Managing the hypertension pandemic in China: a call for system thinking

Non-communicable diseases (NCDs) are threatening global sustainable development. The hypertension pandemic has gained a lot of concern in China recently for both policy makers and analysts. In spite of the severity, international evidence has illustrated that hypertension could be well managed with low-tech, cost-effective and feasible interventions that are delivered from qualified primary care, even in low resource settings.

The management of hypertension has been unsatisfactory in China for more than two decades. Though plenty of effort was made by the public health community in managing the pandemic of NCDs, only until recently, attention has been drawn to health system level factors that may make a change.

Accompanied by the paradigm shift to a “diagonal” approach of disease control, efforts are called by the WHO to harmonize the country’s health system in providing universal essential health care. It seems that there’s a lack of evidence when attempting to answer the “how” question, particularly for low-and middle-income countries (LMICs).

A recent systematic review conducted in 2013, for example, identified 53 studies that analyzed the effects of health system strengthening efforts on hypertension awareness, treatment and control. Among these, only 11 were conducted in LMICs, where only one study was from China. This study, however, did not explore any mechanism of health system strengthening efforts to improve hypertension management.

In order to learn more about how China are improving the country’s health system to manage the hypertension pandemic, we conducted a review which was published in Global Health Research and Policy.

What did we do?

We first developed a conceptual framework based on the WHO health system monitoring and evaluation framework and the six building blocks framework to illustrate how health system factors influence the outcome and impact of hypertension management.

The framework divides these system level inputs into six domains, namely health system governance, physical resources for health, health financing, human resources for health, health information, and health service delivery.

A search, based on the framework, was conducted through PubMed and CNKI with key words such as ‘hypertension’, ‘delivery of health care’ and ‘healthcare financing’ etc. and approximately 591 publications were identified with 93 screened out by title and abstract.

A majority of the results (29) were epidemiological searches purely described by prevalence, awareness, treatment and control of hypertension in China or they reported the experiences of community based ‘on health promotion programs’ (31).

Only 11 results focused on finding a solution for hypertension management from a systematic perspective; this reflected the policy makers generally neglected systematic thinking.

Although a lack of evidence has been found in this review,  health financing draws the most attention. Depending on insurance coverage or whether it’s mandatory or voluntary, finance has a great effect on the management of one’s hypertension management.

What did we learn?

The prevalence of hypertension has been rising rapidly in China. Our systematical search found quite a few epidemiological researches on the prevalence, awareness, treatment and control of hypertension in China which had been intentionally described.

The management of hypertension in China has been reported as a detection problem rather than treatment problem. And the efforts of public health community were also abundant, mainly investing in community based health promotion programs.

However, less attention was paid by the Chinese researchers to investigate in the mechanisms that linked various health system factors to the outcome and impact of hypertension management in China. Thus Joint efforts are required from health system and epidemiological researchers to extent knowledge in this area to address this issue from the perspective of health system research.

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