Improvements in cardiovascular care and outcomes linked with China’s healthcare reforms

19 March 2020

During major healthcare reforms in China from 2009-2016, hospitalisation rates increased and case fatality rates decreased for stroke and coronary heart disease, according to new research from the Nuffield Department of Population Health (NDPH) at Oxford University, Peking University (PKU) and Chinese Academy of Medical Sciences (CAMS) in Beijing. A study of more than 500,000 adults from 10 areas across China showed that the greatest improvements were found amongst lower socioeconomic groups during this period.

China introduced major healthcare reforms in 2009, which were designed to provide affordable and accessible basic healthcare for all by 2020. Health insurance coverage was expanded to cover the entire population, primary healthcare and public health services have been strengthened, public hospitals improved, and a national essential medicines system has been established. During the study period, the number of hospitals in China increased by 44%. However, little is known about the effects of such changes on healthcare use and health outcomes.

A team of researchers investigated trends in hospital admission rates, 28-day case fatality rates and mean length of stay for stroke, coronary heart disease and any cause across different socioeconomic groups between 2009 and 2016. The study was based on the 500,000 people enrolled into the China Kadoorie Biobank, which was established jointly by the three institutes during 2004-08.

Lead author Muriel Levy said: ‘Stroke and coronary heart disease are the leading causes of disease burden in China. Although socioeconomic inequalities in hospital admissions and case fatality for stroke and coronary heart disease persist in China in the study period, improvements in healthcare use and health outcomes during this period have been greatest in rural areas and among lower socioeconomic groups.’

The findings, published in The Lancet Global Health, showed increases in hospitalisation rates, in addition to the rises expected with advancing age and morbidities. During the study period, the additional annual increases were 3.6% for stroke, 5.4% for coronary heart disease, and 4.2% for all hospital admissions. Hospitalisation rates increased to a great extent during the first period of reforms, 2009-2012, compared to the second period, 2013-2016, coinciding with a greater expansion of health insurance coverage.

Co-author Professor Borislava Mihaylova, Senior Health Economist at NDPH, said: ‘Our results suggest that access to and quality of hospital care in China have improved with larger gains among previously disadvantaged population groups. We hope that these findings will inform future policies on universal health coverage to reduce health inequalities in China and other developing countries.’

The researchers found that people in the lowest income group had the greatest annual increase, with hospitalisation rates for stroke rising by 7% and for coronary heart disease by 9.8%. Those with no formal education also had higher annual increase in hospitalisation rates from stroke (7.0%) and coronary heart disease (8.2%).

Overall, hospitalisation rates were higher for people living in urban rather than rural areas. However, the annual increase in hospitalisation rates during the study period were higher for those living in rural areas for both conditions. Rural hospitalisation rates for stroke rose by 4.5% per year, while in urban areas, this figure was 3.3%. For coronary heart disease, the increase was 8.4% in rural areas, and 3.6% in urban areas.

During the study period the annual reduction in fatality rates was two-fold greater for residents living in rural than in areas for stroke (11.9% vs 6.4%) and for coronary heart disease (16.7% vs 8.3%) respectively. The reductions in case fatality are likely to reflect improvements in the quality of hospital care.

Overall, the mean length of hospital stay decreased by around 2% annually (by about 2 days for stroke and by 1 day for coronary heart disease between 2009-2016), but decreased to a greater extent in the highest socioeconomic groups for stroke and coronary heart disease, which may also reflect improvements in hospital efficiency.

Study author and Co-Principal Investigator of the China Kadoorie Biobank, Professor Liming Li, from Peking University, China, said: ‘The present study demonstrated clear beneficial effects of changes in healthcare provision in China, as the most disadvantaged groups had the highest annual increases in rates of hospital admission and greatest reductions in case fatality rates.’

Despite the improvement, gaps in hospital admission and case fatality rates between socioeconomic groups have persisted during these reforms, likely reflecting further differences in healthcare seeking and affordability.

Study author and Co-Principal Investigator of the China Kadoorie Biobank, Professor Zhengming Chen, from NDPH said: ‘As well as continuing to monitor the hospital admission and case fatality rates in the population, further research is needed to assess which particular aspects of health insurance policies are the chief determinants of such changes. This should help optimise health insurance policies and further reduce disparities in healthcare provision between urban and rural areas.’

Notes to Editor 

For further information or to request an interview, please contact Helen Tunnicliffe on 01865 289707, email

Alternatively, contact the researchers Muriel Levy (, Dr Yiping Chen (, Professor Robert Clarke (, or Professor Zhengming Chen ( directly. 

The paper in The Lancet Global Health is openly accessible and can be found here once the embargo lifts:

This research was part funded by the Wellcome Trust and the Medical Research Council.

Nuffield Department of Population Health 
The Nuffield Department of Population Health (NDPH) is a world-leading research institute, based at the University of Oxford that investigates the causes and prevention of disease. NDPH has over 500 staff working in a number of world-renowned population health research groups, including the Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), the Cancer Epidemiology Unit (CEU), the National Perinatal Epidemiology Unit (NPEU) the World Health Organization Collaborating Centre on Population Approaches for Non-Communicable Disease Prevention (CPNP) and other groups working on public health, health economics, ethics and health record linkage. It is also a key partner in the new Oxford University Big Data Institute.

China Kadoorie Biobank
The China Kadoorie Biobank (CKB) was set up to investigate the main genetic and environmental causes of common chronic diseases in the Chinese population. During 2004-8, over 510,000 adults aged 30-79 were recruited from 10 geographically defined regions of China, with extensive data collection by questionnaire and physical measurements, and with long-term storage of blood samples for future study. All the participants are now being closely monitored for death and other health-related outcomes through linkage with established registries and health insurance databases in the study areas. The CKB is run jointly by the Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU) at the University of Oxford’s Nuffield Department of Population Health, Peking University, and the Chinese Academy of Medical Sciences (CAMS).