Harnessing the opportunity to achieve health equity in China
Authors: Zhicheng Wang, Ge Yang, Yan Guo
Journal: The Lancet Public Health (2021)

The Chinese Government has transformed its development paradigm in the past 4 years. It has gradually shifted its goal from the efficiency-orientation model towards one which prioritises social equity and sustainability. Indeed, it has reported having eliminated absolute poverty by 2020,1CGTNZero poverty: China eliminates absolute poverty one month before self-imposed deadline.https://news.cgtn.com/news/2020-11-23/China-eliminates-absolute-poverty-one-month-before-schedule-VEp8VAJJS0/index.htmlDate: Nov 23, 2020Date accessed: August 25, 2021Google Scholar and stated in the Central Financial and Economic Affairs Commission of the Chinese Communist Party, that the need for income redistribution should be emphasised, and that highly profitable enterprises should make greater contributions to address social disparity in China, to boost social justice and equity.2Financial TimesChina's Xi calls for wealth redistribution and clampdown on high incomes.https://www.ft.com/content/87c3aa02-f970-48c8-b795-82768c9f7634Date: Aug 17, 2021Date accessed: August 25, 2021Google Scholar As a pivotal component of social equity, health equity is the equal opportunity to attain full health potential regardless of one's socioeconomic position. Therefore, the shift of the focus of the macropolicy towards social equity might also indicate the need to promote health equity in China. The social determinants of health are the structural and systemic factors that influence health. Thus, it is crucial to address the social determinants of health to achieve health equity, which will not only improve the health status of vulnerable populations, but also refine social structure and boost social equity. Health equity is a multidimensional concept, and in respect of the widely acknowledged PROGRESS framework,3O'Neill J Tabish H Welch V et al.Applying an equity lens to interventions: using PROGRESS ensures consideration of socially stratifying factors to illuminate inequities in health.J Clin Epidemiol. 2014; 67: 56-64Summary Full Text Full Text PDF PubMed Scopus (376) Google Scholar health inequities can be reflected in multiple dimensions, such as geographical region, race or ethnicity, occupation, level of education, and economic status. For instance, geographical and ethnic disparities in maternal and under-5 child mortality rates have been reported for China.4Wang Y Li X Zhou M et al.Under-5 mortality in 2851 Chinese counties, 1996–2012: a subnational assessment of achieving MDG 4 goals in China.Lancet. 2016; 387: 273-283Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar, 5Liang J Li X Kang C et al.Maternal mortality ratios in 2852 Chinese counties, 1996–2015, and achievement of Millennium Development Goal 5 in China: a subnational analysis of the Global Burden of Disease Study 2016.Lancet. 2019; 393: 241-252Summary Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 6Huang Y Shallcross D Pi L et al.Ethnicity and maternal and child health outcomes and service coverage in western China: a systematic review and meta-analysis.Lancet Glob Health. 2018; 6: e39-e56Summary Full Text Full Text PDF PubMed Scopus (27) Google Scholar Substantial regional variability in the levels and trends of maternal and child mortality has also been reported between counties in China.4Wang Y Li X Zhou M et al.Under-5 mortality in 2851 Chinese counties, 1996–2012: a subnational assessment of achieving MDG 4 goals in China.Lancet. 2016; 387: 273-283Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar, 5Liang J Li X Kang C et al.Maternal mortality ratios in 2852 Chinese counties, 1996–2015, and achievement of Millennium Development Goal 5 in China: a subnational analysis of the Global Burden of Disease Study 2016.Lancet. 2019; 393: 241-252Summary Full Text Full Text PDF PubMed Scopus (50) Google Scholar Children younger than 5 years of ethnic minorities were found to be lagging behind in service coverage, with higher odds of mortality and lower access to child health-care services than Han children.6Huang Y Shallcross D Pi L et al.Ethnicity and maternal and child health outcomes and service coverage in western China: a systematic review and meta-analysis.Lancet Glob Health. 2018; 6: e39-e56Summary Full Text Full Text PDF PubMed Scopus (27) Google Scholar Population-based observational or surveillance studies in China seldomly report their findings by social determinants of health features, and thus only the status quo is presented, without further insight of health status across subgroups. Additionally, as appealed by Sustainable Development Goal 17,7UN Department of Economic and Social AffairsSustainable Development Goal 17: Strengthen the means of implementation and revitalize the global partnership for sustainable development.https://sdgs.un.org/goals/goal17Date: 2021Date accessed: August 25, 2021Google Scholar the importance of collecting data on social determinants of health to generate disaggregated health data has been further emphasised, especially in the COVID-19 era.8Khalatbari-Soltani S Cumming RC Delpierre C Kelly-Irving M Importance of collecting data on socioeconomic determinants from the early stage of the COVID-19 outbreak onwards.J Epidemiol Community Health. 2020; 74: 620-623PubMed Google Scholar The current policy designation in China also does not contain a clear description of the concept of health equity, with only a limited focus on urban–rural disparities in health. There is clearly a gap in health equity in China, and we need a more systematic and comprehensive monitoring framework for the social determinants of health in both academic and policy environments. There have been extensive efforts by the Chinese Government to alleviate absolute poverty over the past 8 years. A variety of poverty-reduction health policies and programmes have been launched in impoverished areas, and it has substantially improved the general wellbeing of the poorest with some success.9CGTNPoverty alleviation via healthcare.https://news.cgtn.com/news/2019-10-17/Poverty-alleviation-via-healthcare-KQ2aiQGjiE/index.htmlDate: Oct 17, 2019Date accessed: August 25, 2021Google Scholar However, there remains no operationalised definition of health equity with regards to health policies. For example, there was no clear plan or action to monitor health equity, particularly in populations with different socioeconomic positions. As per the Healthy China Action plan,10Chinese GovernmentHealthy China Action (2019–2030).http://www.gov.cn/xinwen/2019-07/15/content_5409694.htmDate: July 15, 2019Date accessed: August 25, 2021Google Scholar the goal to achieve health equity by 2030 has been stated, and more than 100 health indicators have been proposed to improve health behaviours and outcomes. However, the indicators were all related to the measurement of aggregated health status, and thus there seems to be inadequate attention to the distribution of health indicators in populations with different socioeconomic status. This could potentially undermine the efforts by the Chinese Government to alleviate poverty, because the absence of a monitoring framework for health equity is like a missing piece of the puzzle in the big picture of health equity. Therefore, in light of the high-level political commitment to strengthen social equity that is already in place, we call for more operationalised policies to improve the current situation of health inequity in China and to address the health equity problem in a more systematic way. Chinese health departments should take advantage of China's development paradigm shift to emphasise health equity in Healthy China 2030, and should identify the main connotations of health equity, monitor the development of relevant health indicators and health equity, and make continuous efforts to achieve better health and health equity by 2030. We declare no competing interests.