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China's public health system: time for improvement

The SARS-CoV pandemic in 2003 prompted the first substantial improvement of the public health system in China since the reform and opening up, and these improvements have greatly helped the country to contain the COVID-19 pandemic through effective resource sharing and the tracking of close contacts.

Although important advancements have been made to the Chinese public health system, we have to ensure it is robust enough to respond appropriately to emerging and traditional health challenges.

The COVID-19 pandemic has made it clear that governance needs to address gaps in the public health system in order to provide resilience. First, the concept of health needs to be revised: although a prevention-oriented health policy has been promoted in China since the 1950s, the overall health system still remains heavily focused on disease treatment, therefore the concept of health needs substantial change at the institutional level and in the construction of an integrated health service system. Second, the undervalued and underemphasised status of public health needs to change: the growth rate of health expenditures for public health institutions is much lower (from ¥48·8 billion [6·5%] of total government health spending in 2011 to ¥135·3 billion [7·5%] in 2019) than for clinical institutions (from ¥101·2 billion [13·6%] of total government health spending in 2011 to ¥673·5 [37·4%] in 2019).

The number of health personnel in the Chinese Center for Disease Control and Prevention (CDC) (the principal sector of public health in China), as a percentage of the total number of health staff, was 3·3% in 2004 after the SARS pandemic but by 2019 was only 1·45%.

Increasing government investment in public health together with improving mechanisms for subsidising public health institutions and linking salaries to performance rather than fixed remuneration directed from government is essential. Additionally, to attract and retain qualified personnel, discrimination against people in the public health sector must be eliminated, the role of public health professionals who work behind the scenes to provide evidence for policy makers must be recognised, and the salary of people working in public health should be aligned with their social value and consistent with that of clinical personnel at the same level. Third, the skills of professionals must be improved: to address complex public health issues, extending public health education beyond medical knowledge and integrating content from related disciplines (eg, law, political, social sciences and humanities) is indispensable. Moreover, retraining of personnel is vital to ensure there are enough trained personnel to respond to crises such as pandemics. Fourth, the core capabilities of the Chinese CDC must be refined: on May 14, 2021, the National Bureau of Disease Control and Prevention was established to promote public health in a comprehensive manner, marking a major step forward in enhancing the nation's post-epidemic public health governance.

However, it is not clear how the Chinese CDC operates, especially at the grassroots level. Therefore, core capabilities should be refined to ensure more efficient cooperation at all levels, including national (eg, global public health governance, personnel education, and advanced laboratories for precision diagnosis), provincial (eg, professional training and precision diagnosis at the local level), municipal (eg, identifying health issues and intervention), and county level (eg, developing skillsets for epidemiological investigation and meaningful health education). Additionally, building regional public health centres and public health information platforms based on health informatisation technologies will help to develop material reserves and organisational channels needed to address public health issues. Fifth, clinical treatment and prevention needs to be better integrated: in order to improve the response of public health systems to substantial infectious disease threats and growing non-infectious disease challenges (eg, diabetes, hypertension, stroke, cancer and tobacco use), it is imperative that the insufficient integration of medical treatment and public health is addressed.

Treatment and prevention currently fall into two isolated sectors. Hospitals need to promote public health by encouraging clinicians to prescribe health education as well as traditional prescriptions for drugs. Additionally, clinical and public health institutions (such as the fever clinic and infection department) can share personnel and data, and this will be conducive to the decision-making involved in population health and crisis prevention. Importantly, the establishment of an effective incentive mechanism (eg, making professional experience in public health a prerequisite for the promotion of clinicians) is important for integrating medical treatment and public health. Sixth, collaboration needs to happen across sectors: the widespread effect of public health issues highlights the need for actions taken at multisectoral level beyond the public health field, such as the public, private, and grassroots sectors including village and neighbourhood committees.

Finally, the legal framework for public health development should be improved (eg, responsibility rules, regulation on production and sales of emergency materials, information management, and security supervision) to ensure the health of the population. If these public health principles can be implemented in China, a country of more than 1·4 billion people, they will also be of use for other countries that are in the process of developing a resilient public health system.

We declare no competing interests.