Analysis of Responsibilities and Coordination Among Key Stakeholders in Chronic Disease Prevention and Control in China Based on the Innovative Care for Chronic Conditions Framework

JIANG Hanhong, ZHANG Tianfeng, YANG Yanlin, ZHOU Chufan, PAN Jie, WANG Xiuli

Abstract

Chronic diseases pose a major public health challenge in China. Clarifying the responsibilities of key stakeholders in chronic disease prevention and control and fostering synergy among them are essential to advancing the goals of the Healthy China 2030 Initiative. Utilizing the World Health Organization's Innovative Care for Chronic Conditions (ICCC) framework, we systematically analyzed how stakeholder responsibilities are defined in China's chronic disease prevention and control system, along with current coordination efforts and persistent challenges. We propose the following reform recommendations: strengthening governmental leadership by improving legislation and policy implementation standards, expanding health insurance coverage, and enhancing capacity building at the primary care level alongside patient education; establishing cross-departmental coordination mechanisms, encouraging social sector engagement, and improving communication, referral, incentive, and oversight mechanisms; accelerating the development of information system in central/western and rural areas, and promoting the application of big data and artificial intelligence technologies; fostering a supportive social environment through implementing incentive measures, promoting primordial prevention, and advancing healthy community initiatives. The implementation of these multifaceted measures is expected to enhance the quality and efficiency of chronic disease prevention and control, thereby contributing to the achievement of the goals of the Healthy China Initiative.

 

Keywords: Chronic disease, Stakeholder responsibility, Coordination mechanism, Review

 

Full Text:

PDF


References


LIU B B, TIAN Q F, GUO J L. Analysis of chronic diseases and comorbidities in middle-aged and elderly population in China. Medicine and Society, 2022, 35(8): 58-61. doi: 10.13723/j.yxysh.2022.08.011.

XU Q Q, YAN Y F, CHEN H, et al. Predictions of achievement of Sustainable Development Goal to reduce age-standardized mortality rate of four major non-communicable diseases by 2030 in China. ChinJ Epidemiol, 2022, 43(6): 878-884. doi: 10.3760/cma.j.cn112338-20211028-00830.

PENG W, CHEN S, CHEN X, et al. Trends in major non-communicable diseases and related risk factors in China 2002-2019: an analysis of nationally representative survey data. Lancet Reg Health West Pac, 2024, 43: 100809. doi: 10.1016/j.lanwpc.2023.100809.

LI Y, ZENG X, LIU J, et al. Can China achieve a one-third reduction in premature mortality from non-communicable diseases by 2030?BMC Med, 2017, 15(1): 132. doi: 10.1186/s12916-017-0894-5.

TU W J, ZHANG X, WANG H Q. et al. Establishing integrated chronic non-communicable disease management clinics to address China's looming health burden. Military Medical Research, 2025, 12(1): 25. doi: 10.1186/s40779-025-00616-0.

LÜ L T, DENG S L. The current status and development strategies of chronic disease management in China. Chinese Journal of Health Policy, 2016, 9(7): 1-7. doi: 10.3969/j.issn.1674-2982.2016.07.001.

WANG X D, YU C J, QU X G, et al. The implementation path of citizen participation in “Healthy China 2030” strategy: from the perspective of social governance. Chinese Journal of Health Policy, 2017, 10(5): 39-44. doi: 10.3969/j.issn.1674-2982.2017.05.007.

LONG C X, LI C L, FAN Y D, et al. Quantitative analysis of chronic disease prevention and treatment policy texts in China: three-dimensional framework based on policy tools, policy evolution and policy subjects. Chinese General Practice. 2025, 28(20): 2457-2463. doi: 10.12114/j.issn. 1007-9572.2024.0480.

WU S Y, CAI Y Y, XU X Y, et al. Challenges and opportunities for integration of medication and prevention of common chronic diseases in China. Chin J Public Health, 2019, 35(10): 1289-1292. doi: 10.11847/zgggws1126005.

ZHU X, CHEN A Y. Enlightenment of foreign classical chronic disease management modes on the management of chronic diseases in China. Chinese General Practice, 2023, 26(1): 21-26. doi: 10.12114/j.issn.1007-9572.2022.0370.

ONI T, MCGRATH N, BELUE R, et al. Chronic diseases and multi-morbidity-a conceptual modification to the WHO ICCC model for countries in health transition. BMC Public Health, 2014, 14(1): 575. doi: 10.1186/1471-2458-14-575.

NUÑO R, COLEMAN K, BENGOA R, et al. Integrated care for chronic conditions: the contribution of the ICCC Framework. Health Policy, 2012, 105(1): 55-64. doi: 10.1016/j.healthpol.2011.10.006.

TE V, MA S, POR I, et al. Diabetes care components effectively implemented in the ASEAN health systems: an umbrella review of systematic reviews. BMJ Open, 2023, 13(10): e071427. doi: 10.1136/bmjopen-2022-071427.

LIU X D, XU N, LIU J T, et al. Review on chronie disease prevention and control policy research in China. Medicine and Society, 2018, 31(6): 5-7. doi: 10.13723/j.yxysh.2018.06.002.

ZHU X Q, CHAI Y R. Research progress on mobile Internet platform in rehabilitation management of patients with chronic diseases. Chinese Nursing Research, 2023, 37(21): 3863-3868. doi: 10.12102/j.issn.1009- 6493.2023.21.012.

NI Z, WANG Y, QIAN Y. Privacy Policy Compliance of chronic disease management Apps in China: scale development and content evaluation. JMIR Mhealth Uhealth, 2021, 9(1): e23409. doi: 10.2196/23409.

SHEN H H, ZHAO J, FU Y X, et al. Policy instrument analysis of chronic disease prevention and control policies in China. Chinese General Practice, 2021, 24(13): 1637-1643. doi: 10.12114/j.issn.1007-9572.2021.00.186.

JIANG Y Y, QI L, MAO F, et al. Research on the status of multi-sector cooperation in national chronic disease comprehensive control and prevention demonstration areas. Chinese Journal of Health Policy, 2019, 12(11): 59-66. doi: 10.3969/j.issn.1674-2982.2019.11.011.

JIA N X, ZHANG J Q, WU X. Systematic analysis of influencing factors of chronic disease policy execution. Medicine and Philosophy, 2024, 45(11): 34-38. doi: 10.12014/j.issn.1002-0772.2024.11.07.

LIU L Q. Promoting contracted services of family doctors to strengthen the construction of hierarchical medical system. Chinese General Practice, 2018, 21(1): 1-4. doi: 10.3969/j.issn.1007-9572.2018.01.001.

GUO J, SUN H J, CHEN Y, et al. Construction of on-site evaluation index system for integration of medical and preventive services for chronic diseases in primary health care institutions. Chinese General Practice, 2023, 26(28): 3489-3495. doi: 10.12114/j.issn.1007-9572.2023.0277.

ZHOU Z, JIN D, HE J, et al. Digital health platform for improving the effect of the active health management of chronic diseases in the community: mixed methods exploratory study. J Med Internet Res, 2024, 26: e50959. doi: 10.2196/50959.

ZHANG M, SHI Y, ZHOU B, et al. Prevalence, awareness, treatment, and control of hypertension in China, 2004-18: findings from six rounds of a national survey. BMJ, 2023, 380: e071952. doi: 10.1136/bmj-2022-071952.

LI Z, SHI J W, CHEN N, et al. The problem analysis and breakthroughs of domestic and overseas chronic disease management models based on the systematic review. Chinese General Practice, 2020, 23(28): 3516-3521. doi: 10.12114/j.issn.1007-9572.2020.00.216.

LI J, ZHANG H Y, YANG J. Implications of domestic and foreign typical chronic disease management models for rural chronic disease management in China. Chinese General Practice, 2022, 25(16): 1935-1941. doi: 10.12114/j.issn.1007-9572.2021.00.327.

LI X, KRUMHOLZ H M, YIP W, et al. Quality of primary health care in China: challenges and recommendations. Lancet, 2020, 395(10239): 1802-1812. doi: 10.1016/S0140-6736(20)30122-7.


Refbacks

  • There are currently no refbacks.