To Battle CVD in China, the ‘Healthcare Pyramid’ Must Be Flipped

China’s current healthcare system is too weak to combat the rising tide of CVD among the country’s estimated 1.4 billion people, mainly due to lack of targeted public health efforts and an ineffective primary care network, researchers conclude.

An aging population, high dietary salt intake, and consumption of one-third of the world’s cigarettes provide a partial explanation for the approximately 45% increase in CVD that occurred in China from 1990 to 2013. This rise is quadruple that of the United States in the same time period and triple that of Europe, Xin Du, MD, PhD (Capital Medical University, Beijing, China), and colleagues report in a paper published online June 17, 2019, ahead of print in the Journal of the American College of Cardiology.

“Increasing the numbers of beds and facilities, with a focus on cure, is only a temporary solution. Greater efforts are required to strengthen primary care with integrated solutions for preventing and managing chronic conditions,” they write.

Lack of manpower is another significant obstacle, with “no effective systems for monitoring the update and effectiveness of BP control and other CV prevention strategies in primary care in China,” Du and colleagues note.

The Chinese government has launched a number of national programs aimed at improving various aspects of health, including mandating nutrition labeling for packaged food, banning smoking in public places and increasing the tax on cigarettes, reducing inhaled particulate matter, and encouraging better overall diet and fitness among the general population. About 10 years ago they also launched a national program to provide free essential public health services, which marked the start of more structured primary care in the country, Du and colleagues point out.

While preliminary data suggest that some public health measures such as hypertension control are working and medication use and blood pressure monitoring are increasing, “the primary care workforce is insufficient to deliver effective care to the approximately 200 million high-risk members of the Chinese population, and much of the existing health workforce does not have adequate skills to manage those with hypertension or have access to appropriate antihypertensive medications,” they write.

Flipping the Pyramid

In the paper, they argue that the entire healthcare pyramid of China needs an overhaul. In its current state, the pyramid has tertiary care as its base, with primary care and public health promotion filling the narrow top portion.

“Investing more resources to primordial care, strengthening primary care, and improving the quality of tertiary care will flip the inverted pyramid of the healthcare system and improve the effectiveness of the management of cardiovascular disease in China,” Du et al write.

“Sure, it's doable,” said Jeffrey P. Koplan, MD, MPH (Emory University, Atlanta, GA), an expert on the Chinese healthcare system who was not involved in the study. He told TCTMD that while there is plenty of reason for optimism that the country can make needed improvements and restructure the healthcare pyramid, it will take time, vision, and adequate resources.

"Fortunately, China has demonstrated its ability to confront a need and address that need,” Koplan said, citing drastic improvements the country has made to its transportation infrastructure in recent decades as well as successful ongoing efforts to ban smoking in public places that he has witnessed firsthand.

“It gives me great hope for the future that as people in China recognized the harms, they will improve,” Koplan noted.