790 million). China has since had the largest rural-to-urban migration
in human history, with the rate of urbanisation increasing from 17·9% to 56·1%, and
the urban population from 170 million to 771 million, between 1978 and 2015 (figure
1
).
29
China's urbanisation rate is estimated to increase to 60% by 2020, with an additional
100 million people moving from rural to urban areas by that time.
30
In the long term, China's urban population is expected to keep increasing as a result
of pro-urbanisation development policies and the replacement of the so-called one-child
policy with a universal two-child policy in 2016. The total urban population is likely
to reach 1070 million by 2030.
10
Figure 1
Total population, urban population, and total built-up area, 1978–2015
Source: National Bureau of Statistics of China.
28
Notably, rates of population increase have been unequal across Chinese cities. Megacities
such as Beijing, Shanghai, Guangzhou, and Shenzhen have the fastest rates of growth,
while cities in northeast China show a net loss of population (appendix). These regional
disparities in population growth will probably continue. Population density is predicted
to peak in Beijing (at 25% higher than 2010 densities) and Shanghai (at 36% higher
than 2010 densities) around 2030.
31
In line with this population growth, the number of cities in China has increased from
193 in 1978 to 656 in 2015. Panel 2
shows how cities are defined in China. Simultaneously, the total built-up area in
China increased from less than 10 000 km2 in 1978 to about 52 100 km2 in 2015 (figure
1), reflecting the vast scope of the construction of new cities and the expansion
of existing ones.
35
The fastest rates of urbanisation have been in eastern China, where the built-up area
in 9 cities increased by more than 20-times between 1990 and 2010.
36
Panel 2
Definitions of major geographic terms used in this study
•
City can be translated as Shi (市) or Cheng Shi (城市) in Chinese and they refer to different
geographic units.
•
Shi (市) refers to an administrative division and in China there are four types: municipalities
directly under the central government (Zhi Xia Shi [直辖市]), of which there are four
(Beijing, Shanghai, Tianjin, and Chongqing); vice-provincial city (Fu Sheng Ji Shi
[副省级市]), of which there are 15; prefecture-level city (Di Ji Shi [地级市]), of which
there are 276; and county-level city (Xian Ji Shi [县级市]), of which there are 361.
Each Shi (市) is responsible for urban and rural areas in its boundary.
32
•
Cheng Shi (城市) refers to an urban area, including urban districts and townships. Urban
districts are continuous built-up areas in city districts, seats of districts, or
cities that do not have city districts. Townships are continuous built-up areas in
county seats and towns. In urban districts and townships, residential committees are
the basic administrative unit of governance.
33
•
The urban population is the number of people who live in urban areas.
•
Urban agglomeration is a spatially compact, economically highly integrated cluster
of cities. Such clusters centre on a mega city, with three or more metropolitan areas
or large cities forming the core region. The core region is connected to peripherals
with highly developed networks for transportation and other infrastructure, within
the reach of a daily commute. China has proposed the development of five national-level
urban agglomerations, nine regional-level urban agglomerations, and six subregional-level
urban agglomerations.
34
Urbanisation in China has been driven mainly by industrialisation, which led to a
long period of thriving economic development. Between 1990 and 2014, the industrial
sector has been responsible for an increase of at least 40% in GDP
37
—more than any other sector in China—making it the most important sector for driving
economic development and urbanisation in this period. Migrants from rural areas provide
the labour force that is required for rapid industrialisation and urbanisation in
China. In fact, it is the migration of 226 million rural residents to urban centrer
between 2001 and 2010 that has dominated the increase in the country's urban population
over the past 40 years of rapid urbanisation.
38
According to the latest survey by the National Bureau of Statistics,
39
which examined 445 Chinese cities, there were 137·4 million migrant workers and 39·1
million family members of migrant workers living in urban areas at the end of 2015.
Most migrants (61·3%) lived in east China, with the remaining migrants split among
central (16·4%), western (19·5%), and northeastern (2·8%) China. About 59·9% of rural
migrants lived in cities with more than 1 million residents.
39
Migrant workers are expected to continue to contribute to the growth of the urban
labour force through to 2030, with an estimated 6 million new migrant workers leaving
rural areas for cities each year between 2013 and 2030.
40
Although cities, especially large cities, are projected to continue to attract migrants,
provinces in central China are likely to keep supplying migrants to more developed
regions.
31
China's urban population is rapidly ageing while it grows. The Fourth National Survey
on Urban and Rural Elderly in China showed that by 2015 about 52% of people older
than 60 years were living in urban areas, compared with 34% in 2000.
3
Developed cities tend to experience ageing populations earlier than less developed
cities. For example, Shanghai first surpassed the threshold where 10% of its population
was older than 60 years in 1982 (when the national figure was just 5%);
41
whereas Beijing did not reach this threshold until 2000. Within megacities, the ageing
population also showed a tendency towards suburbanisation, with seniors moving from
the centre of the city to its edge and from outer suburbs to the urban fringe.
42
The rapid ageing of the urban population in China is the result of improved socioeconomic
conditions in combination with unique and intensive government interventions in population
planning, namely the late, long, and few and one-child policies, which led to a 70%
decrease in fertility rate in less than 20 years. The former policy was introduced
in the early 1970s and promoted delayed marriages, long intervals between childbirths,
and fewer children. The one-child policy was launched in 1979–80 and restricted most
urban couples to one child each.
43
Improved socioeconomic conditions in urban areas contributed to longer life expectancy.
The average life expectancy of male urban residents in 2010 was estimated to be 7·09
years longer than that of their rural counterparts, with female urban residents living
6·64 years longer.
1
Even with the shift in January, 2016 away from the one-child policy to a universal
two-child policy, ageing of the Chinese population is projected to continue. It is
estimated that the percentage of people aged 65 years or older will increase to 18–20%
of the total population by 2030.10, 44 The pace of population ageing in China has
been even faster than that in most developed countries.
45
Projected fertility rates and expected population age structures show that, in the
decades to come, most older people in China will live in urban areas. By 2030, around
207 million people aged 65 years or older are projected to live in urban areas, compared
with 52 million in 2010; 93 million people will live in rural areas by 2030, compared
with 67 million in 2010.
10
The ageing urban population poses a serious challenge to the management of urban health
in China.
Cities hold the key to a healthy China
Two defining factors underscore the role of cities in the creation of a healthy China.
First, the health of 771 million urban residents is, naturally, a major element in
the achievement of national health goals. Second, cities are best positioned to implement
comprehensive health management in China.
Cities play a dominant role in Chinese society, not only because most of the population
are urban dwellers but also because cities have substantial political and economic
power. For example, in 2013, five national-level urban agglomerations (Beijing–Tianjin–Hebei,
Yangtze River Delta, Pearl River Delta, Yangtze River Mid-reach, and Chengdu–Chongqing)
accounted for just 9·1% of total land area in China but contributed half of GDP and
had 65% of total foreign direct investment.
46
Meanwhile, the income gap between urban and rural dwellers is widening. The ratio
of per capita disposable income in urban areas to that in rural areas has increased
from about 2·57 in 1978 to 2·73 in 2015.
28
Given the increase in urban population over the same period, this has led to a growing
share of national household wealth in urban areas.
Since 1978, when the central government devolved political and economic power to cities
following economic reforms, cities in China have had broad administrative resources
that allow them to form local development strategies, set local taxation rates, and
control the use of urban land.
47
This decentralisation of power gives cities autonomy in the promotion of economic
development but also enables them to delay or block the implementation of central
governance reforms that are deemed incompatible with local development goals.
48
Although regional governance arrangements, such as the development of urban agglomerations,
have re-emerged in response to pressure from provincial governments and the central
government, these efforts have primarily aimed to enhance coordination among cities
in development and are unlikely to change the dominant role of cities in local governance.
49
In parallel with their increasing social influence and political and economic power,
cities in China have been going through a transformation of living standards, with
major consequences for population health and wellbeing. Cities can offer considerable
advantages over rural areas in terms of the provision of clean water, rapid transit,
sanitation, education, health care, and other public services.
50
For example, in 2015, the number of medical practitioners (including assistant medical
practitioners), per 1000 residents in urban areas was 3·72 compared with 1·55 in rural
areas, nurses 4·58 versus 1·39, and hospital beds 8·27 versus 3·71.
51
According to multiple measures, cities in China benefit from improved health care
and social development; most notably, substantially increased life expectancy. In
2010, life expectancy for urban male residents was 74–81 years across China's provinces
compared with 67–74 years for rural male residents. Similarly, urban female residents
had a life expectancy of 77–84 years compared with 69–78 years for rural female residents.
1
Data from the past three national censuses (1990, 2000, and 2010) and a 1% sample
census in 2015 show that the positive correlation between average life expectancy
and the proportion of urban population at the provincial level became stronger as
the latter increased (figure 2
).
Figure 2
Life expectancy and proportion of urban population in each province, 1990, 2000, 2010,
and 2015
Source: National Statistical Bureau of China.28, 29
However, the health and social advantages enjoyed by the urban population in China
are challenged by the various consequences of China's rapid urban development, including
a massive and ageing urban population, environmental pollution, large-scale internal
migration, lifestyle changes, and rising social inequality.52, 53 Health-care systems
in urban China are particularly strained by growing urban populations,54, 55 rapidly
increasing prevalence of non-communicable diseases,
4
and rising health inequalities (with respect to disease burdens and life expectancy).5,
56 These trends represent cracks in the foundation of health and wellbeing in Chinese
cities that need urgently to be addressed.
To deal with these challenges, policies and actions that tackle social and environmental
determinants of health will be required. Under China's unique governance structure
(figure 3
), cities are the most suitable entities to implement the new comprehensive health
policies specified in the Healthy China 2030 plan. Although, in the past, health management
policy focused on health care (making it largely the business of the health sector),
cities in China are uniquely equipped to drive health care forward because future
strategies will require a focus on a much broader set of social and environmental
determinants, which are clearly beyond the scope of what the health sector can accomplish
alone. In urban China, health departments sit at the same level in the governance
structure as other municipal departments. Because departments compete for authority
and resources to meet their individual goals, it is difficult to establish effective
interdepartmental collaborations across sectors.
57
Thus, city-level governments uniquely possess the required political power, economic
and human resources, and institutional structures to implement the new health policies.
Cities already allocate the largest portion of public health investment; for example,
the split of public expenditures on health in 2011 was 10:20:70 for national, provincial,
and city (including prefecture-level and county-level expenditures) levels.
58
These resources will be key to the achievement of future gains in health in China,
particularly because many health issues, such as those associated with infectious
diseases, can only be tackled through coordinated actions across the urban–rural spectrum.
59
Cities are often better positioned to start and lead such efforts because China's
governance system has historically used cities to control the countryside.
60
Figure 3
Governance structure relevant to urban health management
Municipal governments at or above the prefecture and district or county levels consist
of bureaus that are responsible for different aspects of city life. Sub-district offices
are branches of district or county governments. Residential committees are self-governance
organisations that allow for some sovereign decision making on community issues. All
levels work together in a linked governance network.
Section 2. Major challenges to urban health in China
Cities in China are facing many health challenges caused by the fast-paced changes
in lifestyle and environments associated with urbanisation. In particular, non-communicable
diseases, emerging infectious diseases, injuries, mental disorders, and the need to
provide care for a rapidly ageing urban population are eroding the urban health advantage
to city residents. At the same time, cities need to keep control of rising healthy
expenditure and reduce health inequity.
Non-communicable diseases
Status
In China, non-communicable diseases have replaced communicable diseases as the primary
contributor to overall disease burden. Cardiovascular diseases, cancer, and respiratory
diseases were among the leading causes of early death in 2015.
4
Non-communicable diseases are becoming more prevalent because rapid ageing of the
population increases the pool of susceptible older adults, treatment advances prolong
life, and lifestyle and environmental changes increase risks.
Cardiovascular diseases
Stroke has been consistently ranked as the top cause of death in China in three Global
Burden of Disease studies4, 61, 62 since 2010. Other cardiovascular diseases, such
as ischaemic heart disease, are also among the top ten causes of death, and mortality
caused by coronary heart disease is rising. In 2013, the mortality rate for cardiovascular
diseases among urban residents in China reached 259 per 100 000 people, accounting
for 41·9% of all-cause deaths, which was a 69% increase in mortality from 2003 (174
per 100 000 people).
63
Cancer
Cancer is a major public health problem and has been the leading collective cause
of death in China since 2010.
64
Cancer incidence and cancer-related mortality in urban China have both changed in
recent decades (figure 4
). At the national level, the number of cancer-related deaths in 22 cancer registries
increased substantially from 51 090 in 2000 to 88 800 in 2011 (a 78% increase).
64
The estimated age-standardised incidence rate in urban areas increased from 135 per
100 000 people in 1989 to 149 per 100 000 people in 2008, with the greatest increase
seen between 2000 and 2008.
65
The rise in overall cancer incidence is significant in the more industrially developed
east China and larger cities, especially for lung, colorectal, and breast cancer.
66
There were mixed trends in cancer-related mortality: although mortality caused by
cancers of the stomach, oesophagus, nasopharynx, and cervix uteri decreased, lung
and breast cancer mortality increased between 1987 and 2009.
67
In urban China, the 2015 age-standardised estimate for all-cancer incidence was 192
per 100 000 people and for all-cancer mortality was 110 per 100 000 people.
64
Figure 4
Total cancer mortality, 1990–1992 and 2013
1990–92: (A) men and (B) women. 2013: (C) men and (D) women. The inset shows the islands
of the South China Sea. Source: National Cancer Center of China.
Respiratory diseases
It was estimated that the prevalence rate among adults (>18 years) in urban China
in 2013 was 3·32% (95% CI 3·17–3·47) for chronic obstructive pulmonary disease, 2·01%
(1·90–2·13) for asthma, and 0·61% (0·55–0·68) for asthma–chronic obstructive pulmonary
disease overlap syndrome.
68
Children bear a substantial burden of respiratory disease. Prevalence of asthma among
children younger than 14 years increased from 1·6% in 2000 to 2·1% in 2010 in 33 cities,
with children aged 3–6 years having the highest prevalence in both years and onset
before 6 years old seen in nearly 80% of cases. This increase in prevalence was mainly
observed in megacities, provincial capitals, and eastern coastal cities.
69
Children are at risk from not only ambient air pollution but also indoor air pollution.
A 2008–09 survey
70
of 31 049 children aged 2–14 years in seven cities in northeastern China showed that
recent home renovation and polyvinyl chloride flooring projects contributed significantly
to respiratory symptoms and asthma.
Diabetes
In 1994, China conducted a national survey on diabetes in 19 provinces and municipalities
according to the WHO standard; the results showed that diabetes prevalence among urban
adults (25–64 years old) was 2·9%.
71
The 2010 study
72
of non-communicable disease surveillance in China found the age-standardised prevalence
of diabetes for urban residents older than 18 years to be 14·3%. In 2013, this value
decreased slightly to 12%.
73
However, 47% of the urban adult population was estimated to have either diabetes or
prediabetes, which is only slightly lower than the estimate (49–52%) for the US population.
74
The speed at which urban populations in China are catching up with their counterparts
in developed countries with respect to such health risks is alarming.
Risk factors
The rising incidence of non-communicable diseases and mortality related to these diseases
in urban China has been attributed to demographic, environmental, and lifestyle changes
caused by economic growth and rapid urbanisation, including ageing population, environmental
pollution, low levels of physical activity, unbalanced diets, smoking, and alcohol
consumption.63, 66, 75
Air pollution
Air pollution is the most challenging environmental issue faced by cities in China.
According to the 2016 Report on the State of Environment in China,
76
only 84 (25%) of 338 cities reached the target enforcement levels in 2016. Over the
past decade, concentrations of PM10, SO2, nitrogen dioxide (NO2), and PM2·5 have started
to decrease, although ozone (O3) concentrations continue to rise. These trends reflect
China's commendable efforts to mitigate SO2, nitrogen oxides (NOx), and primary fine
particle emissions. Efforts to control volatile organic compounds emissions have been
somewhat successful,77, 78, 79, 80 as shown in figure 5
.
Figure 5
Annual concentrations of major pollutants in 31 major cities, 2003–12
Theil-Sen estimator and corresponding 95% CIs are represented by dots and lines. Source:
data for PM2·5 were obtained from satellite-derived products and other data were from
China Statistical Yearbook of Environment 2003–12.
81
PM2·5=particulate matter with a diameter of less than 2·5 μm. PM10=particulate matter
with a diameter of less than 10 μm.
Urbanisation is undeniably linked to the increase in air pollution in China. PM2·5
concentrations in urban environments are highly correlated with urban population,
with larger cities generally having worse PM2·5 pollution than do smaller cities.
82
The dramatic increase in the use of coal for power generation and industrial and domestic
heating is one of the key causes of this pollution.
83
In 1970, China produced less than 10% of the world's coal, but that figure increased
to nearly 50% by 2012.
84
Coal combustion generates substantial pollution, contributing 90% of SO2 emissions,
70% of dust, and 67% of NOx emissions in China.
85
Coal consumption in China will gradually decrease in the coming decades because of
the slowing economy and the adoption of clean technologies. The International Energy
Agency predicted that coal demand in China will decrease by 15% for 2016–40 but that
the share of coal in the power mix will still be about 45% in 2040.
86
Rapid urbanisation is also linked to the drastic increase in the ownership of private
vehicles and a surge in the use of diesel trucks.
87
Nationwide in 2006, vehicles are estimated to account for 24% of national NOx emissions,
29% of non-methane volatile organic compounds, and 20% of carbon monoxide (CO) emissions,
with even higher fractions in urban areas.
88
It is often overlooked that most of urban dwellers' exposure to ambient pollution
occurs indoors.
89
Because people spend most of their time indoors, indoor air pollutants can cause substantial
damage to health.
90
Volatile compounds, including 1,3-butadiene, formaldehyde, 1,4-dichlorobenzene, and
benzene, are indoor air pollutants that are significantly associated with increased
cancer risk among Chinese urban working men (2·93 [95% CI 1·65–4·71] additional cases
per 10 000 people exposed) and women (2·27 [1·27–3·65] additional cases per 10 000
people exposed); 70% of the increase in risk is due to exposure at home.
91
These compounds are released from building materials and decorative products, including
plastic furniture and home decorations, polymeric floor and wall coverings, synthetic
wood products, and synthetic cleaning agents.90, 92 Indoor heating and cooking with
coals and biomass are also important sources of particulate matter and CO in some
urban residences in regions that need heating in winter and in less economically developed
regions.
93
Throughout cities in China, lung cancer has increased with worsening air quality.
According to the National Central Cancer Registry, 348 107 (57·5%) of 605 946 new
lung cancer diagnoses in 2010 were in people who came from urban areas. The age-standardised
incidence rate in urban areas (36·4 per 100 000 people) is also higher than it is
in rural areas (33·3 per 100 000 people).
94
Air pollution directly affects cardiovascular diseases. A nationwide time-series analysis
done in 272 cities between 2013 and 2015 showed that each 10 μg/m−3 increase in daily
concentrations of PM2·5 was associated with increments of 0·27% in mortality from
cardiovascular diseases, 0·30% from coronary heart diseases, and 0·23% from stroke.
95
Worsening air quality also contributes to increasing mortality from respiratory disease.
It has been estimated that an increase of 10 000 tonnes of industrial SO2 would increase
mortality from respiratory diseases by 0·03 per 10 000 people in 116 prefectural-level
cities, with spatial spillover effects leading to an increase in mortality of 1·54
per 10 000 people in neighbouring cities. For soot emissions, the same increase would
increase mortality from respiratory diseases by 0·07 per 10 000 people, with spatial
spillover effects also leading to an increase of 4·12 per 10 000 people in neighbouring
cities.
96
The overall toll of air pollution on the health of urban residents of China is substantial.
According to the latest estimate by WHO,
75
ambient air pollution in cities led to an age-standardised death rate of 70 per 100 000
people in 2012, which is much higher than the worldwide average of 47 per 100 000
people. The loss of disability-adjusted life-years was estimated to be 1546 per 100 000
people.
Water pollution
Surface water and groundwater in urban China are often polluted. In 2016, a water
quality survey of 6124 monitoring wells installed in 225 prefecture-level cities found
that 45·4% of wells were poor quality and 14·7% were very poor quality, according
to Ministry of Environmental Protection standards.
76
Major pollutants of urban water supplies include nitrates, heavy metals, petroleum
hydrocarbons, pesticides, and organic chemicals. The increase in water pollutants
in urban China is mostly driven by industrial sources, thus are a result of economic
growth.
97
These increases are accompanied by emerging problems with organic contamination of
urban water supplies; for example, with hormones, antibiotics, surfactants, endocrine
disruptors, human and veterinary pharmaceuticals, X-ray contrast media, and human
metabolites.
98
With respect to provision of safe drinking water for the urban population, China's
issues are compounded: water shortages are widespread and water pollution worsens
these shortages. Two-thirds of cities face water shortages,
99
mainly because of low water availability per person and spatiotemporal mismatches
of supply and demand. Annual water availability per person in China is only 34% of
the world average.
100
To manage the shortage of available water supplies, some cities limit water consumption
on certain days or times, with adverse consequences for industrial output and domestic
life. Cities sometimes switch to lower quality supplies to meet excess demand, with
dire consequences for public health. The 2005 national survey of safety of potable
water sources showed that 638 cities and towns were using sources that did not meet
the drinking water standards, directly affecting 56·95 million people.
101
Although this situation has improved, 86 (10%) of 897 water quality monitoring sites
of potable water sources in prefecture-level cities and above still failed to meet
national standards in 2016.
76
Key contaminants of urban drinking water supplies that have been detected at concentrations
that are harmful to health include nitrates, arsenic contents, and disinfection byproducts.102,
103 These contaminants are associated with increased risk of cancer and skin and kidney
disease.
104
Low levels of physical activity
In China, as in cities around the world, urban residents are increasingly sedentary.
A study
105
on children and youth aged 9–17 years in 11 cities showed that only 22·6% of boys
and 11·3% of girls met the physical activity recommendations of at least 60 min per
day of moderate-to-vigorous physical activity. Similar trends have been seen among
adults in China's cities. Work and domestic physical activity levels of adults fell
by nearly half over 20 years (1991–2011) and were negatively associated with living
in more urbanised areas.
106
Alarmingly, in urban adults participation in moderate or vigorous physical activity
outside of work was as low as 7·9% in the International Collaborative Study of Cardiovascular
Disease in Asia
107
done between 2000 and 2001.
Surveys of urban residents confirm that associations between walkable features of
the built environment and walking—as established through research in other countries–are
also true for China.
108
The proximity of non-residential locations, parks, non-park physical activity facilities,
and pedestrian infrastructure are positively associated with physical activity, while
density of development has negative effects. These negative effects might be explained
by the scarcity of recreational space in high-density developments and a perception
of overcrowding.
109
Rapid urban expansion and an increase in car dependency have exacerbated urban and
environmental challenges to health that mirror those in western cities (eg, substantial
deviations from traditional high-density, pedestrian-oriented and cyclist-oriented
urban areas), including issues like longer commutes, traffic congestion, and air pollution.110,
111 By contrast to the low-density suburbs that are common in some western countries
(eg, USA), emerging suburbs in China's large cities are characterised by high-density
development, with housing in the suburban peripheries and much longer commute times
between home and work, which remains mostly in urban centres.
110
Physical activity is also negatively associated with car ownership and screen time
(ie, time spent watching television or using a computer), but is positively associated
with bicycle ownership and blue-collar jobs.
107
As suburban expansion continues to retreat from urban centres, suburban residents
have long commutes and few public transport options. This trend, combined with the
rising disposable income of urban residents, has resulted in an exponential increase
of cars in cities; the number of cars owned by urban residents increased from 0·17
million in 1984 to 88·4 million by 2012.
112
By 2035, total number of vehicles in China is predicted to reach 565 million, of which
345 million (61%) will be privately-owned cars in urban areas.
113
Screen time is especially important in mediating physical activities among youth,
particularly as high screen time is also associated with depression, anxiety, and
lower satisfaction with school life in urban areas.
114
Unbalanced diets
People in cities have higher food consumption per person and different diets than
those in rural areas. Between 1980 and 2010, urban dwellers derived 46·7% of food
energy from meats, vegetables, and fruits, whereas the rural population obtained most
of their food energy from cereals (71·0%). This disparity is because urban residents
have more disposable income and a greater array of food choices.
115
The urban population also consumes more processed food than the rural population;
the China Health and Nutrition Survey
116
showed that residents in three megacities (Beijing, Shanghai, and Chongqing) got 21·8%
of their energy from processed foods in 2011, compared with only 10·2% in rural residents
in nine provinces.
Tobacco and harmful use of alcohol
Urban residents are more exposed to advertising of tobacco than their rural counterparts
are.
117
In 2015, the prevalence of current tobacco smoking in urban residents older than 15
years was 26·1% (95% CI 23·3–29·1), including a staggering 49% (45·0–53·0) of men
and 2·7% (1·8–3·9) of women. These values did not significantly differ from those
in 2010, when the population-standardised prevalence of current tobacco smoking was
47·5% for urban men and 2·5% for urban women.
117
The prevalence of current smoking in rural men decreased from 56·9% in 2010 to 55·4%
in 2015, while the rate for rural women increased slightly from 2·5% in 2010 to 2·8%
in 2015.
Urban residents in China also maintain high levels of alcohol consumption. The 2010
China Chronic Disease and Risk Factor Surveillance study
118
measured the current drinking rate—defined as having consumed alcohol in the 12 months
before the survey—of urban residents over 18 years at 39·8%, which was higher than
that of rural residents (34·9%). Although the current drinking rate was higher in
urban residents than in rural residents, the harmful drinking rate (ie, >61 g pure
alcohol per drinking day for men and >41 g for women) was higher in rural residents
than in urban residents. In 2010, harmful drinking rate was 7·5% among current drinkers
in urban areas, compared with 10·2% in rural drinkers. The 2013 update of the survey
73
found that the current drinking rate in urban areas was 39·1% (35·4% in rural areas)
and the harmful drinking rate in urban areas was 7·3% (10·3% in rural areas). Drinking
is more acceptable than smoking in Chinese culture. For example, a study in northern
China showed that 41·4% of urban residents and 32·1% of rural residents believe that
alcoholism requires no treatment.
119
The sale and consumption of alcohol are only weakly regulated by the government.
120
Extreme weather events
Urban living is linked to climate-related health risks, such as urban heat island
effects. A study
121
in Hong Kong found that for each 1°C the daily high temperature increased over 29°C,
all-cause mortality rose by 4·1% (95% CI 0·7 to 7·6%) in areas with strong urban heat
island effects, but only 0·7% (95% CI −2·4 to 3·9%) in areas where such effects were
absent. China is projected to become warmer in the 21st century, with the number of
days during which air temperature exceeds 35°C in southern China increasing by 30
by 2050 under a moderate growth scenario (ie, representative concentration pathways
4·5).
122
The associated increase in extreme heat events could have important public health
consequences in cities, especially for vulnerable populations, such as children and
elderly people. Under the representative concentration pathways 4·5 scenario with
medium population growth, heat-related deaths among people older than 65 years in
Beijing would increase by 13·1 times compared with expectations under the baseline
1980s climate. Even with adaptation measures in place, the increase is expected to
be significant.
123
Future climate change is also anticipated to increase risks of other diseases, such
as infectious diseases, mental illness, respiratory diseases, and injuries. In China,
the interaction between climate and risk factors can be acute because of its large
population and the predicted pace of climate change.
124
Metabolic risk factors
Metabolic disorders are major risk factors for cardiovascular disease in China and
are epidemic in the urban Chinese population. A survey
125
of 33 urban communities in northeast China (2009–10) reported an overall prevalence
of metabolic disorders of 27·4%. Male adults with higher education level and higher
family income had a higher prevalence of metabolic disorders than their counterparts
with lower education and family income. Higher levels of physical activity were associated
with decreased prevalence of metabolic syndrome among men. The situation in children
and adolescents is even more worrisome. Between 1991 and 2011, the prevalence of overweight
and obesity in children (aged 6–17 years) more than doubled from 15·7% to 32·7%; in
the same period, obesity more than tripled from 3·6% to 13·7%.
126
This rising trend is more substantial in economically developed regions. Between 1980
and 2010, the prevalence of overweight and obesity increased from 3·8% to 32·6% for
male students (aged 7–18 years) and from 3% to 19·1% for female students in large
coastal cities. Even in the least developed cities, overweight and obesity increased
from 0·7% to 17·6% for male students and 1·2% to 9·4% for female students.
127
High incidence of metabolic disorders also leads to other non-cardiovascular diseases.
For example, fatty liver disease, which is estimated to affect 27% of the urban population,
is related to obesity and metabolic disorders.
128
Obesity also interacts with other risk factors. For example, a study
129
done in seven northeastern cities of China found that obesity increased children's
susceptibility to the adverse health effects of ambient air pollution by amplifying
the association between long-term air pollution exposure and blood pressure.
Infectious diseases
Status
Urbanisation has altered patterns of infectious disease occurrence in China (figure
6
). The incidence of diseases caused by environmental pathogens or carried by environmental
vectors is decreasing in urban areas, mostly because of improved living environments,
investments in infrastructure, advances in treatment and prevention technologies,
and a strong political commitment to infectious disease control.
130
At the same time, the large population, extensive transportation networks within and
between cities, and large-scale rural–urban migration maintain a high risk of emerging
infectious diseases from both domestic and international origins.
131
The trend of mortality from infectious disease between 1990 and 2010 reflect the contrasting
effects of these factors. Between 1990 and 2000, relative risk of mortality from infectious
disease in urban residents (5–89 years old) decreased by 44%; however, the rate in
2010 was almost the same as in 2000 and there was even a slight increase of 14% between
2000 and 2005.
132
Figure 6
National reported incidence (per 100 000 people) of nine infectious diseases in rural
and urban areas in China, 2005–14
Source: China Center for Disease Control and Prevention.
Risk factors
The expansion of modern urban transportation systems can contribute to changes in
the speed and scale of the spread of infectious diseases. In particular, increasing
contact rates among people in crowded urban areas, who are then connected to distant
populations through transportation networks, make pandemic control difficult as conventional
spatial barriers to transmission break down. The booming aviation industry and growth
of international trade and tourism further increase the risk of imported infectious
diseases.
133
For example, a flight from Hong Kong to Beijing on March 15, 2003, is widely regarded
as responsible for the long-distance transmission of severe acute respiratory syndrome,
134
and national highways further promoted the spread of the disease to places adjacent
to Beijing, such as Shanxi, Hebei and Inner Mongolia.
135
Another example is the 2009 outbreak of influenza A H1N1 (swine flu) in China, which
was originally caused by cases imported through international air travel from Mexico;
136
the subsequent domestic spread of the epidemic is thought to have been mostly through
domestic flights and ground transportation (railways and highways). A 50% reduction
in trans-city and local travel would have resulted in an estimated 50·2% reduction
of total cases.
137
International travellers also increase the risk of vector-borne diseases faced by
China, as was the case for the unprecedented 2014 outbreak of dengue in Guangzhou,
which accounted for 52% of all cases in China for 1990–2015.
138
Increasing volumes of rural-urban migration might also exacerbate the threat of infectious
diseases in urban areas. Many migrants live in urban villages, construction sites,
dilapidated private housing, illegal basements, and former underground air-raid bunkers.
139
Crowding and unhealthy living conditions in these environments can expose this group
to a higher risk of diseases (such as tuberculosis) than that of the general urban
population.
59
Crowded living conditions and other socioeconomic constraints can also make it difficult
for migrants to relocate with their spouses. The prevalence of multiple sexual partners
and commercial sex among rural migrants are significantly higher than among non-migrants.
140
Migrants also tend to be less knowledgeable about prevention strategies for sexually
transmitted diseases, thus increasing their vulnerability.
141
Since the early 2000s, urbanisation in China has been associated with rising HIV transmission
in conjunction with a major expansion of the commercial sex industry and high mobility
of female sex workers.
142
By 2014, there were 500 000 reported cases of people living with HIV/AIDS and 160 000
reported deaths. Some social groups are particularly vulnerable; HIV/AIDS among men
who have sex with men is a growing concern, with HIV prevalence at 7·7% in 2014. The
increasing number of illicit drug users in urban China has also increased transmission
risks. Among injection drug users in 2014, the HIV rate was estimated at 6·0%.
143
Since China embraced globalisation and open markets, the use of illicit drugs has
become increasingly prevalent in cities. In 1991, the number of registered illicit
drug users of all types in China was 148 000, but this figure increased to 2·5 million
by 2016.144, 145 Although official statistics do not distinguish between urban and
rural areas, it can be reasonably assumed that the former bear the bulk of the burden.
Injuries and injury-related deaths
Status
Injuries, including road injuries and self-harm, were among the top ten causes of
death in China in 2015.
4
In urban areas, traffic-related deaths were the leading cause of injury-related death,
followed by falls and suicides.111, 146 The standardised death rate caused by road
injuries during 2004–05 was nearly double the 1992 figure. A reduction in injury rates
to those of countries with low injury-related mortality would recover 65% of the life
expectancy lost because of injury in urban China, amounting to a saving of 436·4 million
years of life based on 2005 population counts.
147
The high incidence of injuries in cities has caused substantial economic losses. For
example, the costs of health care, social security and welfare resulting from pedestrian-related
injuries alone in Shanghai were about 13·5% of its GDP in 2006.
148
The burden of injury-associated mortality mostly falls on senior citizens, children,
women, and migrants. In Shanghai, 56·8% of all pedestrian-related deaths for 2001–10
were in people aged 65 or older, with the mortality rate estimated to be 13·61 per
100 000 people.
148
Injury was the leading cause of death of children aged 1–4 years (43·0% of all deaths)
and 5–14 years (50·1% of all deaths) in urban China.
149
Furthermore, in both urban and rural areas, the probability of being injured is higher
for children from poor families than for those from wealthy families.
150
Urban women have lower injury-related mortality than do urban men; the number of injury-related
deaths reported for urban women was 2912–4081 per year for 2004–10, compared with
5733–7734 per year for urban men.
146
Violent injuries to women in urban areas is an increasing and alarming issue, with
prevalence reaching 10·7% (95% CI 7·8–15·5) in 21 cities in 2011. A high male-to-female
ratio, population growth rate, and unemployment rate were associated with increased
risk of injuries caused by physical attacks against women in cities. This situation
is an issue of public health and human rights.
151
Urban migrants experience a higher burden of morbidity and mortality from occupational
injury than do non-migrants. For example, 85% of deaths in the construction industry
were among migrant workers in 2004.
152
Children in migrant households had higher incidence of injury than did children in
resident households. In Guangzhou for 2008–12, the adjusted incidence rate of injury-related
death of children in migrant households was 3·5 times higher than that in resident
households.
153
Risk factors
Injuries and injury-related mortalities in urban China are rising because of increasing
exposure to risk factors, which include the expanding urban population, rising motorisation
rate, intensive construction, and urban development. For example, the high pedestrian-related
death rates among elderly people are partly due to the ageing urban population and
increasing car ownership rate in cities.
148
Large-scale rural-to-urban migration by migrants and their concentration in high-risk
occupations contribute to the high prevalence of occupational injuries among migrants.
152
Besides these factors, natural hazards are a growing risk factor for injuries and
injury-related death in Chinese cities. Although rapid urbanisation and economic growth
have enabled cities to mobilise more resources to prepare for and respond to such
disasters, vulnerability to natural disasters will probably continue to rise in cities
with rapid population growth as a result of poor implementation of urban planning,
construction of low-quality infrastructure and housing, strained social services,
and segmented disaster management systems.154, 155 Large and growing populations live
in disaster-prone regions because of a legacy of restricted regional planning (figure
7
). More than half of the cities in China with a population of more than 500 000 people
are located in areas with substantial seismic risk;
157
dozens of large cities are located in areas where risk of land subsidence is high
or in mountainous zones with high risk of landslides.
154
This situation has occasionally led to major loss of life and property; for example,
the 2010 landslide in Zhouqu, Gansu province killed nearly 1500 people.
158
Figure 7
Cities considered at risk of natural disasters
Natural disasters include storm surges, landslides, cold waves, heatwaves, floods,
and earthquakes. The inset shows the islands of the South China Sea. Source: World
Atlas of Natural Disaster Risk.
156
Poor implementation of urban design can contribute to increased vulnerability. For
example, urban flood damage is becoming more common; between 2008 and 2010, nearly
two-thirds of surveyed Chinese cities (n=351) reported severe flooding and more than
a third had more than three major floods.
159
Major contributing factors included the rapid expansion of impervious surfaces over
natural land, modification of river channels, and difficulty in the development of
flood protection infrastructure because of existing underground structures and high-density
built-up environments.
160
By 2050, the frequency of heavy rainstorms in China might increase by as much as 33%,
further increasing flooding risk.
122
China's coastal cities are especially vulnerable to sea level rises, land subsidence,
and extreme weather. It is projected that these forces will lead to the breaching
of nearly half of the seawalls and embankments in Shanghai by 2100, meaning nearly
half of the city's land area will be at risk of serious flooding.
161
Mental disorders
Status
Urban residents in China are more depressed than ever before. The prevalence of major
depressive disorders in urban adults was 1·7% for 2001–10.
162
Based on the 2012 China National Health and Wellness Survey, the prevalence of mental
health disorders was 6% in urban areas.
163
Highly populated cities along the eastern coast (such as Shenyang and Shanghai) and
cities in west China that have high population densities had poorer depression scale
scores than did other cities.
164
The prevalence of mental health problems is high among migrant workers. For example,
a survey
165
in Shenzhen estimated that 34·4% of migrant workers had mental health problems. However,
only a small portion of people have been diagnosed and treated. For example, only
8·3% of those with a major depressive disorder were diagnosed and of those, just 51·5%
were currently being treated.
161
Rising medical costs are a further economic burden for patients, with the average
annual cost per patient increasing from $1095 in 2005 to $3665 in 2013.
166
Major depressive disorders substantially affect individuals and society. People with
such disorders reported lower health-related quality of life scores and had lower
productivity and resource utilisation.
163
Risk factors
The continued socioeconomic transformations of urban communities, rises in income
inequality, and fading interpersonal trust are leading risk factors of mental disorders.
167
For example, the perception of a connection to one's neighbourhood was shown to have
a strong negative association with severity of post-traumatic stress disorder symptoms
and risk of depression in young adults (15–19 years old) in Shanghai.
168
Among migrant workers, the major risk factors for mental disorders are undesirable
working and living conditions.
165
Other factors, such as drug use, alcohol abuse, and homelessness, have contributed
to the increased prevalence of mental health problems.
162
Caring for urban elderly people
Survey data and self-reported health data highlight a decline in the general health
of elderly residents in China's cities. Nearly half of elderly people have non-communicable
diseases and this trend is predicted to last into 2020.
169
Chronic respiratory disease, cerebrovascular disease, and ischaemic heart disease
are the three largest contributors to the probability of death for people aged 50–75
years.
56
Diseases commonly associated with ageing are also prevalent. For example, according
to a national survey done in 2008–09, the prevalence of dementia in individuals aged
65 years or older in urban areas was 4·4% (95% CI 3·9–4·9) compared with 6·2% (5·5–7·0)
in rural areas. For Alzheimer's disease, prevalence was 2·4% (2·0–2·8) in urban areas
and 4·4% (3·7–5·0) in rural areas. For vascular dementia, prevalence was 1·6% (1·3–1·7)
in urban areas and 1·4% (1·0–1·6) in rural areas.
170
The self-reported health status of elderly urban residents decreased significantly
in China between 2001 and 2013, with mean scores for self-reported physical health
declining from 70·86 (SD 28·08) to 61·46 (23·16) and mental health scores declining
from 75·63 (25·73) to 64·59 (21·76).
171
The increasing health needs of elderly people and dwindling resources are main contributing
factors for declining health among elderly urban residents. According to 2010 census
data, of people aged 65 years or older in urban areas, roughly 78% were classified
as healthy, 18% were unhealthy but able to care for themselves, and 4% required assistance.
Nationwide, the demand for health-care services increased by 15·2% in 2015 compared
with a decade ago. Health expenditure on elderly people as a percentage of GDP increased
from 2·1% in 1993 to 3·4% in 2013.
45
Notably, rising health costs have substantially burdened older people. For example,
the average monthly pension for 79·74 million retired enterprise workers was ¥2200
($354) in 2015.
172
In comparison, an analysis of national household survey data (2007–11) on medical
spending on five major chronic diseases among urban residents, including those aged
65 years or older, found that the annual cost per capita for residents with cardiovascular
disease was ¥8954 (about $1356), and ¥8914 (about $1350) for residents with diabetes.
173
Elderly people in urban China often rely on their families for financial support and
care. Family support accounted for 24% of financial resources for people aged 65 years
or older in 2010. However, increased life expectancy, the one-child policy, and changing
cultural patterns have led to more elderly people to living alone than ever before.
The 2010 census estimated that there were 6·32 million households of people aged 65
years or older who lived alone in urban areas.
45
The situation is more severe in large cities. In Beijing, 50% of empty-nest families
and 80% of healthy retired urban residents live alone.
174
Elderly people who have lost their only child face the greatest challenges in meeting
their care needs. As of 2015, an estimated 1·6 million families in China are in this
situation, a number that is expected to increase to 4·5 million by 2050.
175
The shortage of family care has generated substantial pressure to develop a long-term
care system, consisting of institutional and community care facilities in urban China.
By the end of 2014, there were 16 549 nursing homes in urban areas, providing 2·65
million beds; 1·28 million people used these facilities. Compared with 1978, the number
of nursing homes and people served increased by more than 22 times and the number
of beds increased by more than 2654 times.
176
Despite substantial progress, the long-term care system in urban China still cannot
meet the huge demand. The total number of people who used the system was less than
2% of the urban population aged 65 years or older, implying a huge gap between supply
and demand. In addition to this shortage of facilities, affordability, efficacy, and
regulatory oversight are major challenges.
177
Rising health expenditures
Along with rising industrialisation and urbanisation and an ageing population, Chinese
people are facing the dual health threats of infectious and chronic diseases. Meanwhile,
the desire for better health services and attention to health have also risen in tandem
with higher living standards. The result of which was a sharp rise in health expenditure
in China, especially in urban areas (figure 8
).
Figure 8
Health expenditure, 1978–2015
Source: National Health and Planning Commission.
51
The bars show the expenditure by government, society (mainly from institutions and
enterprises), and individuals. The lines show expenditure in urban and rural areas.
According to government statistics, health expenditure in urban areas was ¥2·66 trillion
($4394 billion) in 2014, which was 75% of the national total.
51
Health expenditures paid by individuals decreased from 59% in 2000 (the highest since
1978) to 32% in 2014; the government contributed 15·5% in 2000 and 30·0% in 2014,
whereas society (mainly from institutions and enterprises) contributed 25·6% in 2000
and 38·1% in 2014.
178
This change reflects an improved structure of health financing. However, compared
with other major economies in the world, the public share of health expenditure is
relatively low. According to the Word Bank, the percentage of general governmental
expenditures on health as a fraction of total government expenditures was 10·4% in
China in 2014, compared with 19·7% in Germany and 21·3% in the USA.
179
Health expenditure per capita and as a share of consumption expenditures are also
changing in urban China (figure 9
). Still, because the share of health expenditure covered by the public health-care
system has been steadily increasing, the ratio of personal health expenditure to personal
consumption expenditure has not grown between 2000 and 2014.
Figure 9
Health expenditure per capita and its share in the consumption expenditure in urban
China, 2000–14
Sources: China Health Statistical Yearbook 2003–09
180
and China Statistical Yearbook of Health and Family Planning 2015.
181
Given the need to improve the health conditions of elderly people and the expected
response of health spending to rising incomes, the share of health expenditures in
GDP is projected to increase substantially over the coming decades in China.
182
Per capita medical expenses are forecasted to increase constantly, with an average
annual growth rate of 2·2% between 2010 and 2030.
183
China's total public health expenditure is expected to reach 6–10% of GDP under different
scenarios.
182
Health inequity
Health equity refers to the attainment of the highest level of health for all people.
In the 1970s, China was a model of health equity for the rest of the world for its
provision of universal health care. However, the first health reform, which stretched
from the mid-1980s to the end of the 1990s, changed China's health-care system permanently.
The reform successfully introduced market mechanisms but undermined universal access
to health care. In 1981, 70% of the population was covered by three insurance schemes:
the Government Insurance Scheme, the Labor Insurance Scheme for urban residents, and
the Co-operative Medical System for rural residents. Preventive care was provided
by the government at nearly zero cost to recipients. During the reform, many people
lost their insurance coverage when state-owned enterprises were shut down and when
collective farms were dismantled. Coverage under all insurance schemes dropped to
20% in 1993.
184
Because of these and other factors, health inequity across sex, age groups, and geographic
locations is increasing in terms of disease burdens and life expectancy. For example,
life expectancy for men in Tibet in 1990 was 18·9 years (95% uncertainty interval
16·0–21·8) shorter than their counterparts in Shanghai; life expectancy for women
was 21·4 years (18·7–24·3) shorter. Less developed regions also had higher burdens
of infectious disease (eg, tuberculosis) than did developed regions.
56
Equity in the health-care system deteriorated so rapidly that, in 2000, the WHO considered
China one of the least equitable systems in the world; fairness of financial contributions
to health care in China were ranked 188th of 191 countries and regions.
185
The Chinese Government started the second stage of reform in 1998 but health inequity
was not a central focus. Health inequity was still ubiquitous; for example, life expectancy
in different regions still varied by as much as 11·8 years (95% uncertainty interval
9·3–14·5) for men and 12·8 years (10·7–15·0) for women in 2013.
56
The difference in height between urban boys in east and west China actually increased
during 1985–2010, highlighting the disparity in child development in different regions.
186
Among Chinese adults, the values of the Apouey index of health inequality increased
by 126·8% between 1997 and 2009 in urban areas.
5
Professional, income, sex, and age distinctions have an ever-greater role in Chinese
society, with social and economic inequalities contributing to increased health inequity.
Widened income inequality is one reason why economic growth since the second stage
of health reform did not improve health equity in China. The Gini coefficient of family
income in urban areas of China was 0·51 in 2012,
187
significantly higher than the national value of 0·40 for the USA and the average value
of 0·32 for Organization for Economic Co-operation and Development countries in the
same year.
188
Between 1991 and 2006, income changes in urban areas accounted for 7·1% of rising
inequality of urban health.
189
In 2013, economic status was estimated to account for 13–14% of health inequality
in urban populations.
190
Urban residents can be divided into groups of poor, lower middle, upper middle, and
rich based on household income and regional characteristics.
191
The minimum living standard for urban residents set by local governments is used as
an urban poverty line for the practical purposes of providing social relief or assistance
to poor urban households. With the expansion of rural-to-urban migration and the extensive
urban economic reforms of the late 1990s, the population of the urban poor substantially
increased, only levelling off since 2010 (figure 10
).
Figure 10
Population below the minimum living standard for cities, 1996–2014
Source: China Civil Affairs' Statistical Yearbook 2015: Statistics of China Social
Services.
176
Several paths can lead residents into urban poverty. In addition to the traditional
urban poor who have lived on low-income social security welfare, a new class of urban
poor includes those who were unable to reap the benefits of rapid urbanisation and
economic development. These include the unemployed and those underemployed because
they do not have the skills required for emerging jobs or they lack the mobility needed
to seek job opportunities.
192
Another group consists of those whose rural Hukou (mandatory system of residence registration)
changed to urban as a result of government reclassification of their land (ie, from
rural to urban). Without the proper skills and necessary social capital to help them
to adapt to new urban life, these individuals tend to work in poorly paid, labour-intensive
jobs without job security. Despite their access to urban Hukou and qualification for
social security welfare, many of them have substandard living conditions. The new
urban poor also tend to be spatially segregated and confined to certain old neighbourhoods
(eg, urban villages) in cities.
193
Access to urban public services is another contributing factor to social segregation
and poverty among migrants.
194
Although many migrants have established long-term de facto residences in places far
from their Hukou registration, because the Hukou system is the basis for access to
essential supplies and services, urban immigrants without a local Hukou are often
unable to access these resources, including public schools and public health services.
195
In Beijing, Shenzhen, Guangzhou and Hangzhou, migrants do not qualify for public housing
rentals; even in cities where they do qualify—such as Shanghai and Chongqing—strict
rules apply. In Shanghai, about 70% of total housing poverty involves rural migrants.
196
Many urban villages are populated with migrant workers. Although these are not officially
recognised as slums, they often have inferior environmental and housing conditions
than other urban neighbourhoods.
193
In addition, the Hukou system also restricts migrant employment opportunities and
increases commuter times because affordable local housing is scarce.
197
A new policy is expected to relax the Hukou system in medium-sized and small-sized
cities but continue to strictly control it in the large cities where most migrants
congregate.
198
The existence of different types of health insurance in urban China also adds to health
inequity. The two major state-run medical insurance programmes—Urban Employee Basic
Medical Insurance and Urban Resident Basic Medical Insurance—increase inequalities
in outpatient utilisation but reduce pro-rich inequities in inpatient utilisation.
199
In addition, subscriptions to less generous programmes, such as the Urban Resident
Basic Medical Insurance scheme, are associated with decreased utilisation of general
physical examinations.
200
Inequity in access to health services for urban China is another major contributor
to health inequities. Given that most of China's health service resources are located
in urban areas, uneven urbanisation across the country is responsible for unequal
availability of and access to various health services.
201
Among prefecture-level cities, there is inequity in the health service (table
). The number of health-care personnel per 10 000 people based on populations in administrative
areas or populations in urban districts both show that the divergence between the
top-ranked cities and the bottom-ranked ones is substantial. Given that most of the
bottom-ranked cities are third-tier cities located in the south and southwest of China,
appropriate policies are needed to address this disparity. The National Plan for New
Urbanization 2014–20 emphasises urbanisation in China should be focused on small-sized
and mid-sized cities and towns, therefore these health service inequities need to
be acted upon in a timely manner.
Table
Numbers of registered doctors and doctor assistants per 10 000 people in cities at
prefecture-level and above in 2014
181
Top five
Bottom five
Based on populations in administrative areas
1
Shenzhen (84)
Xinyang (ten)
2
Dongguan (79)
Anshun (ten)
3
Daqing (73)
Shaoyang (nine)
4
Beijing (68)
Longyan (nine)
5
Taiyuan (52)
Dazhou (nine)
Based on populations in urban districts
1
Daqing (108)
Baoshan (15)
2
Ordos (100)
Suqian (15)
3
Kaifeng (92)
Dazhou (13)
4
Henyang (88)
Guigang (12)
5
Shenzhen (84)
Yichun (12)
Section 3. Management of health challenges in urban China
Cities have taken actions to address urban health challenges. Most notable among these
actions are controlling environmental pollution, improving livability of urban environments,
enhancing disease prevention and control, advancing universal health coverage, and
testing new methods in urban health management. Evidence summarised in this section
show that substantial health improvements have been achieved. Nevertheless, there
are still gaps that need to be addressed.
Environmental pollution
Cities in China have taken widespread actions to control pollution in urban areas.
China recently added PM2·5 to its national Ambient Air Quality Standards and issued
a major policy in 2013—the Action Plan on Prevention and Control of Air Pollution—to
target reductions in PM2·5 through control of industrial emissions, promotion of clean
energy, reduction in emissions from road traffic, and other measures. During the 5-year
period covered by the plan (2013–17), the Beijing–Tianjin–Hebei region committed to
reduce annual average PM2·5 by 25%, Yangtze River Delta by 20%, Pearl River Delta
by 15%, and other major cities by 10%.
202
Similar action was taken to address water pollution. In the Action Plan for Water
Pollution Control issued in 2015, the focus was on the reduction of highly polluted
urban water bodies in urban areas and the improvement of quality of drinking water
sources for cities. According to the plan, by 2030 all highly polluted water bodies
will have been remedied and 95% of drinking water sources for cities at prefecture-level
and higher will have level 3 national water quality standards (ie, safe for drinking,
fishing, and swimming).
203
China is also taking actions to transform energy intensive industry, which is considered
the root of many environmental pollution problems. For example, in 2014, China accounted
for 23% of global primary energy consumption; of this energy, 69% was used in the
industrial sector (figure 11
). The manufacturing industry contributed most to total industrial output and its
energy intensity ranked second among all sectors.
37
In 2015, the State Council published Made in China 2025, a plan designed to improve
the quality of China's manufacturing industry.
205
The plan provides policy guidance for the replacement of energy intensive industries
with service-oriented industries and is expected to lead to reduced industrial pollution.
Beyond direct measures for pollution control, more than 200 cities have adopted low-carbon
development goals, including a reduction in the intensity of CO2 emissions and energy
consumption for buildings and for the transportation and industrial sectors.
206
Figure 11
Final energy consumption, 2000–14
Source: China Energy Statistical Yearbook 2014
204
and China Statistical Yearbook 2015.
37
TCE=tonne of coal equivalent.
The government is also working to improve transparency in environmental governance.
The Open Government Information Regulations and the Environmental Information Disclosure
Measures were passed in 2008. Accordingly, the number of environmental information
queries received and answered by the Ministry of Environmental Protection increased
from 68 in 2008 to 1076 in 2013.
207
In 2008, the Institute of Public & Environmental Affairs began tracking the transparency
of pollution information in China; the number of cities achieving a passing grade
increased from just 4 (3·5%) of 113 in 2008 to 21 (17·5%) of 120 in 2015.
208
Substantial progress has been made in some heavily polluted cities. Annual PM10 concentrations
in 86 major cities decreased from 116 μg m−3 in 2001 to 85·3 μg m−3 in 2011. The number
of days with a PM10 concentration above Chinese ambient air quality standards (24
h mean 150 μg m−3) also decreased, from 66 in 2001 to 28 in 2011. The number of days
with a PM10 concentration that exceeded WHO guidelines (24 h mean 50 μg m−3) decreased
from 294 in 2001 to 250 in 2011. Premature deaths caused by PM10 pollution as a fraction
of all deaths decreased from 13·5% in 2001 to 11·6% in 2011.
209
The mean annual concentration of PM10 in 2017 for cities at prefecture-level and above
was 22·7% lower than that in in 2013. Between 2013 and 2017, PM2·5 concentrations
declined by 39·6% in Beijing–Tianjin–Hebei, by 34·3% in Yangtze River Delta, and by
27·7% in Pearl River Delta. All cities achieved the targets for the reduction of PM2·5
specified in the Action Plan on Prevention and Control of Air Pollution.
210
The reduction of environmental pollution has resulted in positive changes for health.
In Taiyuan city, improvements in air quality between 2001 and 2010 are estimated to
have prevented 2810 premature deaths and reduced the total disability-adjusted life-years
associated with air pollution from 52 937 to 22 807.
211
The exposure of children to lead in urban China is also declining. Between 1990 and
2009, mean blood lead concentration in urban children at 0–6 years of age decreased
from 7–10 μg dL−1 to 2·5–6·0 μg dL−1 and the prevalence of children with increased
blood lead concentration (≥10 μg dL−1) decreased from 30–50% to 1·5–15·0%. This decline
can be attributed to the phase-out of leaded gasoline, use of clean energy, and relocation
of heavy polluters.
212
Despite many achievements, environmental governance in urban China needs to be strengthened.
Current practices are largely top-down, relying heavily on enforcement by governments.
Efforts to use market mechanisms to regulate pollution, such as through compulsory
pollution insurance, have had mixed success to date. The compulsory pollution insurance
programme is unpopular because of its weak legal basis, poor technical support, unattractive
coverage and premium rates, and low demand among industrial companies.
213
Although environmental policies often target large industrial companies, the polluters
that cause the highest intensity of damage to population health are medium-sized facilities;
larger facilities generally have more effective pollutant control technologies or
are located farther away from densely populated areas, or both.
214
Given that it will take time to substantially reduce ambient air pollution in major
cities in China and that most exposure to air pollution occurs indoors, the control
of indoor pollutants (of both outdoor and indoor origin) is a feasible interim solution
for the reduction of overall exposure and corresponding health risks.
Programmes such as those devoted to the achievement of low carbon cities could help
to avoid characteristic urban environmental harms, but the resources and long-term
commitments needed for their success in China are still absent.
206
Furthermore, the public is largely at the receiving end of environmental management,
having at best a restricted participatory role. The government remains cautious about
such participation; people are encouraged to reduce personal emissions and to monitor
sources of pollution but citizens and NGOs are restricted in terms of the actions
they can take to confront environmental pollution. For example, environmental NGOs'
access to state institutions are intentionally restricted.
215
Livability of urban environments
Cities in China have made considerable progress in the improvement of urban living
conditions over the past four decades, particularly in terms of basic infrastructure
and sanitation. Large-scale government investment has resulted in mass construction
of basic infrastructure in cities. In 1978, fixed-asset investment in urban service
facilities was ¥1·2 billion (about $2·7 billion when adjusted for inflation) nationwide,
but this figure reached ¥1·6 trillion ($257·8 billion) in 2015.
216
This investment has helped to improve water and gas supplies, heating, road and rail
transit systems, sewerage and wastewater treatment, waste management, and flood control,
while improving the design and aesthetics of the urban landscape. One key example
is the improved water services that have expanded across cities in China, achieving
coverage of 98·1% of urban residents in 2015 from just 53·7% in 1981.
216
This improvement might contribute to the lower mortality rate of oesophageal cancer
in urban areas (89·1 per 100 000 people) than in rural areas (285·9 per 100 000 people)
in 2015,
64
because the consumption of untreated water from polluted sources has been positively
associated with oesophageal cancer in rural areas.
217
Greenspace and open space, including greenways, parks, and other urban conservation
lands, has increased in 97% of prefecture-level cities because of its known benefits
for urban quality of life, public health, and climate change adaptation.
218
Governments at various levels have used large-scale urban development projects to
target specific aspects of urban infrastructure. For example, between 2000 and 2010
in China, massive inner-city renewal and urban expansion projects progressively removed
slum-like residences, replacing them with high-rise modern residential blocks.
219
The Hygienic Cities movement is a hallmark of urban development in China that resulted
in an unprecedented level of improvement in urban sanitation across China's cities
(panel 3
). The policies aimed to create better living environments for urban residents through
the improvement of waste management and personal hygiene habits and the elimination
of urban decay.
220
Municipal governments launched major initiatives focusing on sanitation, urban infrastructure,
and environmental protection. For a city, city district, or town to attain the title
of National Hygienic City (or District or Town), it has to meet more than 100 criteria
and pass an initial 3-year period of scrutiny and periodic unannounced inspections.
6
As of March, 2015, 216 cities and 42 urban districts met these stringent criteria
(appendix). There are also 679 National Hygienic Towns. Hygienic cities and districts
performed better, on average, with respect to waste treatment, air pollution control,
urban greening, infrastructure construction, and health promotion than did non-designated
cities and districts.
221
Panel 3
Weihai—the first National Hygienic City
Weihai, a coastal city in Shandong province, was the first to be certified a National
Hygienic City in 1990. The improvements to the urban environment made during and after
the certification campaign have brought substantial health benefits to its 2·8 million
residents.
To meet the stringent requirements, Weihai invested heavily in various urban environmental
improvements. It has built facilities to process waste, achieved a 100% processing
rate, and formed a partnership with New York City, NY, USA in 2016 to deal with ocean
waste. Given its coastal location, coastline restoration and environmental management
were prioritised. Weihai has controlled pollution in all urban rivers and grounded
66 000 cars that failed to meet emissions standards. It has also closed the door to
companies with high energy consumption and pollution, turning down US$2 billion in
foreign direct investment and ¥20 billion ($3·2 billion) in domestic investment between
1989 and 2012.
As a result of these efforts, the water qualities of all city seashores in Weihai
now meet national standards and Weihai ranks best in the country on this measure.
Its air quality is consistently ranked the best in Shandong province. In 1997, Weihai
was one of the first six cities to be certified as a National Model City for Environmental
Protection. Life expectancy increased from 72·0 years in 1985 to 81·1 years in 2015,
substantially exceeding the national average of 76·34 years.
11
The success of the National Hygienic City programme in Weihai is a result of the realisation
by its leaders that efforts to achieve this status would help them protect the natural
environment, which is a unique resource of the city. The title helps the city stand
out from larger, more prominent Chinese cities and provides credibility in attracting
both domestic and foreign direct investments. Weihai's example shows that tightly
aligning a health programme with local government development pathways guarantees
its success.
These improvements were associated with important health gains. For example, the incidence
of infectious gastrointestinal diseases in National Hygienic Cities was reduced by
an average of 2·8% 4 years after certification and the incidence rates of other infections,
including vector-borne, zoonotic, blood-borne, and sexually transmitted diseases,
were lower than in control cities. Health literacy of people living in National Hygienic
Cities is higher than that in control cities and poor sanitary habits, such as public
spitting and littering, declined, while physical activity increased.
6
China established a national emergency management platform to reduce the health, social,
and economic effects of natural disasters, environmental and industrial incidents,
public health events, and security challenges. The platform integrates multiple functions,
such as daily emergency management, risk analysis, monitoring and control, risk forecasting
and early warning, integrated coordination, decision-making assistance, command and
dispatch, simulation, and training. The platform has greatly improved the capability
and efficiency of the government when dealing with emergencies.
222
For climate-mediated risks in particular, the central government released the Action
Plan for Urban Adaptation to Climate Change in 2016
223
and selected 28 cities in 2017 to be involved in a pilot programme to build climate-adaptive
cities. These cities will use a comprehensive approach to adapt to future climate
change; for example, through modifying urban planning and design, improving monitoring
and early warning systems, adopting engineering and nature-based methods to increase
cities' resilience, and working together with the international community.
224
In addition to government-led programmes, the private sector has used innovative ways
to improve health in cities.
111
For example, China's dockless bike-sharing programme, which launched in Beijing on
Sept 1, 2016, has expanded to more than 200 cities by the end of 2017. More than 25
million bikes have been made available to the public and 300 million people have registered
as users.225, 226 The rapid development of bike-sharing programmes has been facilitated
by mobile technologies whereby users can access any available bike immediately and
can park bikes in any public space after use, with the entire process of renting,
returning, and paying completed via an application on users' mobile phones. The bike-sharing
programme has reduced car use, alleviated traffic jams, and reduced emissions in cities,
while satisfying urban residents' transportation needs in Chinese cities. Nationwide,
the programme has saved users 760 million hours in commuting time. In addition, 1·4
million tonnes of gasoline has been saved because of reduced car use; 4·2 million
tonnes of carbon and 3·2 million tonnes of PM2·5 emissions have been avoided.
226
Bike sharing programmes are expected to continue to expand and become more popular.
However, although this programme should be credited for making urban transportation
greener, the traffic safety and parking issues associated with the explosive growth
of bikes in cities have caused concern. City governments and the private sector should
work together to solve these emerging problems.
The dominant role of government in China has allowed for urban environmental improvements
of unprecedented speed and magnitude. However, there are inherent limitations in this
centralised approach. Most environmental policies and management efforts were designed
to address immediate environmental crises rather than the long-term health of the
urban environment. This approach has also failed to address social equity concerns.
227
For example, residents of old city districts often reap little reward from urban regeneration
efforts; they are often inadequately compensated and are frequently relocated to the
urban fringe.
228
Environmental governance in cities in China is characterised by multi-sectoral administration,
conflicting responsibility, scarcity of public participation, and local interest-centred
frameworks, which, together, result in heterogeneous efforts and resources for environmental
management.
229
Since public participation is still restricted, more flexible and pragmatic policies
are needed to facilitate this input in complex political contexts.
228
Disease prevention and control
As in most of the developed world, prevention is the cornerstone of infectious disease
management in China. Major initiatives include mass immunisation, timely detection
and reporting of and response to infectious disease outbreaks, and measures to control
transmission. The widespread improvement of urban infrastructure since the economic
reform, particularly the construction of central water supply systems, public toilets,
and wastewater treatment facilities, has helped to limit the transmission of many
infectious diseases. By 2015, it was estimated that less than 10% of fecal coliform
from human sources in Chinese waters were from urban areas.
230
The Hygienic City movement has played an important role in controlling the transmission
of infectious diseases, with its strong focus on controlling vectors and cultivating
good habits for personal heath.
6
In 1982, nationwide immunisation for children was started to vaccinate children against
six communicable diseases: measles, poliomyelitis, tuberculosis, pertussis, diphtheria,
and tetanus.
231
Over the years, new vaccines have been successively added to this list; the Instruction
and Procedure for National Immunization Program for Children, passed in 2016, now
includes 14 vaccines covering 15 diseases.
232
The latest National Health Survey on Health Service showed that more than 90% of urban
children younger than 5 years old had received all required vaccines.
233
The central government has also organised frequent large-scale vaccination campaigns
for migrant children. In one such campaign in Guangdong province in 2009, more than
1 million migrant children were vaccinated.
234
These immunisation programmes have led to significant decreases in incidence of infectious
disease in urban populations. For example, the incidence of measles in Beijing has
decreased from 593·5 per 100 000 people in 1951 to 0·5 per 100 000 people, which is
mostly attributed to vaccination coverage rates of 95–99%.
235
China has learnt from previous epidemics of infectious disease. One important lesson
from the management of the 2003 pandemic of severe acute respiratory syndrome was
the value of an effective disease monitoring and early-warning system at national
level. Incomplete and delayed reporting of cases during the outbreak greatly weakened
control efforts. To tackle this issue, the National Notifiable Diseases Reporting
System was set up in 2004 with a mandate to monitor the occurrence of 37 infectious
diseases, as laid out in the Law on Controlling Infectious Disease. By 2009, two more
diseases were added to the reporting list. The national network reduces the average
time between the identification of a disease case and its report to the Chinese Center
for Disease Control from 29 days to under 24 h.
236
Other national disease surveillance systems, such as the Disease Surveillance Points
System, also track the occurrence of diseases and causes. Sentinel surveillance systems
for specific diseases, such as malaria, have been set up at national and regional
level to support the information collected by the standard systems.
The enhanced disease surveillance system has led to better control of infectious diseases
in China. In 2016 alone, around 7 million cases and 18 000 deaths resulting from infectious
disease were reported through the network.
237
The national surveillance system for malaria, established in 2012, has provided data
on epidemics, vectors, and other relevant factors to the national malaria elimination
programme, which allows the programme to investigate and verify individual cases,
screen surrounding populations, and start relevant vector control strategies.
238
The surveillance system has also been useful at detecting emergent infectious disease.
For example, the National Notifiable Diseases Reporting System helped the health administration
in Dongguan (a manufacturing city in Guangdong province with 8 million residents)
to detect an outbreak of dengue and trace its source to a patient just 1 month after
the patient was infected during an oversea trip.
239
Infectious disease prevention has expanded to areas that have historically been stigmatised
in China, such as HIV/AIDS prevention in commercial sex workers. In Wuhan, the 100%
Condom Use Program helped to increase condom use rates in commercial sex workers by
94·5% in 15 months.
240
The central government started a national HIV/AIDS treatment programme in 2003, through
which 157 050 people received antiretroviral therapy by 2011. This programme led to
a 26% relative reduction in HIV transmission in 38 862 treated serodiscordant couples,
indicating that this treatment-as-prevention approach is working in China, although
further studies are needed to assess durability.
241
Infectious disease control in urban China still faces many challenges. Although disease
surveillance networks have proven indispensable, they face the common issues of poor
accessibility, poor data quality, under-reporting, and inadequate staffing and funding.242,
243 For example, a field survey of 161 Disease Surveillance Points System sites in
2009–11 found that the crude under-reporting rate for mortality was 10·7% in urban
areas.
244
Some issues require creative solutions, such as the vaccination of migrant children
whilst on the move with their parents.
234
Other issues face cultural barriers, such as controlling male-to-male transmission
of HIV/AIDS.
245
Management of non-communicable diseases in China has shifted from disease treatment
to prevention in the past decade. The promotion of healthy lifestyles has been prioritised
and people in urban China are encouraged by governments to exercise more. Two national
regulations, the Community Service System Construction Plan (2011–2015) issued in
2011 and the Urban Community Sports Facilities Construction Land Index issued in 2005,
require that any new residential units must include spaces (including green spaces,
open spaces, and yards) and exercise equipment, and specify the size and types of
equipment for residential units of different sizes. Governments also provide incentives
for people to participate in physical exercise, such as competitions and small awards.
More recently, cities have experimented with allowing residents to charge the fee
of using sports facilities to their medical insurance cards as a stimulus.
246
The participation rate in moderate or vigorous physical activity outside of work among
urban adults (≥18 years) was as low as 7·9% in 2001 but increased to 21·6% in 2013.
73
Cities are also getting serious about the control of tobacco use. By the end of 2016,
more than 30 cities in China have passed or are in the process of passing regional
regulations and laws that ban smoking in public indoor spaces. Among them, Beijing
passed the strictest regulation on banning smoking in public spaces (panel 4
). The move, once successfully implemented, will protect 20% of the country's population
from second-hand smoking.
247
Panel 4
Tobacco control in Beijing—the strictest tobacco control policy in China
The Beijing Smoking Control Ordinance, which was passed by the Beijing Municipal People's
Congress in November, 2014 and came into effect on June 1, 2015, is one of the toughest
tobacco control laws adopted in China to date.
Under the law, smoking is prohibited in all indoor public places and many outdoor
public places, such as kindergartens, schools, and child and maternal health centres.
The law includes strong penalties for violations; for example, owners or managers
of premises—not just individual smokers—are liable for fines if they fail to comply.
In addition, the law bans tobacco advertising on mass media, in public places, outdoors,
and on public transport.
The capital's decision to adopt such a strong smoke-free law is important because
other cities across China will seek to emulate Beijing's example. Both Shenzhen and
Shanghai have since passed strong comprehensive smoke-free laws, thereby protecting
well over 60 million Chinese citizens and residents from harmful exposure to second-hand
smoke. More importantly, these cities have now set the benchmark for smoke-free policies
for China.
Successful enforcement of a smoke-free law in a city the size of Beijing—with its
myriad of offices, restaurants, bars, shops, and hotels—is a colossal task. It requires
a visible and ongoing enforcement effort, rigorous application of penalties for offending
smokers and businesses, and substantial investment of resources in public education
and awareness. The Beijing Government has worked hard to enforce the law since it
came into effect. Health inspectors are out in large numbers around the city, checking
venues and ensuring compliance with the law, supported by thousands of community volunteers.
Beijing's residents are actively engaging in the enforcement effort through complaints
to the 12320 hotline or through the hugely popular WeChat social media platform. The
Beijing Tobacco Control Association has an interactive virtual map at its premises,
which shows in real-time the movement of the tobacco control volunteers around the
city and highlights venues or establishments that are being reported for their non-compliance.
This use of integrated innovative technology is impressive and helps to support enforcement
efforts.
The effect the law has had is even more encouraging. Between May, and August, 2016,
the Health Education Centre of Beijing Center for Disease Control and Prevention did
a survey of 10 000 households from 16 districts in Beijing. The results showed a reduction
in adult smoking rates (from 23·4% in 2014 to 22·3% in 2016); a reduction in exposure
to second-hand smoke in various venues; an increase in the quitting rate among adults
(from 14·9% in 2014 to 16·8% in 2016); an increase in public awareness of the harms
of smoking; and a decrease in the number of adults who noticed tobacco advertisements
at point-of-sale. Recent surveys have also shown that there is strong public support
for 100% smoke-free laws.
The Beijing smoke-free law is a major step forward in the battle against tobacco in
China and the people of Beijing are now breathing easier as a result. The success
of the law so far is owed to dedicated enforcement by the government and the high
proportion of well educated people living in Beijing, which tend to be more supportive
of smoking bans. In less developed regions, the implementation of the smoke-free law
will probably face more resistance.
Governments at various levels are trying to increase the health literacy of urban
residents. Three major channels have been used to reach urban residents, including
mass media, community organisations, and the education system. Mass media has a central
role in disseminating health knowledge and information in China because more than
half of Chinese people get their health knowledge from television.
248
Community organisations are another effective way to improve health knowledge. The
centralised government structure allows health information to be passed from the central
government to the smallest communities in China. Cities are also offering health education
classes through primary schools to high schools.
249
In addition to these formal channels, cities in China came up with creative ways to
disseminate health knowledge. For example, the Shanghai municipal government has given
a free health package to 8 million households annually since 2010. The package contains
publications on health, spoons to measure salt, an oil dispenser with measuring marks
to reduce oil use in cooking, and tapes to measuring one's waistline. These small
gifts have been very effective in communicating the concept of healthy lifestyle choices
to a large population.
250
These efforts have led to positive changes. For example, according to a 2015 survey
of 10 000 urban residents in 44 cities, compared with 2013, consumption of carbonated
soft drinks decreased by 21%, chewing gum by 15%, and western fast food by 16%. Further,
73% of survey participants participated in sports activities, which is simliar to
the 70% reported in US cities.
251
Disease screening is another important component of the prevention strategy. In 2011,
the government started a national programme for stroke prevention and screening. The
programme provides free screening to permanent urban residents aged 40 years or older
and more than 4·6 million people have been screened so far. About 0·69 million high-risk
people identified in the initial screening tests had further examinations, and those
diagnosed received advice on treatment. The programme helps the health department
to identify an increasing trend of stroke risk among people aged 40 years or older.
252
Cancer screening services are now increasingly made available to at-risk populations
through health insurance. For example, the proportion of women who had cervical cancer
screening services reached 29·1%, with a higher percentage seen in women with urban
insurance coverage than in those without or with rural health insurance.
253
Some cities even offer free physical examinations for all residents (panel 5
).
Panel 5
Luzhou–free physical examination for all residents
Luzhou city is located in Sichuan province and is formed of 5 million people living
in a mountainous area of about 12 000 km2 in size. In June, 2016, the city started
a project to offer free physical examination to all residents. The entire population
of permanent residents was divided into five age groups: 0–6 years, 7–17 years, 18–34
years, 35–64 years, and 65 years or older. People in the 0–6 years, 7–17 years, and
65 years or older groups were entitled to free annual physical examinations. The rest
were entitled to free biannual physical examinations. The physical examination includes
routine tests, such as blood tests and liver function tests, and specific tests that
were decided by each district (such as digital radiography of the chest). Examinations
are done in health facilities or onsite for people who are handicapped or living in
remote areas.
1·8 million residents were checked in 2016, of which 500 000 had never had a physical
examination. The examinations showed that around 306 000 people had high blood pressure,
99 000 people had diabetes, and 40 000 people had another chronic disease. The results
of each examination were electronically archived and grouped by families, villages,
and communities before storage in community health centres. The archives are updated
dynamically with information on subsequent examinations, treatments, and insurance
reimbursement. Residents can look up their health information via an application on
their mobile device. The examination results were also used to separate people into
three groups: people who need routine health management, people who need specific
attention, and people who need precise health management. The latter two groups include
people with diabetes, high blood pressure, or severe mental health problems, high-risk
pregnant women, and people at high risk of chronic disease. Each individual is assigned
to a management team, which includes a physician and a local government staff. The
team tracks the health status of the person and advises them on how they can manage
their personal health.
Two factors might have contributed to the successful implementation of the free-for-all
physical examination in Luzhou. First, the population size of the city is relatively
small by Chinese standards which keeps the expense at an acceptable level. Second,
Southwest Medical University has been located in Luzhou since 1951. The medical university
and its many associated medical agencies not only provide the human resources necessary
for such a project but they also increase the health awareness of the residents in
general.
Cities in China are using a comprehensive approach to deal with non-communicable diseases.
China started a campaign for the control of chronic diseases in 2010 aimed at four
main types of chronic disease: cardiovascular disease, malignant tumour, chronic respiratory
disease, and diabetes. The campaign integrates disease surveillance, prevention, and
treatment to form a comprehensive strategy. By the end of 2015, 265 counties, city
districts, and county-level cities had been selected as national demonstration sites
to receive this comprehensive approach.
254
The management of mental disorders in cities also requires an increasingly comprehensive
strategy. A grid model has been used in many cities to manage patients with mental
disorder. The model is built on collaboration between public health service agencies
and neighbourhood committees and involves measures that allows for discovering and
treating patients in the community. These measures include health education, physical
examination, regular doctor visits and reports of cases, patient registations, free
treatments, and dealing with emergencies at the community level. The effectiveness
of this model relies on the joint effort of patients' families, communities, and various
government agencies.
255
Results show that this comprehensive management is effective. A meta-analysis
256
of studies between 2004 and 2015 showed that the recurrence rate of severe mental
problems under comprehensive management is 32% of the rate in the control group.
New approaches like patient empowerment, which enables people to take control of their
health, wellbeing, and disease management and to participate in decisions affecting
their care, are being tested for chronic disease management. Self-management of chronic
diseases in Shanghai has shown that identification of responsibilities, integration
of multiple resources, and an emphasis on evaluation can make patient empowerment
an efficient and effective mechanism for the prevention and control of non-communicable
diseases and the achievement of improved health outcomes in patients suffering from
these diseases, especially elderly people (panel 6
).
257
China has also participated in the community-based safety programme initiated by WHO
since 2006 to prevent injury, violence and suicide. By November, 2011, China had 46
designated international safe communities and 244 designated national-level safe communities.
147
Panel 6
Self-management of chronic disease in Shanghai
In 2002, a randomised controlled trial of the Chronic Disease Self-Management Programme
started in Shanghai. Initial results showed that the generic self-management education
programme improved participants' health behaviour, self-efficacy, and aspects of their
health status, and resulted in fewer visits to the emergency room and fewer admittances
to hospital after 6 months. These successes were achieved through locally-based delivery
models and the integration of routines of community government and community health
services.
In 2007, the Health Promotion Committee of Shanghai adopted the recommendation from
the School of Public Health at Fudan University to disseminate chronic disease self-management
through the network of the healthy city in Shanghai. Powerful policy support, defined
responsibilities for the different actors, and active participation from the relevant
population characterised Chronic Disease Self-Management Programme as a tool for the
prevention and control of chronic illness. As of 2016, 420 000 people (most of whom
were elderly) had been organised into 26 000 groups and participated in these activities.
Guided by the principles of doctor–patient cooperation, mutual aid, and self-management,
the programme succeeded in creating a supportive environment for the prevention and
control of chronic disease. Based on an evaluation of the programme in 2011, 63·6%
of group members had sufficient interactive health literacy, 34·6% increased their
physical activity significantly (45·1% increased slightly); 32·5% increased their
vegetable and fruit intake significantly (46·0%increased slightly); 24·9% decreased
their salt intake significantly (58·0% decreased slightly), and 28·3% decreased their
oil intake significantly (55·4% decreased slightly). In this analysis, women tended
to be better at improving their lifestyle behaviours than men were.
The qualitative analysis showed that members listed information exchange, shared experiences,
and an improvement in mood as the biggest gains from participating in the self-management
group. 58·8% of members did voluntary activities, 50·6% did activities organised by
residential committees, and 47·8% did activities organised by various interest groups.
The Chronic Disease Self-Management Programme in Shanghai has been remarkably effective
to date; it has empowered patients to make decisions on self-care and broader collective
actions regarding chronic disease control. Its success in Shanghai can be attributed
to the collaboration between Fudan university and the government. Given that Shanghai
is the most developed region in China, the area's financial resources and well educated
population contributed to the programme's success. Other large cities—such as Beijing,
Guangzhou, and Shenzhen—could adopt the same programme.
Even with the enhanced efforts, there are still gaps in the control of non-communicable
diseases in urban China. Prevention programmes in China often adopt a top-down approach
and, although this method is able to generate positive results quickly, it might not
be enough to address the increasingly complex health issues. For example, an investigation
of health education in six provinces in 2013 found that only 36·1% of the urban residents
aged 18–60 years had adequate health literacy.
258
Multi-sectoral strategies that target the underlying causes of chronic diseases are
nonexistent in most cities. Interventions that are evidence-based, low cost, simple,
sustainable, and scalable need to be developed.
259
The desire and actions of individual urban residents might be the key to success,
rather than more government-sponsored programmes. Without the whole-hearted involvement
of residents, effects from any health promotion programmes will be superficial and
short-lived.
Reformed universal health coverage
Faced with the undesirable consequences of serious health inequity in China, the government
started the third stage of reform in 2009 with recognition that access to health care
is a basic right of citizens and its provision rests with the state. A major goal
of the reform is to implement universal health coverage.
184
Cities in China are acting to expand the health-care sector and make it more efficient,
streamline the health insurance system, and improve affordability of health care,
and make health services increasingly available to underserved groups, such as migrants.
The Chinese Government invested heavily to expand its health-care system and, as a
result, the number of doctors (including assistant doctors), registered nurses, and
hospitable beds increased substantially in urban areas in China. For 2010–15, the
number of medical practitioners increased from 2·97 to 3·72 per 1000 people, registered
nurses from 3·09 to 4·58 per 1000 people, and hospital beds from 5·94 to 8·27 per
1000 people.51, 260 The most notable example is Hong Kong, where government spending
on health service is linked with economic growth and guaranteed by laws (panel 7
).
Panel 7
Hong Kong—guarantee health services with laws
Hong Kong Special Administrative Region is a coastal city in the south of China that
has one of the highest life expectancies in the world. In 2015, life expectancy at
birth was 81·2 years for men and 87·3 years for women, which is above China's national
average of 74·6 years for men and 77·6 years for women and the USA's average life
expectancy of 76·9 years for men and 81·69 years for women.
261
The city is unique because it is one of the few cities in China where the health-care
system is not managed by the central government's National Health and Family Planning
Commission or its subsidiary local health bureaus. Instead, the health-care system
is modelled on the National Health Service in the UK because of Hong Kong's history
as a British colony.
262
The laws and legislations of this system help to ensure access to quality medical
care for its residents. According to the Basic Laws of Hong Kong (article 107), the
government's expenditure needs to be consistent with the city's GDP growth.
263
Article 138 states that the government should develop policies for the development
of western medicine and traditional Chinese medicine and the improvement of medical
and health services. Furthermore, under the provisions of Section 4d of the Hospital
Authority Ordinance (chapter 113), the hospital authority recommends fees for the
use of hospital services by the public based on the principle that no person should
be prevented, through an absence of means, from obtaining adequate medical treatment.
Section 8 of the same ordinance states that the hospital authority might also borrow
money, if needed, to meet its obligations or perform its functions.
These legal protections have created a relatively equitable system such that health
services for most residents in all communities are rarely more than 30 min away from
their homes and access to essential health care is given regardless of their ability
to pay. To provide an average of 5·2 beds per 1000 residents and other health services,
the government owns 42 public hospitals and institutions and employs 6287 doctors
and 20 057 registered nurses. However, the maintenance of these standards over the
past decade has more than doubled government expenditure on health, with HK$67 430
million being spent in 2016 compared with $30 176 million in 2006. This rise led to
a 4% increase in total government expenditure from 14·6% in 2006 to 18·6% in 2016.
Hong Kong's strong economy and independent law system are key to the level of health
services provided in the city. Given that many cities in China now have a strong economy,
other cities should try to secure support for health services through local laws or
regulations.
China has been working to improve the efficiency of its health-care system since 2009.
The basic principle is to tilt resources to primary care and form a hierarchical health-care
system.
264
The government hopes to return non-acute patients back to their respective community
health centres to relieve the burdens of tertiary hospitals, promote a favourable
patient–doctor relationship, maintain the quality of local hospitals, and target limited
resources at populations with greater needs. A series of actions have been implemented
to realise these goals. These actions include making community health centres or town
(or village) clinics the gatekeepers to specialists and other medical resources and
forming a hierarchical structure in different levels of hospitals through strategies
like the bi-directional referral system and health insurance policies.
265
Another important task is to reduce patients' out-of-pocket expenditure by reforming
the revenue system of hospitals and reimbursement procedures.
266
These actions have started to change patterns of health-care use in urban China. Longitudinal
data since 2002 showed that community health centres in urban areas could provide
better health care, demonstrated by an increased breastfeeding rate and decreased
prevalence of lower respiratory tract infection compared with hospital outpatient
clinics.
265
In Fuzhou, patients at community health centres are more likely to report better experiences
with primary care attributes than patients visiting hospital facilities.
267
In Shanghai, a survey of residents showed that they consider community health centres
for convenience, good services, and low cost. On average, they paid ¥16·2 ($2·4) less
for their first visit when using these centres between 2006 and 2010.
268
However, community health centres in China are still not functioning as the first
contact points and regular sources of care. There are still many problems in the development
of these centres, including unsustainable governmental roles, inadequate human resources,
laggard general physician practices, poorly designed payment schemes, and a crisis
of trust.
265
Additional policy efforts are needed to help community health centres to develop.
Recent government investments in public health and primary care alone are not sufficient
and might not be sustainable. It will not relieve an omnipotent government until long-term
self-sustaining mechanisms are established, including a competent general practitioner
system, supportive social insurance reimbursement, appropriate financial incentives
to providers, better transparency and accountability, more regulations for the referral
system, and a legitimate, sustainable, and quality community health system.
269
Health insurance is an important means of achieving universal health coverage. The
health reform that started in 2009 has a clear mandate to increase access to health
care. To fulfil that mandate, the three types of state-sponsored insurance schemes
(Urban Employee Basic Medical Insurance, Urban Resident Basic Medical Insurance, and
new rural cooperative medical system) have been expanded dramatically in China. Findings
from consecutive Chinese National Health Services Surveys
270
showed that medical insurance coverage has increased from 29·7% of the total population
in 2003, to 87·9% in 2008, and 95·7% in 2011 (figure 12
). Only 17 million urban residents (4·1% of all urban residents at the time) enrolled
into a medical insurance programme when they started in 1998.
7
By 2016, the number of people enrolled in urban medical insurance programmes had already
increased to 743·9 million (93·8% of all urban residents).
8
This increased coverage is associated with a substantial increase in health service
utilisation and decrease in economic burden; for example, the Urban Employee Basic
Medical Insurance scheme reduced out-of-pocket inpatient expenditure by 64·5% and
the Urban Resident Basic Medical Insurance scheme reduced it by 45·6%.
272
As a result, the out-of-pocket expenditure as a percentage of private expenditure
on health declined from 95·6% in 2000 to 72·3% in 2014.
273
The national reimbursement ratio, which reflects the average reimbursement level of
state-sponsored insurance, increased from 22·4% in 2009 to 26·4% in 2011.
274
Figure 12
Different types of health insurances held by people living in different parts of China,
2003, 2008, and 2013
LIS=labour insurance system. GIS=government insurance system. RCMS=rural cooperative
medical system. NRCMS=new rural cooperative medical system. UEBMI=urban employee-based
medical insurance. URBMI=urban resident basic medical insurance. URRBMI=urban and
rural resident basic medical insurance. Sources: China Health Statistics Yearbook
2003–09
180
and China Statistical Yearbook of Health and Family Planning 2014.
271
However, the effect of health insurance in China is highly heterogeneous among different
population subgroups. Overall, health insurance leads to greater reduction in economic
burden in retired people but has a smaller effect on decreasing the burden for individuals
with a low income and low levels of education.
272
There is a discrepancy between the reimbursement rate estimated from health expenditure
(26·4%) and the reported reimbursement rate for listed services (50–60%) in 2011.
This discrepancy suggests that the services covered by state-sponsored health insurance
were not sufficient to meet residents' demand.
274
Furthermore, the current health insurance scheme offers weak protection against rare
diseases. It was estimated that, at a national scale, 247 620 urban residents could
be lowered into poverty because of the medical cost caused by seven rare diseases
in 2014.
275
The uneven results are mostly caused by the decentralised and incremental approach
to universal health coverage in China. The varied financing capacity of local governments
leads to high variability of benefit packages for health insurance. For example, a
2011–12 survey of people aged 60 years or older in Xi'an, Wuhan, and Shanghai showed
that the inpatient reimbursement rate was 45·5–81·2%, and the outpatient reimbursement
rate was 4·1–100%. Multiple insurance schemes reduce efficiency and increase abuse
and barriers to access at the same time.
276
The Chinese Government announced its plan to merge Urban Resident Basic Medical Insurance
and new rural cooperative medical system in early 2016, which is a starting point
for the ultimate consolidation of all state-sponsored health insurance schemes and
for the achievement of equal benefits for all.
277
Rural migrants, elderly people, and those with non-communicable diseases in cities
will benefit the most from the consolidation of the existing health insurance schemes
with extended funding pools.
278
Health services to migrants have been strengthened. 98·2% of migrants are covered
by at least one type of medical insurance and 97·9% of migrant children are covered
by the national imunisation programme.
279
Nevertheless, there is room for improvement. For example, in a comparative study
280
done in eight cities in the Pearl River Delta, female migrants of reproductive age
were less covered by health insurance schemes and had less free health care than women
with permanent urban residence.
Build pilot Healthy Cities in China
10 years after the concept of a Healthy City was first introduced in Canada (panel
8
), China started a small-scale trial of building healthy cities. In 1994, the Ministry
of Health worked with WHO to establish a pilot programme that included two urban districts:
Jiading district in Shanghai and Dongcheng district in Beijing. In 2007, ten cities
and towns were chosen by the Ministry of Health for the expanded pilot programme.
284
In 2015, the State Council of China called for building healthy cities in Opinions
of the State Council on Further Strengthening the Patriotic Health Work During a New
Period, which calls for building healthy cities with Chinese characteristics.
285
Then in 2016, after the Healthy China 2030 plan was passed, the National Health and
Family Planning Commission expanded the pilot programme and chose 38 cities as the
first group to be included in the national programme.
Panel 8
The concept Healthy Cities
WHO defines a healthy city as “one that is continually developing those public policies
and creating those physical and social environments which enable its people to mutually
support each other in carrying out all functions of life and achieving their full
potential.”
281
WHO's Europe Office suggests that a city can become a healthy city if it adopts a
Healthy Cities approach. This approach seeks to improve health in cities through good
urban governance that puts health high on the political and social agenda of cities.
The Healthy Cities approach recognises the determinants of health and the need to
engage all stakeholders to address them; this attitude is supported by a set of core
values, including equity, social inclusion, intersectoral management, and community
participation. These values explicitly imply that urban health development is everyone's
business.
282
In 2016, the National Patriotic Health Campaign Committee of China defined a healthy
city as an upgraded version of a hygienic city, stating that “through the improvement
of urban planning, construction and management, (the city) improves the natural environment,
social environment, and health services and popularizes healthy lifestyles to meet
residents' health needs and to achieve the coordinated development of urban construction
and human health.”
The five main focuses of healthy cities in China are constructing healthy environments,
building healthy society, optimising health services, fostering healthy people, and
developing healthy culture. The six key tasks include constructing healthy cells (healthy
schools, institutions, and communities), establishing health governance models, improving
environmental and sanitary infrastructure, enhancing the safety management of drinking
water, improving environmental quality, and improving public security systems.
283
The Healthy Cities movement in its essence is a social movement that mobilises the
entire society to work together to improve urban health. Both leaders and residents
in urban China are not new to this type of social movement thanks to the success of
the Hygienic Cities movement. The Healthy Cities project in China has unique features.
The participating cities focus on five fields: health service, healthy environment,
healthy society, healthy people, and health culture. Municipal governments serve as
conveners while different government agencies organise and implement specific projects
on the ground. Residents, NGOs, and other social enterprises actively participate
in these projects. The Healthy Cities project has been pushed forward by its inclusion
in governmental plans and implementation of specific projects. These measures are
in contrast with the largely project-driven and non-governmental Healthy Cities project
in developed countries.
9
The difference is also clear in the evaluation methods of healthy cities. Overlaps
on indicators for health and environment can be found by comparing the indicators
used in China with those developed by the WHO Europe Healthy Cities Network (appendix);
we found that half of the indicators had an overlap. The Chinese system has more comprehensive
health indicators and the European system has more environmental indicators. However,
the two indicator systems overlap very little on health service and social indicators.
Overall, the indicator system used in China focuses more on measuring results and
less on measuring actions, policies, and governance.
286
So far, the pilot programme has increased integration of health into all policies
and improved health awareness among urban residents in participating cities.
9
Some innovative ways to promote health literacy in residents have been regarded highly
by WHO, including Shanghai's actions to give every family a health guidance book and
a ruler for measuring waist size as gifts from the city. The successful use of mass
media in health promotion and education is a particular strength of the Healthy Cities
project in China (panel 9
). The pilot programme also helped to improve urban environments. In a paired comparison
of 15 healthy cities with 15 non-healthy cities, the programme helped to increase
the proportion of urban domestic sewage that was treated by 32%, the proportion of
urban domestic garbage treated by 30%, and the proportion of qualified farmer's markets
by 40%.
287
Common reasons for successful projects include strong leadership of the government,
availability of a mechanism for wide participation, and a genuine desire to seek collaboration.
Projects that serve the wellbeing of local residents are more likely to succeed if
they have the full support of the local governments and health-relevant policies based
on local conditions.
288
Although actions taken by cities in China are highly diversified and tailored to local
conditions, actions are often quickly adopted at the national scale once they are
proved effective. For example, free health packages have been given to every household
as a way to promote health literacy in many pilot cities since its first use in Shanghai
in 2010.
Panel 9
Wuxi—health education through mass media
Wuxi, a city that is located in Jiangsu province and has 6·5 million people, used
mass media effectively to promote health literacy among residents in its efforts to
become a healthy city.
The city circulates a weekly newspaper that is entirely devoted to health and has
50 000 subscriptions. The city's television stations shot a 60-epsiode sitcom named
Health 66 in 2010, which was broadcasted in Wuxi and 12 other cities in Jiangsu province.
The Center for Disease Prevention and Control of Wuxi worked with a movie company
to produce a six-episode three-dimensional cartoon on smoking control in 2012; the
cartoon won the first prize in a national competition for education materials on public
health and has been viewed nationwide. In 2016, Wuxi Radio Station broadcasted a 25-min
section on healthy lifestyles every Saturday and Sunday. The radio also has a 2 h
call-in programme on health knowledge every Sunday. Monday to Friday, the Wuxi television
station has a 40-min quiz programme on medical knowledge and a 60-min show named Living
up to 100 Years. On Saturday and Sunday, there is a 90-min programme named Zero Distance
to Medical Experts. Famous experts from different hospitals are invited to discuss
the prevention and treatment for different diseases and answer calls from patients.
In addition to its use of mass media, Wuxi city set up a billboard of health information,
built a library of at least 300 books about health in every community, and recruited
464 volunteers to promote health education in communities. These efforts have led
to a health awareness rate of 85% among urban residents (measured through health administration
surverys), which is the highest rate in Jiangsu province.
The success of Wuxi's use of mass media is a good example of how the Healthy Cities
movement can improve health education and health promotion. The social services sector
in the government (culture, propaganda, civil affairs, and sports) works closely with
the health sector to share health information on mass media and in every community.
The decision and investment by the municipal government to make Wuxi a healthy city
provided the political motivation and resources needed for the two sectors to work
together. This type of intersectoral collaboration has been widely applied in other
Chinese cities.
However, there are also lessons that have been learned. First, although cross-sector
collaboration has been emphasised in the pilot programme, projects are still primarily
restricted to public health system. It is still a challenge to break down traditional
barriers between different government agencies and between governments, NGOs, and
private enterprises.
288
For example, there are some general issues with health education in primary and secondary
schools in general, such as a shortage of qualified teachers and materials. The situation
is worse in less developed regions compared with more developed ones and is arguably
caused by the current arrangement in which the National Health and Family Planning
Commission is responsible for health education rather than the Ministry of Education
because this arrangement means that health education in China is done primarily through
informal education avenues.
249
Furthermore, most projects take on soft targets (ie, health promotion) rather than
difficult issues, such as improvement of infrastructure and equity. There is a huge
discordance between the construction of Healthy Cities and urban planning and development.
Finally, assessments on cities focus too much on results rather than progress.
9
Section 4. Healthy cities as the way forward
Despite the great progress that has been made by Chinese cities to address urban health
challenges, it has become increasingly clear that the the health sector alone, with
its traditional piecemeal approach, cannot effectively resolve the modern challenges
to urban health in China. These challenges will best be addressed through a systems
approach—the Healthy Cities approach. There has never been a better time to develop
healthy cities in China because of the favourable political and economic environments
and the advancements in supporting technologies. However, critical barriers to the
success of healthy cities in China need to be addressed. We make five recommendations
to Chinese cities on how to address these barriers.
Why Healthy Cities?
The health challenges faced by Chinese cities today resemble problems that their European
and North American counterparts had in previous decades. In these settings, urban
sprawl and automobile-dominated transportation contributed to increases in air pollution,
road injuries, sedentary lifestyles, and rising obesity and diabetes, among other
issues.
289
Simultaneously, public health management focused on proximate causes of ill health
rather than underlying urban environments or living conditions, meaning that cities
faced new and resurgent epidemics of infectious disease, increases in chronic diseases,
and widening health disparities between social groups.
290
Cities began to realise that the rising health problems created or exacerbated by
economic growth and urbanisation cannot be resolved solely through the health sector.
A population health approach that engages in the ethical and political dimensions
of these challenges, recognising their inherent complexity and embracing new approaches
to the production of scientific evidence and its translation into policy, will be
required to address these problems.
291
The Healthy Cities approach has been proposed as a framework that is capable of tackling
the complex urban health issues of the 21st century.
292
The European experience of Healthy Cities has shown that societal, economic, environmental,
political, and technological forces can determine the success or failure of Healthy
City approaches to urban development,
293
and there are indications that social, political, policy and other conditions are
right for China to successfully adopt the model. China's experience of adopting a
blueprint for eco-civilisation—and the new directives calling for integration of health
into all policies—provide a highly favourable precedent for the Healthy City policy.
A key goal of China's eco-civilisation is to increase the wellbeing of Chinese people
by balancing environmental protection and economic growth. This aim closely matches
the core commitment of Healthy Cities to manage cities for people's physical, mental,
and social wellbeing.
294
Indeed, the emerging paradigm of planetary health underscores the close relationship
between environmental protection and human health.
295
Meanwhile, China's new health directives already embrace many of the central tenets
of the Healthy Cities approach, including equity, health for all, Health in All Policies,
and innovation in health management.11, 296 Never has there been a better opportunity
for cities in China to serve as a vehicle for the implementation of new health policies,
building on valuable experiences and management networks from the county's Hygienic
City movement, which span from the central government down to townships and communities
across the country.
The Healthy Cities approach demands that effective health interventions come from
an effort to understand the constantly shifting dynamic relationship between the urban
environment and human health and wellbeing. Relationships between variables that affect
human health in urban areas are complex, often nonlinear, and might involve substantial
time delays. They typically are involved in feedback loops, which can reinforce or
reduce effects with beneficial or detrimental results.
297
For example, dockless bike-sharing programmes can promote active lifestyles and mitigate
air pollution but might also increase personal exposure to pollutants and injuries
from road traffic accidents (figure 13
).
111
Urban health interventions should be supported by a conceptual and action framework
that can accommodate the dynamics of multiple sectors and multiple scales. This framework
has important implications for the activities of city governments, which will need
to consider infrastructural, environmental, and sociocultural determinants, and to
create capacity and transparent governance across spatiotemporal scales and sectors.
298
Therefore, cities need to take transdisciplinary, interconnected, integrated and inclusive
approaches—systems approaches—to deal with complex health challenges.
294
The Healthy Cities approach intrinsically includes such a framework.
Figure 13
Dockless bike-sharing programme
An optimal time to develop healthy cities in China
The timing is uniquely favourable to shift urbanisation strategies in China from a
land-centred to a people-centred focus,
299
broadening access to basic public services and improving the livability of cities
through investment in social welfare and infrastructure. A massive docket of proposals
exists for large-scale urban renovation and environmental improvement across China,
offering a unique opportunity to construct healthy urban environments by embracing
health as an essential element in urban planning and design. Continuing economic growth
will enable China to make these key investments in healthy cities; the World Bank
predicts that the national economy will grow at a rate of 5–7% between 2016 and 2030
300
and current government expenditure on health is far behind those in developed countries.
As investments in health increase and the engines of economic growth shift from investment
and export-oriented manufacturing to internal consumption and service industries,
a highly favourable economic environment will emerge for tackling the social and environmental
roots of urban health challenges.
301
Technological advancements are also newly positioned to support the development of
healthy cities in China, including internet and mobile technologies. By the end of
2016, the number of internet users in China reached 731 million and internet penetration
reached 53·2%, which is 3·1% above the global average.
302
The attention paid to mobile health (including applications for mobile devices and
wearable sensors) by capital markets is quickly rising, with large internet companies–such
as Baidu and Tencent Groups–investing heavily.
303
Mobile health applications and services potentially enable great flexibility in their
response to public health needs and rapid growth in the utilisation of internet and
mobile applications in health care will offer radically new models for the distribution
of quality medical resources to China's diverse population.
The tremendous success of the Hygienic Cities movement has paved the way for another
health movement that focuses on cities. Although the Hygienic Cities and Healthy Cities
approaches both focus on urban environments, there are some fundamental differences
between the two. The Healthy Cities project is focused on the population, emphasising
the role of cities in the provision of public services and improved equity, and inherently
embraces a systems approach that is geared towards the recognition of and response
to complexity. The Hygienic Cities movement mostly focused on interventions in infrastructure
management and urban sanitation. The Hygienic Cities movement started at a time when
urbanisation in China had just began to accelerate and urgent environmental problems
linked to rapid urban development were in conflict with the population's rising expectations
for health and quality of life in cities.
6
As China approaches a new phase of urban development, the comprehensive and population-centred
Healthy Cities movement will respond effectively to the complex health challenges
arising from this development and to evolving attitudes towards health in China.
304
In doing so, it will help to address the gaps in equitable health and development
that persist despite the successes of the Hygienic Cities project.
Gaps in the development of healthy cities in China
China's pilot programme for building healthy cities capitalised on national cultural
priorities and competencies, emphasising the importance of strong government leadership
and health services in the achievement of its notable successes. However, as the programme
expands to the entire nation, important gaps needs to be addressed. We assessed current
practice in China by surveying the approaches adopted by 36 cities (appendix). Indeed,
cities in China are acting across multiple domains (panel 10
) with key features that include a strong commitment to clean urban environments,
diverse approaches to fostering cultures of health and healthy lifestyles, and a wide
range of support for the urban poor and disadvantaged. Yet, several important gaps
remain with respect to best practices for building global healthy cities, as highlighted
by the WHO and UN Habitat.
305
Panel 10
Major actions taken by the 36 cities in China to build healthy cities
Actions are in decreasing order by the number of times they were reported.
Governance
•
Form a working team in the municipal government
•
Integrate health into the development plan
•
Evaluate performance of participants
•
Enforce existing laws and regulations
•
Set aside budgets for building healthy cities
•
Conduct baseline survey of health in the city
•
Set up a special office dedicated to the building of the healthy city
•
Assess progress regularly
Healthy environment
•
Control emissions of air pollutants
•
Control water pollution
•
Improve infrastructure and facilities
•
Afforestation and greening
•
Garbage collection, recycling, sorting, and burning
•
Industry transition to low-emission technology
•
Expand public transit systems
•
Use clean energy
•
Enhance environmental monitoring
•
Introduce the market mechanism into pollution control
•
Optimise urban planning and design
Healthy society
•
Expand health insurance coverage and improve reimbursement rates
•
Increase the number of people eligible for social welfare and provide financial assistance
to people in need (people who are poor, handicapped, mentally diseased, homeless,
or have lost their only child)
•
Strengthen care for elderly people
•
Increase education equity
•
Encourage social groups and volunteers to get involved
•
Enhance public safety of the city
•
Create jobs
•
Provide housing assistance to low-income families
•
Mediate interpersonal conflicts
Health service
•
Build a hierarchical structure for the health-care system
•
Invest in health-care facilities and personnel
•
Reduce medical costs and out-of-pocket expenditure for patients
•
Strengthen primary health care (family doctors, general practitioners, and community
health centers)
•
Enhance public health management
•
Control chronic diseases
•
Control infectious diseases
•
Control mental diseases
•
Provide health services to migrants
•
Adopt modern technologies in health management, such as electronic health archives,
telemedicine, mobile health, smart medicine, big data, telemedicine, and health information
data centers
•
Increase the use of traditional Chinese medicine
•
Encourage investment in health care from private sectors
•
Develop health industry (medical centers, pharmaceutical industry, and nursing homes)
Healthy people
•
Promote an active lifestyle
•
Strengthen health services for women and children
•
Monitor physical status of the general public
•
Cultivate health culture: controlled smoking and drinking and healthy diet
Health culture
•
Health education through mass media
•
Health education through the school system
•
Health information through internet and mobile platforms
•
Produce publications of health information
•
Health promotion in public spaces (advertisements and billboards)
•
Build health information centres in communities
•
Organise events and competitions to promote health literacy
•
Disseminate health information through doctors and experts
•
Engage private sectors to cultivate a healthy culture
First, among the practices identified as most important for developing healthy cities
globally is a strong emphasis on urban planning and design, including transit-oriented
development, mixed land use, and pedestrian-friendly design, an emphasis that is echoed
by leading international scholars.306, 307, 308, 309 In China, however, few cities
explicitly state an intent to incorporate health into planning. A wealth of evidence
suggests that poor urban planning and design are root causes for many urban health
problems in China, including risks associated with the separation of living and work
places, road injuries caused by pedestrian-unfriendly environments, and increased
vulnerability to natural hazards. This situation represents a substantial gap in China's
efforts to build healthy cities.
Second, healthy city development requires the involvement and empowerment of the private
sector, NGOs and community groups, public–private partnerships, and citizens themselves,
not only in decision making but at the start of projects. By contrast, cities in China
have mostly taken a top-down approach in which the public is relegated to a secondary
role. This situation reflects the historical cultural and governance context of urban
China, where highly centralised decision making is emphasised and there is a reluctance
to empower non-government decision makers. Although this means that city governments
in China can rapidly adopt and disseminate policies, it also complicates the implementation
of the broad engagement that is essential to good outcomes.
Third, best global practices require intersectoral cooperation and joint action as
prerequisites for dealing with complex urban health issues and recommend working across
sectors in the city government and engaging different levels of government agencies.
Place-based intersectoral action for health has the highest potential to successfully
implement Health in All Policies. Although the importance of intersectoral collaboration
is widely recognised in China, a large proportion of practices that are used by cities
to improve health still focus on health care, health promotion, and health management,
which are all traditional health sector approaches. This situation reflects weak intersectoral
collaboration in the development of action plans.
Fourth, best practices generally emphasise reduction of health inequity as a central
target for all actions and suggest using tools—such as the Urban Health Index and
Urban Health Equity Assessment and Response Tool (HEART)—to establish a baseline to
monitor and evaluate progress. Although most cities in China specify various goals
and metrics (eg, targets for pollution control, urban renewal, social welfare, and
health care), the overall effect of these practices on urban health is rarely assessed
and equity analysis is rarer still. Only a small number of surveyed cities had conducted
a baseline population health survey; the absence of such activities will make it more
difficult to assess the overall progress of urban development policies and programmes.
Moreover, the survey also shows that uneven development is constraining progress.
Although highly developed cities (such as Beijing, Shanghai, and Hangzhou) can address
individual health needs and the social roots of health problems, cities in less developed
zones (such as central and west China) still struggle to provide basic public services,
such as garbage collection, public toilets, and basic medical services. It is very
unlikely that these two types of cities can be fruitfully assessed with the same set
of indicators.
Section 5. Recommendations
Together, these gaps represent a crucial barrier to the achievement of healthy cities
in China. We make the following five recommendations, with full consideration of the
unique character and structure of urban China and of experiences from diverse international
settings.
Integrate health in all policies
Health in All Policies was proposed in China as early as 2013 and has since been reaffirmed
in the Healthy China 2030 plan. The concept is considered fundamental to the future
of health management in China; however, there are major barriers to its effective
use in cities. Although there is a consensus that urban planning is an important way
to facilitate healthy urbanisation and respond to global health challenges,
310
the implementation of Health in All Policies will require the replacement of traditional
modes of urban planning with more sophisticated planning architectures that are capable
of achieving multiple health outcomes, capturing development co-benefits, and supporting
policy development and implementation with indicators and evidence.
311
Although recent changes in China's urbanisation strategy have allowed some integration
of health into urban and regional planning, and thus support the implementation of
Health in All Policies, specific changes are still needed in current planning guidance
and methods.
In particular, the guiding principles of traditional urban planning need to be revised
at national and city levels. At the national level, urban and regional planning can
no longer operate as an isolated sector; it needs to be incorporated into an intersectoral
policy framework that involves the entire society. This change will require collaboration
between the government, civil society, and private sector to develop laws, regulations,
and financial incentives that address the basic tenets of sustainable development,
such as quality of life, health advancement, economic development, and environmental
protection, in complementary and synergistic ways. Innovation and coordination needs
to be promoted through the chain of national policy making, planning, and implementation.
At the city level, urban planning needs to evolve from isolating and tackling individual
elements of the urban system to addressing the whole system.
306
Through urban and regional planning and design, a city needs to achieve horizontal
coordination across sectors and with other cities and vertical coordination in the
administrative hierarchy from the central government to regional and local governments.
To build healthy cities, the traditional urban planning system needs reformation.
First, healthy city planning and assessments of health effects should become fundamental
elements of urban planning. Consistent with the Healthy China 2030 plan, indicator
systems and local standards for healthy city and town planning should be established.
City and town plans need to incorporate sections dedicated to healthy city planning,
which should specify goals and overall action plans through field investigations and
analysis of archived materials. The healthy city planning indicator system should
guide urban land use planning and regulatory plans. The goals should be included in
new development and redevelopment projects, guiding the urban site plan, site design,
building design, and landscape design; such considerations will underpin the legal
basis for issuing planning permits.
Second, to truly implement Health in All Policies, the planning and design of healthy
cities should favour urban development projects that reduce human exposure to pollution,
facilitate physical activity, and incorporate clear measures of health and environmental
effects.
312
Wherever possible, the spatial layout of cities should be compact, open, and with
small gridded blocks,
313
with mixed use and multiple functions that help to reduce rush-hour traffic jams and
reduce commute times.
309
Urban environments should be designed in response to the local climate with abundant
and well designed public spaces, walkways, and playgrounds that match the needs of
neighbourhoods and cities. Site selection, planning, and construction of urban development
projects should comply with environmental effect assessments and green building evaluations,
and the health components of projects should be evaluated via the latest science and
technology, through a mandatory, comprehensive process that assesses the effects on
human health. Residential communities should accommodate people at different income
levels, which in turn can promote employment and services across diverse communities,
help to reduce social separation, and contribute to community care for elderly people.
314
Third, the planning and design of healthy cities should contribute to improved urban
resilience for public health emergencies, including through strengthened capacity
for emergency preparation, response, mitigation, and recovery. Identification of the
characteristics of potential public health emergencies in specific cities would facilitate
the development of public health event scenarios that can be assessed formally through
vulnerability analysis, allowing for estimates of the degree of expected damage, affected
area, and spatiotemporal dynamics of the hazard and health effects. Management plans
and strategies should be based on such assessments and resources should be allocated
to reduce the public health burden of emergencies. With the rapid development of information
technologies for health risk communication in urban environments, vulnerable subgroups
should be identified and targeted communications protocols should be developed to
ensure that information reaches these groups during an emergency.
Increase participation
A basic element of the Healthy Cities approach is broad public participation. Cities
in China generally follow a model in which programmes and projects are led by government
with participation by the public. Nevertheless, analysis of current practices suggests
that the public passively receives all information on project planning and implementation.
Channels need to be established to allow individuals, NGOs, and other social enterprises
to voice their opinions and advocate for their priorities with respect to the health
(and other) dimensions of urban projects, programmes, and their management. Strengthening
bottom-up approaches in China would complement China's traditional top-down approach
to governance and would encourage individuals to act more proactively to improve their
health and the health of their communities. Increased public participation in health
management is a high priority task in the Healthy China 2030 plan, laying the foundation
for a more inclusive Healthy Cities project in China. Without an inclusive, broadly
participatory approach that embraces and builds on local knowledge about health and
environment, interventions for healthy, sustainable urban development are ultimately
likely to fail.
315
In practice, the achievement of broad participation will require substantial changes
in procedures and fora for public participation. For example, community participation
in the planning and selection of sites for health-care and service facilities should
be encouraged, and planning and design processes for the redevelopment of urban communities
should involve the public in decisions about land use and transportation. Representatives
of a full set of stakeholders should be involved, rather than merely the subset whose
views and interests match the government's views. Furthermore, the degree of participation
should be enhanced, aiming for a standard of consensus building rather than coercive
approaches that involve manipulation and therapy participation. Finally, a multiple-channel
approach based on trust and transparency should replace the strict reliance on formal,
top-down formulae for participation and early-stage public involvement should be required
of developers and decision makers.
316
Invest in community capacity building
Community participation is closely tied to community capacity building, which is defined
as “the interaction of human capital, organisational resources, and social capital
existing within a given community that can be leveraged to solve collective problems,
and improve or maintain the wellbeing of that community”.
317
Since the launch of economic reform, there has been a steady growth in registered
NGOs, citizen groups, and private foundations in China. These represent potential
partners in the coproduction of knowledge and codesign of interventions and policy,
as intended in systems approaches for healthy cities. However, the participation of
such communities in decision making is scarce and such an absence of transparency
in decision-making processes has strong repercussions for health. The establishment
of favourable policy and legal environments for and encouragement of investments toward
community capacity building should be high priorities.
Community capacity building has been both a means and an end for health promotion
in general
318
and for the development of healthy cities in particular.
319
Such capacity building should emphasise development of the community assets that are
essential to allow urban dwellers to understand the complexities they face in pursuing
healthy lives; in particular, risks and opportunities for physical and mental health
across different urban population groups and cities. The improvement of health literacy
is a central goal, particularly with respect to health education and communication,
disease monitoring and reporting, health-care service evaluation, and healthy lifestyle
promotion. This approach is essentially bottom-up with institutional support because
the actions that are needed should be rooted in the communities of concern.
Community capacity building will lead to community empowerment, through which urban
dwellers from different population groups and across different cities share the responsibilities
and benefits related to healthy city programmes and policies. Public participation
needs to be a part of health-care system reform and should be supported through urban
planning and economic development. This aspect of community capacity building needs
definite and consistent top-down institutional support so that applicable regulations,
practices, and systems can be established. The community-centred nature of community
capacity building for healthy cities in China requires various components to interact,
including citizens, government and health management institutions, health service
agencies, and actors (NGOs, private enterprises, and other social organisations) within
the broader social and political environment.
Engage the private sector
In the 1980s in China, almost all urban workers were employed by state-owned or collectively-owned
enterprises. By 2016, 80% of urban residents worked in the private sector, which also
generates 60% of national GDP.
30
The private sector has an enormous influence on the health of employees and communities
and a responsibility to address its effect on urban health and the environment. Moreover,
there is emerging evidence that corporate involvement and investment in public health
can create valuable opportunities for business.
320
In line with WHO recommendations,
305
healthy cities in China should use the private sector's potential to provide health-related
services, support the adoption of health-promoting behaviours, and contribute to initiatives
that are relevant to public health. To date, private sector involvement in health
care in China is still small. Just 20% of urban hospitals in 2008 were privately owned
and the market share of private health insurance was not substantial.
321
Just 12·3% of all medical treatment visits between January, and November, 2016 were
to private sector facilities.
322
New policies are needed to encourage the private sector to invest more in health facilities
and provide health services, especially to serve marginalised populations. At the
same time, relevant regulatory and supervisory mechanisms need to be strengthened
to improve the quality and consistency of private sector health care.
323
The private sector also has great potential for new investment in health technologies
(eg, internet health and mobile health). For example, WeChat, which is the most popular
messaging app in China, has been shown to be effective in health promotion, patient
care, monitoring, diagnosis, and public health communication.
324
The private sector should also invest more in employee health and occupational safety.
This situation is win-win because improvements in health can benefit businesses through
reduced health-care expenditures, increased revenue, and improved reputation. Although,
in some cities, privately-owned businesses have been involved in health promotion
campaigns, the scale of such programmes is limited and is essentially based on voluntary
participation. Therefore, there is substantial room for expansion. The private sector
can also contribute to promoting healthy behaviour among customers or consumers more
broadly. For example, a recent collaboration between the public health agency and
a restaurant chain in Beijing aimed to cut salt content in food, benefiting customers
and boosting the image of the company as health-conscious (panel 11
).
Panel 11
Xicheng district, Beijing—engage the private sector to promote healthy diet
Qingfeng Steamed Stuffed Buns Restaurant is a restaurant chain that is famous for
its Beijing local food, especially steamed stuffed buns. The restaurant became even
more popular after President Xi Jinping paid an unexpected visit to one of its stores
and ordered a plate of famous buns for lunch in 2013. The Center for Disease Control
and Prevention in Xicheng district started to work with the Qingfeng restaurant chain
to reduce the use of salt in its buns in 2013. After experiments to find a recipe
that decreased salt content by 10% but did not compromise the taste, Qingfeng began
to sell a low-salt version of steamed buns stuffed with shredded seafood in 2013.
In 2015, Qingfeng added another low-salt version of steamed buns stuffed with bamboo
shoots and sauced pork. Both dishes have sold better than the regular versions. In
2015, 235 Qingfeng stores in Beijing started to offer free low-salt buns to selected
elderly people. Qingfeng also use in-store advertisements, WeChat, and the company
website to promote reduced salt consumption to their customers.
To build on the success of Qingfeng, Huatian Catering Group—which owns Qingfeng—now
works with public health specialists to promote low-salt, low-oil, and low-sugar food
in all its restaurants. The Center for Disease Control and Prevention in Xicheng joined
forces with the Association of Catering Business in Xicheng to promote healthy restaurant
foods. So far, 35 restaurants and cafeterias have been certified for their provision
of healthy foods.
Collaborations between restaurants and public health agencies in China are facilitated
by the power of public agencies to issue health permits to restaurants. However, in
this case, the public health agency in Xicheng district went beyond its role as an
administrator and helped restaurants to develop healthy food. There are many other
ways in which public health agencies in China can use upstream preventions and interventions
rather than focusing on downstream interventions.
The private sector should also be accorded more responsibility for environmental management
and harm reduction. Under the 13th 5-year plan, Chinese businesses will be required
to cut water and energy consumption, air pollutants, and carbon dioxide emissions.
Industries that generate a disproportionate amount of pollution relative to output
need to increase efficiency. Increased accountability in the private sector will lead
to improved urban health.
The motivation of private sector involvement in building healthy cities will require
effort from government, business owners, and employees and customers. City governments
can apply financial and policy tools, such as tax credits, favourable loan and land
policies, and purchase of services, to encourage the private sector to invest in health
care and the health industry and to participate in health promotion. Employees and
customers, once equipped with better knowledge on occupational health and product
safety, can become a driving force for improved health. Business owners should embrace
the opportunities that accompany actions to improve the health of employees, customers,
and the environment. Third-party assessment reports that rank the engagement of businesses
in urban health can be good incentives in this effort.
Promote intersectoral actions
One of the most serious challenges to the assurance of urban health is the formal
segregation of design and management tasks within cities. The complexity of causal
feedbacks across sectoral boundaries can lead to ineffective responses and unintended
consequences if actions address only isolated parts of a larger problem. Further,
health is often narrowly conceptualised in terms of access to medical or public health
services and quality of care, rather than as the result of interacting social, environmental
and economic systems that act in a particular context. This characterisation contributes
to misunderstanding of the health consequences of actions in other sectors. A short-term
vision for decision making can add to this problem. Decisions about urban design or
management based on short-term considerations can fix features of the built environment
but might continue to generate health problems in the long term.
All of these situations have been observed in Chinese cities. Health is often not
a priority for municipal leaders. There are scarce incentives for non-health sector
agencies to contribute and changes in leadership often make it difficult to maintain
intersectoral actions on health. To be successful in the pursuit of intersectoral
actions health, cities in China need to recognise the necessity of whole-of-government
and whole-of-society approaches.
325
For example, cites need to break the barrier of information sharing among different
government sectors (panel 12
). This recognition then needs to cause institutional changes to facilitate intersectoral
collaboration, including formal mechanisms to ensure their long-term sustainability.
Finally, cities should provide incentives for intersectoral collaboration.
Panel 12
Yichang—break the barrier to information sharing among different sectors
Yichang is a city in Hubei province. As of 2015, there are 1·28 million registered
residents in its urban districts. The city started to manage its five urban districts
using a grid system in December, 2010. The 112 urban neighbourhoods were divided into
1421 grids, with each grid containing about 200–300 households. Grids are monitored
by full-time staff who are responsible for reporting anything that happens in their
grid directly to the city information hub through a specialised mobile application.
The information hub is linked to different databases in more than 30 departments and
offices in the municipal government. All relevant databases are updated once new information
comes in.
The Health Management Analysis Center is a component of the hub that started to collect
health data in 2015. It has connections to 173 health-care facilities and 368 pharmacies.
So far, the centre has built 1·3 million copies of electronic archives that, in real-time,
collect patients' health information, including physical exam records, X-ray images,
prescriptions, and other health and medical information. Because the centre is linked
to databases managed by the Public Security Department and the Urban Housing and Construction
Department through the hub, it can trace each person to his or her home. This feature
has been very helpful in the prevention and control of diseases and the allocation
of medical resources. The 1421 grid monitor staff help the centre to collect health
information (such as mental disorders and emergencies) as it occurs in the grid on
a real-time basis and conduct specific surveys on topics, such as health insurance
coverage.
The successful information sharing among different sectors in Yichang can be attributed
to the commitment of city leaders to information technology, its centralised political
system, and its relatively small population size. The grid system and the real-time
information sharing from health-care facilities and pharmacies ensures that there
are no gaps in health information at sub-city levels. Although this approach has merits,
there are concerns about privacy issues and the safety of personal information. There
is an urgent need for laws and regulations that clearly define the boundary and responsibility
of the government, health services, and any other third-party entities on the collection
and use of personal health information in China.
In addition, a mechanism is urgently needed to allow the health effects of urban management
to be assessed and controlled, which will require changes in governance structures
and management procedures. Currently, each city's Patriotic Health Campaign Committee
is responsible for activities related to the Healthy Cities movement. The committee
consists of members from different municipal departments and is led by a vice mayor
or mayor, but its actions are often run by the local health family and planning commission.
This arrangement makes sense when health is narrowly defined as access to medical
or public health services and quality of care, since the local health family and planning
commission is responsible for these functions. However, the need for intersectoral
actions in building healthy cities renders such arrangements obsolete; the Patriotic
Health Campaign Committee office, when subsumed within the health family and planning
commission, does not have the required authority to coordinate multi-sectoral action
for health. To resolve this, responsibility for the administration of the Patriotic
Health Campaign Committee should be transferred from the local health family and planning
commission to the mayor's office. More importantly, the committee should review major
policies and plans for urban development and management, conduct formal assessments
of the health effects where appropriate, and decide whether candidate policies and
projects should be revised to reduce long-term negative effects on health.
To maintain the sustainability of intersectoral efforts, municipal governments should
integrate actions to build healthy cities into long-term governmental plans and legal
and regulatory frameworks. Some cities have already begun such work, including the
Beijing municipal government's Healthy Beijing People: 10-year action plan for promoting
people's health (2009–2018) or Hangzhou's 13th 5-year plan for the construction of
a Healthy City in Hangzhou in 2016. However, most cities do not have a long-term plan
for the development of a healthy city.
It would be naive to assume that intersectoral actions will automatically emerge from
the establishment of an institutional mechanism. Non-health sectors need to be motivated
to address health issues. The success of the Hygienic Cities movement offers some
valuable lessons. Among the keys to its success were the competitive campaigns organised
by the National Patriotic Health Campaign Committee. Although the requirements for
National Hygienic City status are stringent, cities are willing to invest substantial
resources to compete for this recognition. In addition to reputational advantages
for the city itself, attainment of the title is one factor recognised during the assessment
and promotion of city officials, thus the project helps to motivate strong leadership.
326
A well-organised competitive campaign is also linked to the breaking of intersectoral
barriers and the enhancement of public awareness and involvement.
327
Similarly, a reward system should be implemented to incentivise officials at various
levels to seek intersectoral collaborations when building healthy cities. Most importantly,
city performance in terms of health should be incorporated into the criteria used
for the promotion of mayors, as assessed through the indicators discussed.
A lesson fromHealthy Cities projects in Europe is that strong local leadership and
policy change can be driven by international collaboration. International recognition
can be a strong motivating factor for cities and international linkages can provide
insights to and generate innovation for all participants.
328
Chinese cities should actively participate in the international network of healthy
cities, taking leading roles where feasible.
Set local goals for 2030 and assess progress periodically
Building healthy cities in China serves to improve the health of people in participating
cities and to achieve the goals specified in the Healthy China 2030 plan. As discussed,
China's national health goals cannot be achieved without addressing the health of
the 71% of the population that live in urban areas. Actions should therefore address
both goals. Cities in China today vary widely in the extent to which they have taken
actions towards the development of healthy cities and the degree to which they meet
the health needs of their citizens. However, all cities will eventually need—at a
minimum—to meet national targets by 2030, which will require short-term and mid-term
goals and plans that are specific to each city.
To date, goals specified by cities in the pilot Healthy Cities project often reflect
specific actions that address social and environmental determinants of urban health
but not overall progress for health. For example, most cities set specific targets
for the provision of sports facilities in cities, such as exercise facilities within
a 15-min walk of residences. Although the attainment of this target certainly improves
the likelihood that citizens will exercise, the numbers of people who actually exercise
and meet fitness goals is generally unknown. Furthermore, too many specific targets
will make it difficult for politicians and the public to easily gauge progress. Therefore,
targets should be selected on the basis of an understanding of urban systems, prioritising
variables that provide the most information about the city's ability to foster sustainable
health outcomes.
Because all Chinese cities will ultimately need to meet the goals specified in the
Healthy China 2030 plan, we suggest that these are used as the minimum long-term goals
for building healthy cities. Some cities, like Shanghai and Suzhou, have already achieved
some of these goals and can therefore specify higher targets. Baseline health surveys
are needed to allow short-term and mid-term goals to be set on the basis of each cities'
specific status and available resources. This process should be combined with a systematic
analysis of existing strengths and gaps in health management to ensure action plans
are tailored to local needs.
Regular assessments of progress should follow the adoption of goals and be based on
a combination of self-evaluation and third-party evaluation. The indicator system
for healthy cities developed by the National Patriotic Health Campaign Committee provides
detailed data, allowing health experts to identify drivers of progress or hurdles.
However, because the system is not easily understood by the public, a simplified indicator
system is needed. As a starting point, we suggest a system based on three indicators:
life expectancy, premature death rate from chronic diseases, and a composite index
derived from the WHO HEART tool. The first two are included in the Healthy China 2030
targets and reflect the status of health and of the health-care system, respectively,
in metrics that are easy to understand. Both indicators are monitored regularly by
the Disease Surveillance Points System so no extra effort will be required. The third
indicator reflects the status of health inequity. Since health for all is a guiding
principle in the Healthy China 2030 plan and an international focus, it is key that
progress in this area be measured. Most indicators in the WHO HEART tool are also
used in the indicator system for healthy cities in China and should therefore be easy
to attain. This simplified indicator system can be used to evaluate the performance
of mayors and inform the public on progress made toward health goals.
High-quality data are a precondition for realistic goals and the measurement of progress.
Although China has built strong surveillance networks to monitor diseases, risk factors,
and the health history of citizens, data availability at city level is still poor
and the quality of data generated by different networks is highly variable.
243
Data at the sub-city level are also crucial,
305
but have rarely been available in urban China. Monitoring networks are urgently needed
in cities to provide timely and accurate information on the status of urban environments
and resident health. Strengthened government-operated monitoring networks should be
complemented by collaboration with private companies on big-data technologies. For
example, diseases in cities can in some cases be tracked using internet query data,
which was the case for hand, foot, and mouth disease in Chengdu (figure 14
, appendix). Data from governmental networks can be integrated with data from wearable
sensors, mobile platforms, the internet, and remote sensing to establish an urban
health monitoring network that is multi-scale, long lasting, and real time.
Figure 14
Hand, foot, and mouth disease in Chengdu, 2013–16
Weekly number of cases reported to the Sichuan Center for Disease Control and Prevention.
Enhance research and education on healthy cities
The magnitude of the health challenges facing Chinese cities is much larger than in
Europe and North America because of the relative size of its urban population and
rate of socioeconomic change. New thinking and innovative ideas will be needed to
successfully apply the Healthy Cities approach in this context; existing methods need
to be rigorously assessed before large-scale adoption. In particular, research based
on integrated monitoring through modern technologies, interdisciplinary studies, and
quantitative modelling will need to be further advanced to support the development
of healthy cities.
It will be extremely useful for cities to understand the health effects of management
measures that have been or will be taken. However, the prediction of potential health
effects or attribution of changes to particular policies and actions is rarely straightforward.
In Europe, the realist evaluation framework has been proposed as a way to tackle the
complex evaluation of the health effects and outcomes of the Healthy Cities movement.
329
As discussed, we propose an interdisciplinary approach that is based on both qualitative
and quantitative analyses of future scenarios and a consideration of demographical,
socioeconomical, environmental, and political conditions. Individual environmental
exposure and physiological indicators at the city level, effects of environmental
factors on the morbidity and mortality of urban population, and risks of disease transmission
via population migration networks on a global scale should be comprehensively analysed
with the support of advanced models (eg, to integrate cities as a module into the
Earth system simulator). A better understanding of the underlying mechanisms and causal
systems that affect urban health will lead to improved policy making and forecasting
of the health effects and outcomes of management measures. In addition, more systematic
measurement and assessment of all dimensions of urban health on local, regional, and
global scales would provide unbiased data for forecast models and support evidence-based
policy making. The Chinese Government should increase investment in research and development
and form partnerships with universities, research institutes, and the private sector
to enhance research in these fields.
Finally, urban planners and public health practitioners are fundamental to the success
of the Healthy Cities movement in China; traditional training in these fields needs
to evolve to meet current needs. Curricula for urban planning programmes in higher
education institutions should expand to include topics related to the interactions
of society, environment, economy, and health. Urban planning elements as diverse as
housing, transportation, information technology development, and land use can affect
health through their influence on food access, physical activity, housing quality,
health information, access to care, transport choice and affordability, school locations,
social equity, clean air and water, and other factors.
330
Therefore, a multi-scale, cross-sectoral vision of urban health should be built into
city and regional planning programmes to ensure that urban planners are fully aware
of the various elements required for a healthy city. If health cannot be given proper
consideration in the design and planning of districts, communities, individual buildings,
and urban infrastructural elements (such as roads), the healthy functioning of an
entire city is unlikely to be achieved. A healthy city should also have the capacity
to shield its citizens from potential health risks. Correspondingly, the curricula
of public health programmes should provide the skills and knowledge needed to work
together with urban planners to jointly develop strategies that address the root causes
of poor health, rather than simply targeting specific diseases or individual behaviours.
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Looking forward
Urbanisation in China will continue to advance in years to come, sustained by policies
that favour sustainable urban development and economic initiatives centred in cities.
As long as the unprecedented pace and scale of urban growth continues, the health
and wellbeing of millions of urban residents and the sustainability and livability
of cities in China will depend on decisive action to secure and strengthen the Chinese
Dream for future generations. Because of their dominant role in China's political,
social, and economic systems and as the focus for scientific and technological innovation,
cities are key to the successful control of health challenges both within and beyond
city boundaries. In the words of Jaime Lerner, “cities are not the problem; cities
are the solution”.329, 331 Four decades ago, as a result of health innovations like
barefoot doctors and community health care centres, China improved the health of millions
of rural dwellers, thus providing the world with a model for good health at low cost.
332
Today, the drive to develop healthy cities in China and create the world's first ecocivilisation
is set in the context of an unprecedented global push for sustainable development,
in the form of the Sustainable Development Goals and the paradigm-shifting idea of
planetary health. These powerful ideas reinforce and support one another and give
us confidence that cities in China can face the aforementioned challenges and once
again lead the world in securing sustainable health for all.