Executive Summary

The Chinese government has made a strong political commitment to achieving the
healthrelated SDG targets, particularly by issuing the Healthy China 2030 Planning Outline
(Healthy China 2030) in 2016 by the State Council. China faces unique health challenges in
addition to those common to middle-income countries. These include the highest hepatitis
burden in the world, accounting for one-third of the 240 million people living with chronic
hepatitis B, and lacking an effective, comprehensive hepatitis disease control program. More
than 300 million smokers live in China, around one third of the world’s total, yet limited
prevention measures exist. China accounted for around 35% of global deaths due to ambient air
pollution in 2013 but faces substantial challenges to improve air quality. There are further
significant challenges to reducing regional social and health disparities in the context of sluggish
economic growth, enlarging income gaps, an aging population, and urbanization.

Background
The Sustainable Development Goals (SDGs), also known as the Global Goals, were
adopted by all United Nations Member States in 2015 as a universal call to action to end poverty,
protect the planet and ensure that all people enjoy peace and prosperity by 2030.
China has achieved almost all of the Millennium Development Goals (MDGs), including
substantial reductions in extreme poverty, increased access to primary and secondary education,
and improved environmental sustainability and gender equality. On three health-related MDGs,
China exceeded average progress globally between 1990 and 2015. This includes an average
reduction in neonatal, infant, and under-five mortality of over 80% and a reduction of 74.9% in
maternal mortality. HIV/AIDS prevalence has remained low, with over 80% of eligible patients
receiving antiretroviral treatment. New cases of tuberculosis (TB) and malaria have continued to
decline. The key drivers of success in achieving the MDGs in China include economic growth,
increased public investment in health, the development of health-related laws and regulations,
the establishment of state-supported health insurance schemes to increase population coverage,
and multisectoral coordination and collaboration domestically and internationally.
Building on the success of the MDGs that ended in 2015, the United Nations (UN)
Sustainable Development Goals (SDGs) constitute the new development agenda until 2030. Of
the 17 SDG goals, only goal 3, “ensure healthy lives and promote well-being for all at all ages,”
explicitly addresses health, although 10 other goals involve health-related indicators. To monitor
and evaluate the progress of member states, the Inter-Agency and Expert Group on SDG
Indicators announced a total of 232 monitoring indicators, 50 of which are health related.
A number of initiatives have been launched to track global progress toward health-related
SDGs, including Monitoring Health for the SDGs, Atlas of the SDGs, Index and Dashboards,
and Global Burden of Disease (GBD) Study.
The Chinese government has made a strong political commitment to achieving the
healthrelated SDG targets, particularly by issuing the Healthy China 2030 Planning Outline
(Healthy China 2030) in 2016 by the State Council. But according to this recent article in PLOS
Medicine, written by us along with collaborators in China, China’s progress toward the 2030
Sustainable Development Goals (SDGs) is unimpressive, even worrying. Without effective
policy interventions; new drugs, vaccines, and other technologies; and greater public spending,
China will achieve only 12 out of the 28 health-related SDG targets.

Problem

China faces formidable challenges in achieving the health-related SDGs. A recent

analysis of the GBD Study 2017 found that China ranked 88th among the 195 countries and
territories evaluated based on the health-related SDG index, an overall measure of the 41
healthrelated SDG indicators (the definition of each indicator can be found in another article
published elsewhere). China scored 62 in the health-related SDG index, slightly higher than the
global median index of 59.4 but much lower than the top three countries, which all scored 83.0.
China performed especially poorly in hepatitis B incidence, air pollution mortality, poisoning
mortality, and mean particulate matter (PM) 2.5, with the indices all below 40.

Our research identified five key health challenges that China must meet in order to be successful.

1. Hepatitis. China has not developed a comprehensive national plan for hepatitis control,
despite having the highest hepatitis burden in the world. Existing hepatitis control efforts
such as HBV vaccination for children, transmission from mother to baby prevention, and
some hospital-based safety measures are managed by different agencies with unstable
financing. Recent research found that rates of case notification and effective treatment of
hepatitis are low because of poor diagnosis, high health care costs, and stigma.
2. Tuberculosis. China has the second largest number of patients with MDR-TB and the
case notification rate is very low. In 2016, only 2,016 patients with MDR-TB were
detected, of which only 68 percent have been put on treatment, although the situation has
improved slightly in recent years. Without detection or effective treatment, ending the
epidemic of MDR-TB is impossible.
3. Noncommunicable diseases. There are insufficient prevention and health promotion
efforts to address the risk factors for NCDs including smoking, drinking, physical
inactivity, being overweight, and diet-related deficiencies. Mental health is a neglected
issue in China as well. As the leading cause of death in China, NCDs will continue to be
a major disease burden during the next decade.
4. Out-of-pocket spending. Government spending on health has increased significantly.
However, almost a third of the total health expenditures were borne by households as out-
of-pocket payments. Consequently, a big part of the financial burden of health care falls
on service users, particularly the poor in rural areas. Additionally, the majority of
expenditures were directed to treatments while public health programs, of which many
have been proved to be cost-effective in disease prevention and control, barely received 6
percent of total spending.
5. Aging. The final grand challenge that China needs to tackle in the upcoming decades is
the health of a rapidly aging population. In 2017, there were over 228 million people
aged over 60 years in China, and this number is projected to double by 2050. These
dramatic changes in population age structure will lead to a rising burden of age-related
 diseases, geriatric syndromes, and caregiving, which has profound implications for
China’s health care system.

Policy Options

To achieve the health-related SDGs, China needs to do three things:

1. China has to develop an action plan that prioritizes key policy interventions for target
populations. As an emerging policy and public health priority in China, population aging
calls for aligning the health system with an aging population to provide affordable and
high-quality health and long-term care services to achieve healthy aging and universal
health coverage. This action plan must include ways to mobilize adequate resources to
tackle these challenges.
2. China must take a series of concerted actions including but not limited to increased
investment in public goods and services for health, addressing rural-urban and regional
inequities, tackling new emerging health challenges, and ensuring that no one is left
behind.
3. Finally, China has to tackle several cross-cutting issues such as better regulations,
effective organizational structures, and rapid human resource development in order to
meet the health-related SDG targets.

China’s success in reaching the MDGs between 2000 and 2015 made the world confident that it
would be equally successful between 2016 and 2030, and hit the SDG targets. Our work provides
a warning that China is no longer on track to meet its health goals. Indeed, unless it acts quickly
and comprehensively, it will miss more than half of health-related SDGs.

Key areas for policy change and implementation

a. Tackling child overweight and obesity

International experience shows that increasing taxes on sugar-sweetened drinks, subsidizing
healthy foods/diets, implementing school-based nutrition interventions, and regulating food and
drink sale markets would have positive impacts on the reduction of overweight and obesity.
Therefore, appropriate strategies, policies, laws, and regulations should be developed and
implemented to address this rising problem.

b. Improving breastfeeding
Many strategies could be used to increase breastfeeding in China: establishing more baby-
friendly hospitals and clinics; expanding health education programs, including peer
education/support; targeting not only women of reproductive age but also the public as a whole;
and setting up more places friendly for breastfeeding at working units and communities.

c. Enhancing access to reproductive health services including

strengthening sexual education
Induced abortion has increasingly become a very serious problem, particularly among unmarried
women and teenage girls in China. The government needs to improve access to reproductive
healthcare, particularly for vulnerable groups, and develop more health education programs via
social media, public adverts, or school-based education platforms. Contraceptive services and
products should be made more easily available and covered by either the government budget or
health insurance to all those who need it (not just married women).

d. Strengthening care and control of key infectious diseases

China has developed and implemented good policies and taken appropriate actions on
HIV/AIDS over the past decades. Nevertheless, China should also develop more proactive
policies and actions on tackling TB/MDR-TB and hepatitis B and C—the top three infectious
diseases in terms of burden of disease and number of patients. More favorable policies should be
developed by health insurance schemes in China to support these patients to seek affordable
care, including new diagnostics and drugs, as required. The government budget earmarked for
control of these diseases should be increased, and better used, and funding for public health
intervention programs should be allocated toward these priorities.

e. Developing and implementing effective preventive

interventions for
NCDs

Community-based interventions, particularly targeting key risk factors of NCDs, must be

developed and implemented in order to prevent more people from developing NCDs. A set of
concerted interventions, including the enforcement of relevant health legislation (e.g.,
implementing the Framework Convention on Tobacco Control); increasing tobacco and alcohol
taxes; strengthening the control on the packaging and advertising of tobacco products; ban on
public smoking; adopting social media to promote healthy lifestyles including reducing the
intake of salt, cooking oil, and sugar; increasing physical exercise; and improving air quality,
must be developed under the auspices of the national health commission, in collaboration with
other relevant ministries, and with the support of local governments at different levels.

f. Developing adequate systems to address the rise in mental health challenges

China has a significant number of people who require mental health care, especially people with
depression and anxiety. However, it has not yet established a system within the health sector to
address the needs of, and demands for, mental health care. Prioritized actions might be the
development of school-based life skills training for young people, and community-based mental
care including treatment of depression and other common mental illnesses.

g. Adapting effective interventions to reduce road injuries

Safety belts [78], safety seats for children [79], and helmets [80] are very cost-effective ways to
reduce road injuries. Laws, regulations, and public education should be enforced and
implemented at the same time to increase the awareness of the public.

Recommendations

China needs to take concerted actions to overcome challenges and achieve the health-
related SDGs. In those areas in which China has already achieved the SDG targets—for instance,
in maternal and child health and nutrition—the government should synthesize the experiences
and best practices that can be applied to the provinces that need to catch up. These experiences
and best practices could also be disseminated to other low- and middle-income countries that are
developing their national strategies in advancing the health-related SDGs via South–South
cooperation and the Belt and Road Initiative.
The government needs to examine the root causes of the health problems in areas in
which China has formidable challenges in achieving the health-related SDGs by 2030 and
develop and implement a feasible action plan under the current socioeconomic context of China.
Then, the plan should prioritize key policy interventions for the target population and mobilize
adequate resources to tackle these health challenges. Given the limited available health
resources, it is critically important to identify which populations should be prioritized for which
interventions and develop appropriate approaches to reach these targeted populations. For
example, reproductive health interventions may be targeted to rural-to-urban migrant women and
adolescents and students from universities and middle and high schools. To better control
infectious diseases (e.g., TB and hepatitis), poor and other vulnerable groups should be
prioritized. In addition, it is important to address common problems by tackling cross-cutting
issues in advancing the health-related SDGs. Key strategies include (1) enhancing the
enforcement of the health-related laws and regulations, (2) establishing an effective
organizational structure of government agencies and defining their responsibilities and functions
clearly for implementing health-related SDG targets under the auspices of the State Council, and
(3) strengthening the development of human resources for health, especially for the least
developed regions.
The improvement of the Chinese people’s health status lies not only in health sector
development but also in the overall sustainable development of socioeconomic and other sectors.
China needs to imbed health into all the national and provincial policies, increase health
investments, and improve financing mechanisms to provide better financial protection for those
seeking essential healthcare.