Health system reform in China: the challenges of multimorbidity
Authors: Tiemin Zhai, John Goss
Journal: The Lancet Global Health (2020)

As ageing in the global population accelerates and life expectancy increases, disability and multimorbidity has become a substantial challenge for the global health system.1Whitty CJM MacEwen C Goddard A et al.Rising to the challenge of multimorbidity.BMJ. 2020; 368l6964Crossref PubMed Scopus (106) Google Scholar Multimorbidity increases the complexity of diagnosis and treatment of non-communicable diseases, reduces a patient's quality of life, and is associated with an increase in risk of death.2Nunes BP Flores TR Mielke GI Thumé E Facchini LA Multimorbidity and mortality in older adults: a systematic review and meta-analysis.Arch Gerontol Geriatr. 2016; 67: 130-138Crossref PubMed Scopus (313) Google Scholar In The Lancet Global Health, Yang Zhao and colleagues3Zhao Y Atun R Oldenburg B et al.Physical multimorbidity, health service use, and catastrophic health expenditure by socioeconomic groups in China: an analysis of population-based panel data.Lancet Glob Health. 2020; 8: e840-e849Summary Full Text Full Text PDF Scopus (98) Google Scholar examined socioeconomic group differences in the prevalence of physical multimorbidity, and the association between physical multimorbidity, health-care use, and catastrophic health expenditure. They found that multimorbidity presents substantial challenges for China in promoting healthy ageing, as proposed by the Healthy China 2030 strategy.4Chen P Li F Harmer P Healthy China 2030: moving from blueprint to action with a new focus on public health.Lancet Public Health. 2019; 4: e447Summary Full Text Full Text PDF PubMed Scopus (58) Google Scholar Several innovative findings from this study suggest options for better health policies for China and low-income and middle-income countries. Zhao and colleagues found that the prevalence of physical multimorbidity was higher in poorer regions than in more affluent regions, and that physical multimorbidity is strongly linked to increased health service use and the occurrence of catastrophic health expenditure. These findings highlight how health system reform in China could be improved. We believe that the high prevalence of physical multimorbidity identified in this study among the older population is indicative that China should consider changing from a fragmented health service provision system to a health care system that integrates preventive care and medical treatment, and manages patients with non-communicable diseases holistically. In particular, focus should be given to reducing the prevalence of risk factors.5Yang G Kong L Zhao W et al.Emergence of chronic non-communicable diseases in China.Lancet. 2008; 372: 1697-1705Summary Full Text Full Text PDF PubMed Scopus (410) Google Scholar Because physical multimorbidity is associated with increased use of health-care services and increased likelihood of catastrophic health expenditure, China should consider changing health insurance payment rules to improve financial risk protection for patients with physical multimorbidity. Specifically, moving from a fee-for-service and single disease-based payment system to a comprehensive payment system would enable coexisting non-communicable diseases to be treated and reimbursed efficiently. Additionally, more outpatient services related to non-communicable diseases should be included in the benefit packages of national basic health insurance schemes and the reimbursement level should be increased, because household out-of-pocket payments on outpatient services have been found to be a major driver of catastrophic health expenditure.6Saksena P Xu K Durairaj V The drivers of catastrophic expenditure: outpatient services, hospitalization or medicines? World Health Report (2010) background paper, 21. World Health Organization, Geneva2010Google Scholar These changes might rebalance health insurance benefits away from inpatient services. The higher prevalence of multimorbidity among the poorer regions relative to the more affluent regions supports a movement to take measures to promote poverty alleviation in China, since, as stated by the Chinese Government, 2020 is the year to achieve the goal of “building a moderately prosperous society in all respects”, and the year to overcome poverty.7Li K Report on the work of the government. The State Council of People's Republic of China, March 16, 2019http://english.www.gov.cn/premier/speeches/2019/03/16/content_281476565265580.htmDate accessed: April 20, 2020Google Scholar Preventing and treating non-communicable diseases more effectively will also reduce poverty because non-communicable diseases are a major determinant of poverty.8Islam SMS Purnat TD Phuong NTA Mwingira U Schacht K Fröschl G Non-communicable diseases (NCDs) in developing countries: a symposium report.Global Health. 2014; 10: 81Crossref PubMed Scopus (244) Google Scholar Further analysis of which diseases are the most common causes of multimorbidity among the older population, increase health service use the most, and are the major drivers of catastrophic health expenditure would be useful to develop efficient targeted approaches to address the challenges caused by multimorbidity. Different combinations of comorbid conditions will require different approaches to prevention and treatment. In summary, Zhao and colleagues have contributed new knowledge that will assist with improving health system reform to promote healthy ageing and reduce inequities. We declare no competing interests. Physical multimorbidity, health service use, and catastrophic health expenditure by socioeconomic groups in China: an analysis of population-based panel dataConcerted efforts are needed to reduce health inequalities that are due to physical multimorbidity, and its adverse economic effect in population groups in China. Social health insurance reforms must place emphasis on reducing out-of-pocket spending for patients with multimorbidity to provide greater financial risk protection. Full-Text PDF Open Access