Quantitative Analysis on NCDs Prevention and Control Policies Based on the Perspective of Policy Instruments - China, 1990-2020.

What is already known about this topic?: Noncommunicable diseases (NCDs) are a major public health problem in the world. NCDs are the leading cause of premature deaths and disabilities among Chinese residents, resulting in heavy economic and health burdens. What is added by this report?: This study conducted a quantitative analysis of the policy texts on NCDs prevention and control in China from 1990 to 2020, based on the perspective of policy instruments. It was discovered that China's NCDs prevention and control policies developed rapidly from the ground up over the 30 years from 1990 to 2020 and that the majority of China's NCDs prevention and control policies were environment-oriented, while supply-oriented and demand-oriented policies were insufficient. What are the implications for public health practice?: The findings of this study suggested that increasing supply-oriented and demand-oriented strategies should be prioritized in the future formulation and revision of NCDs prevention and control policies. Copyright and License information: Editorial Office of CCDCW, Chinese Center for Disease Control and Prevention 2022.

Noncommunicable diseases (NCDs) are responsible for almost 71% of all deaths globally (1). The number of deaths due to NCDs in China accounted for 86.6% of total deaths in 2012 (2). However, the unhealthy lifestyle of Chinese residents is still prevalent, such as excessive intake of salt and edible oil, sugary beverage consumption among children and adolescents, smoking, alcohol consumption, and lack of physical activity (2). In order to maintain the people’s health, China has issued a number of policies, plans, and national actions for the prevention and control of NCDs. In particular, the Medium- and Long-Term Plan for the Prevention and Treatment of NCDs (2017–2025), the Outline of the Plan for “Healthy China 2030”, and the Healthy China Action (2019–2030) promulgated by the Chinese State Council put forward a series of indicators for NCDs control. It is necessary to systematically review the strategies for NCDs prevention and control in China so as to achieve the goal of healthy China. Based on the theory of policy instruments, we conducted a textual content analysis and a quantitative analysis of the policies on NCDs and their behavioral risk factors that were issued by the State Council and relevant national ministries and commissions from 1990 to 2020. It was found that China’s NCDs prevention and control policies experienced rapid development during the 30 years from 1990 to 2020 and that the majority of China’s NCDs prevention and control policies were environment-oriented, while supply-oriented and demand-oriented policies were insufficient. These findings suggested that attention should be paid to increasing supply-oriented and demand-oriented strategies during the formulation and revision of NCDs prevention and control policies in the future.

The methods of policy document system retrieval and policy text research were conducted in this study. The national health-related policy documents were searched in the portals of the Central Government and national ministries and commissions with the keywords of NCDs and their behavioral risk factors. The inclusion criteria of the policy documents included the following: 1) the release date should be between 1990 and 2020; 2) the departments releasing policy documents were the State Council and relevant national ministries and commissions; 3) the forms of policy documents included laws and regulations, planning, circulars, opinions, measures, announcements, health industry standards and guidelines (issued or guided and supported by health administrative departments), programs (policies); 4) the public form of the policy documents was published online on the official website; and 5) the content of policy documents was closely related to the prevention and control of NCDs or 4 behavioral risk factors (unhealthy diet, use of tobacco, harmful use of alcohol, and physical inactivity). The exclusion criteria included the following: 1) news reports, conference speeches, work reports and interpretation of policy documents related to the prevention and control of NCDs or their behavioral risk factors; 2) only keywords of NCDs or their behavioral risk factors, no substantive content; and 3) documents included in the policy text pool.

The main information elements of the policy document texts were extracted to form an analysis database, including the name of the policy document, the release unit, the release time, the document number, the file type, and the text items. The material was classified using the policy instrument theory, which divided policy instruments into three categories: supply-oriented, environment-oriented, and demand-oriented (3). Figure 1 shows the categories and mechanisms of policy instruments for NCDs prevention and control. Based on the perspective of policy instruments, a textual content analysis and a quantitative analysis were conducted with policy documents on NCDs and related behavioral risk factors in China that were issued between 1990 and 2020. Both analyses were carried out using SPSS software (version 16.0, SPSS Inc., USA).

Figure 1

Categories and mechanisms of policy instruments for noncommunicable diseases (NCDs) prevention and control.

This study retrieved 645 documents publicly available on national-level networks, excluded 233 according to the inclusion and exclusion criteria, and finally included 412 policy documents in the analysis. Among the 412 policy documents, 39 policy documents on NCDs prevention and control were released from 1990 to 2005, accounting for 9.5% of the total number of documents, 149 were released from 2006 to 2015, accounting for 36.2% of the total, and 224 were released from 2016 to 2020, accounting for 54.4% of the total (Figure 2).

Figure 2

The Distribution of the release time of policy documents on noncommunicable diseases prevention and control in China in 1990–2020.

Among the NCDs policies released in 1990–2020, on a type basis, 59 policy documents were supply-oriented, accounting for 14.3% of the total number of documents; 340 were environment-oriented, accounting for 82.5% of the total; and 13 were demand-oriented, accounting for 3.2% of the total. Supply-oriented, environment-oriented, and demand-oriented policies all showed an increasing trend, and environment-oriented policies were significantly higher than supply-oriented and demand-oriented policies. After 2011, supply-oriented and demand-oriented policies gradually increased, but their proportions were still low (Figure 3).

Figure 3

The Distribution of the types of policies on noncommunicable diseases prevention and control in China in 1990–2020.

Among the 4,455 pieces of policy instruments for NCDs prevention and control, on a content basis, 78.2% were environment-oriented, and 18.0% and 3.9% were supply-oriented and demand-oriented, respectively. In all the policy instruments, strategy-based measures accounted for 46.1% of the total policy instruments, followed by goals and planning, which accounted for 14.5%; capital investment, talents building, and information support accounted for 1.5%, 3.0%, and 3.8% of the total policy instruments, respectively; finance, taxation, and laws and regulations accounted for 0.1%, 0.2%, and 1.8% of the total policy instruments, respectively. In the supply-oriented policy instruments, public service investment accounted for 31.6%, information support 21.0%, and talent building and capital investment, respectively, 16.5% and 8.3%. In the environment-oriented policy instruments, strategic measures accounted for 59.0%, and laws and regulations, taxation, and financial instruments accounted for 2.3%, 0.3%, and 0.2%, respectively. In the demand-oriented policy instruments, cooperation models accounted for 30.1%, and government service procurement and government service outsourcing accounted for 2.9% and 1.7%, respectively (Table 1).

Table 1

The Distribution of various policy instruments for noncommunicable diseases prevention and control.

Type of policy instrument	Sub-item	Number	Type-based proportion (%)	Total-based proportion (%)
Supply-oriented	Capital investment	66	8.3	1.5
	Talent building	132	16.5	3.0
	Public service investment	253	31.6	5.7
	Information support	168	21.0	3.8
	Institution/facility construction	181	22.6	4.1
	Subtotal	800	100.0	18.0
Environment-oriented	Goals and planning	648	18.6	14.5
	Strategic measures	2,054	59.0	46.1
	Finance	6	0.2	0.1
	Taxation policy	11	0.3	0.2
	Medicare support	113	3.2	2.5
	Standards and guidelines	215	6.2	4.8
	Laws and regulations	80	2.3	1.8
	Social promotion	275	7.9	6.2
	Organizational safeguard	80	2.3	1.8
	Subtotal	3,482	100.0	78.2
Demand-oriented	Government procurement	5	2.9	0.1
	Pilot projects	36	20.8	0.8
	Government service outsourcing	3	1.7	0.1
	Price regulation	21	12.1	0.5
	Experience demonstrations	47	27.2	1.1
	International communication	9	5.2	0.2
	Cooperation models	52	30.1	1.2
	Subtotal	173	100.0	3.9
Total		4,455	100.0	100.0

DISCUSSION

China’s NCDs prevention and control policies have grown rapidly out of nothing over the 30 years from 1990 to 2020, especially after 2016, when such policy documents reached a peak. This is mainly related to factors such as rapid social and economic development, the shift of residents’ disease and death spectra to NCDs, the increasing importance attached by the Party and the government to NCDs prevention and control, and the fulfillment of international commitments in China (4-6). In 2016, China made clear the guiding principle of integrating health into all policies, and issued programmatic policy documents such as the Outline of the Plan for “Healthy China 2030”, the Medium-and Long-Term Plan for the Prevention and treatment of NCDs (2017–2025), and the Healthy China Action (2019–2030). A series of supporting policy documents for the implementation of these programmatic documents was also introduced by the involved ministries, resulting in a large increase in the number of documents released. “Healthy China” was elevated to a national policy, highly placed on the development agenda, with NCDs prevention and control policies gradually changing from “disease-centered” to “health-centered.”

Policy instruments are the means and measures to achieve policy goals. Different types of policy instruments have different roles and mechanisms. This study showed that national NCDs prevention and control policies used a combination of three types of policy instruments, namely supply-oriented, environment-oriented, and demand-oriented policy instruments, with the amount to which they were used varying substantially. Environment-oriented policy instruments accounted for 78.2%, while supply-oriented and demand-oriented instruments occupied 18.0% and 3.9%, respectively. Giving full play to the complementarity of different policy instruments was the key to the rational allocation of policy instruments (7). In this sense, environment-oriented policy instruments were overrepresented in China’s NCDs prevention and control policies, while supply- and demand-oriented instruments were underused, which was consistent with the results of similar studies in the fields of pension services, healthy city construction, and so on (8-9). On the one hand, it reflected that decisionmakers were expected to support NCDs prevention and control by creating a favorable policy environment. On the other hand, it also suggested that decisionmakers should consider the rational distribution of various policy instruments as NCDs prevention and control was a complex and systematic project, so as to give full play to the “impetus”, “pull” and “influence” of supply-, environment-, and demand-oriented instruments (9).

The study implied an unbalanced internal composition of each type of policy instruments. In supply-oriented policy instruments, public service investment accounted for one-third, while talent building and capital investment were inadequately designed. At present, the situation of NCDs prevention and control is severe, while understaffing and insufficient capacity and funding are common problems facing NCDs prevention and control nationwide. In the national disease control system, full-time personnel for NCDs prevention and control accounted for only 3.2% of in-service staff, with a wide gap in western regions, especially in primary medical institutions (10-11). China’s NCDs prevention and control is mainly financed by central and local governments, but the funding is inadequately guaranteed in some underdeveloped regions, so local governments need to explore a variety of sound funding models and sustainable funding guarantee mechanisms (12). The environment-oriented policy instruments were dominated by strategic measures and goals and planning, with laws and regulations, taxation and finance accounting for a small proportion (less than 3%), suggesting that decisionmakers tended to create a favorable policy and social environment and facilitate consensus on enhanced NCDs prevention and control through moderate instruments such as formulating strategies, planning and goals. However, as NCDs prevention and control involves economic, cultural, environmental, and other factors, the most cost-effective method is mandatory control through laws and regulations, as well as economic regulation through taxation and finance (13). The Basic Health Care and Health Promotion Law, released on December 28, 2019, is China’s first basic and comprehensive law on health, which would drive the rule-of-law process of NCDs prevention and control (14). In the demand-oriented policy instruments, government procurement and government service outsourcing accounted for less than 3%. These instruments can motivate and attract stakeholders such as social organizations and enterprises to be actively engaged in NCDs prevention and control, thus effectively reducing government investment in talent building, capital and technology, and forming an effective pull for NCDs prevention and control (15). To meet people’s health needs, it is critical to strengthen the development of demand-oriented policies, promote government procurement, pilot projects for NCDs prevention and control, experience summary, demonstration, and promotion (16), and provide a variety of multi-level, effective, and convenient NCDs prevention and control services.

This study is subject to certain limitations, which might cause some biases in the results. First, as policy texts were obtained through an online search, policy documents that had not been made public could not be included. Second, given the rich connotations of policy instruments themselves, different types of instruments may have intersected attributes and blurred boundaries, and the coding of instrument categories may be somewhat subjective.

Conflicts of interest

No conflicts of interest reported.