Temporal and spatial analysis of anthropogenic mercury and CO2 emissions from municipal solid waste incineration in China: Implications for mercury and climate change mitigation.

The contribution of municipal solid waste incineration (MSWI) to anthropogenic mercury and CO2 emissions have become increasingly important over the past decade. This study developed an inventory of anthropogenic mercury emissions and CO2 emissions during the period of 2014-2020, of MSWI process in China using a bottom-up inventory at the plant level. Overall, national MSWI anthropogenic mercury emissions increased from 2014 to 2020 by province. It was estimated that total 8321.09 kg of anthropogenic mercury emissions from 548 MSWI plants were scattered in 31 provinces of mainland China in 2020. The average intensity of mercury emission in China was 0.06 g·t-1 in 2020, which was much lower than the pre-2010 level. Furthermore, the increased CO2 emission generated by MSWI from 2014 to 2020 is 1.97 times. Anthropogenic mercury emissions and CO2 emissions were concentrated mainly in developed coastal provinces and cities. The general uncertainty of national mercury emissions and CO2 emissions was estimated to be -123% to 323% and -130% to 335%, respectively. Furthermore, future emissions were predicted from 2030 to 2060 based on different scenarios of the independent and collaborative effects of control proposals, the results indicate that the enhancement of advanced air pollution control technologies and effective management of MSWI represent pivotal factors in realizing future reductions in CO2 and mercury emissions. The findings will supplement those for mercury and CO2 emissions, and be useful for relevant policy-making and to improve urban air quality, as well as human health.

The change of drug utilization in China's public healthcare institutions under the "4 + 7" centralized drug procurement policy: Evidence from a natural experiment in China.

Background: Improving drug accessibility and rational drug use are major challenges for China's healthcare reform. In 2018, the Chinese government introduced a novel nationwide policy of centralized drug procurement for off-patent drugs, focusing on improving drug utilization patterns of public medical institutions. Objective: To estimate the impacts of the Chinese centralized drug procurement policy (the so-called "4 + 7" policy) on drug utilization in public medical institutions. Methods: A retrospective natural experimental design and difference-in-difference method were applied using cross-region data extracted from the national procurement database. Eleven "4 + 7" pilot cities (intervention group) and eleven non-pilot provinces (control group) were matched. In addition, "4 + 7" policy-related drugs (n = 116) were selected as study samples, including 25 drugs in the 4 + 7" procurement List ("4 + 7" List drugs) and their alternative drugs (n = 91) that have not yet been covered by centralized procurement policy. Then, the "4 + 7" List drugs were divided into bid-winning and non-winning drugs according to the bidding results, and they were sorted into generic and original drugs. Defined daily dose (DDD) was used to standardize the quantity of drugs used. Results: In the 1-year procurement period, the overall completion rate of agreed procurement volume reached 191.4% in pilot cities. Owing to policy impact, the consumption increased by 405.31% in bid-winning drugs (ß = 1.62, p < 0.001) and decreased by 62.28% (ß = -0.98, p < 0.001) in non-winning drugs. The overall use proportion of bid-winning drugs increased from 17.03% to 73.61% with statistical significance (ß = 1.48, p < 0.001), and increments were also detected in all healthcare settings, regions, and anatomical therapeutic chemical (ATC) categories (all p-values < 0.05). Generics and originators were detected with 67.53% increment (ß = 0.52, p < 0.001) and 26.88% drop (ß = -0.31, p = 0.006) in consume volume. The use proportion of generics increased from 59.23% to 78.44% with significance (ß = 0.24, p < 0.001), as well as in tertiary hospitals (ß = 0.31), secondary hospitals (ß = 0.23), and primary healthcare centers (ß = 0.11) (all p-values < 0.001). The use proportion of relatively quality-guaranteed drugs (i.e. bid-winning and original drugs) increased from 56.69% to 93.61% with significance (ß = 0.61, p < 0.001), and similar increments were also detected in all healthcare settings, regions, and ATC categories (all p-values < 0.05). Conclusion: Healthcare providers demonstrated good compliance with the "4 + 7" policy in completing contracted procurement volume. Centralized drug procurement policy promoted drug consumption gradually concentrated on bid-winning drugs, generic drugs, and more importantly, quality-guaranteed drugs.

Changing Characteristics of Pharmaceutical Prices in China Under Centralized Procurement Policy: A Multi-Intervention Interrupted Time Series.

Objective: National centralized drug procurement organized by the Chinese government currently represents the largest group purchasing organization worldwide, to establish a reasonable price formation mechanism. This study aimed to evaluate the effects of centralized procurement policy on drug price and price ratio in China. Method: Monthly drug procurement data of public medical institutions were extracted from the national procurement database, including 11 pilot cities and 36 months from January 2018 to December 2020. Centralized procured INNs (International Nonproprietary Names) (n = 25) and their alternative INNs (n = 96) were selected as study samples. Centralized procured INNs were divided into bid-winning and non-winning products according to the bidding results. Drug price, price distribution, and price ratio were measured. Multi-intervention interrupted time series analysis was performed to estimate the policy impacts in two centralized procurement periods. Results: The price of centralized procured INNs showed an immediate drop of 44.57% (ß = -0.59, p < 0.001) at the policy implementation, among which bid-winning drugs decreased by 61.71% (ß = -0.96, p < 0.001). No significant change in the price level or trends was found for non-winning products and alternative drugs in the first-year procurement period (all p-values > 0.05). During the second-year procurement period, alternative drugs in four therapeutic categories detected significant increases in the price level (all p-values < 0.05). The overall coefficient of variation of price distribution exhibited upward trends after policy implementation. Among the most centralized procured INNs, the price ratio between certificated generics (generics that have passed the consistency evaluation) and original drugs declined significantly after policy intervention (p < 0.05), whereas the price ratio between uncertificated and certificated generics increased significantly (p < 0.05). Conclusion: Chinese government-organized group purchasing resulted in prominent price reduction of bid-winning drugs. The policy observed a short-term "spillover" effect of synergistic price reduction, while the effect wore off after 1-year procurement period. The extremely dispersed price distribution, as well as unreasonable price ratios, requires further effective price regulation means.

Trends and Associated Factors of Dietary Knowledge among Chinese Older Residents: Results from the China Health and Nutrition Survey 2004-2015.

Promoting a healthy diet of the elderly is an important task in the current "Healthy China Action". This study aimed to describe the changing trends of the dietary knowledge elderly Chinese during 2004-2015 and to examine the associated factors of dietary knowledge. Elderly people aged ≥60 years were included as study subjects from the China Health and Nutrition Survey 2004-2015. A total of 15,607 samples were involved in the analysis. The correct rate of dietary knowledge items followed upward trends over time, except for two items regarding physical activity intensity (Question 11, Cochran-Armitage χ2 = 20.05, p < 0.001) and healthy weight (Question 12, Cochran-Armitage χ2 = 43.93, p < 0.001). Four of the twelve dietary knowledge items consistently followed the lowest correct rate between 2006 and 2015, regarding physical activity intensity (Question 11, 24.5%-25.8%), staple food consumption (Question 5, 36.6%-41.5%), animal product consumption (Question 6, 45.8%-59.5%), and fatty meat and animal fat consumption (Question 7, 63.6%-64.9%). Participants who had a lower educational level or lived in rural areas or western regions, did not know about the Chinese Food Pagoda (CFP) or Dietary Guidelines for Chinese Residents (DGCR), and did not proactively look for nutrition knowledge were less likely to have adequate dietary knowledge literacy. Targeted interventions should be developed to promote dietary knowledge level of the elderly.

Engaging village health workers in non-communicable disease (NCD) prevention and control in Vietnam: A qualitative study.

The burden of non-communicable diseases (NCDs) continues to grow in Vietnam, and reducing the burden of NCDs is a national priority. This study explored perspective of community health workers (CHWs), known as Village Health Workers (VHWs) in Vietnam, and public health leaders towards potential of expanding VHWs' role to deliver NCDs prevention and control services, and determined barriers and facilitators. We conducted focus group discussions (FGDs) with VHWs (n = 24) and in-depth interviews (IDIs) with public health administrators (n = 13). The findings show that VHWs in Vietnam deliver multiple public health services, including several NCDs related services. Perceived barriers include lack of policy support, shortages of trained health personnel, lack of training, imbalanced workload and inadequate remuneration. Perceived barriers include lack of policy support, shortages of trained health personnel, lack of training, imbalanced workload and inadequate remuneration. Facilitators include government commitment to NCDs prevention and control, priority on capacity building, professional recognition and provision of incentives with availability of appropriate resources. While additional quantitative studies are needed to supplement the current qualitative findings, the current results inform the policy and intervention development in engaging VHWs in the delivery of community-based NCDs prevention and control initiatives in Vietnam.

Barriers and Facilitators of Engaging Community Health Workers in Non-Communicable Disease (NCD) Prevention and Control in China: A Systematic Review (2006⁻2016).

Background: Non-communicable diseases (NCDs) have become a dominant disease burden in China. Although China has a prevention-centered NCD strategy, the implementation effect in the community has been subjected to manpower and financial difficulties. Engaging community health workers (CHWs) in community-based interventions may be a cost-effective approach to relieve the resource shortage and improve health. This review aimed to synthesize evidence on types of NCD-related care that was provided by CHWs in China, and to identify relevant barriers and facilitators. Methods: A literature search was conducted in Medline, PubMed, ProQuest, and Google Scholar databases for English-written, peer-reviewed articles published from 1996 to 2016 that reported findings from NCD-related interventions delivered by CHWs in China. Each article was extracted independently by two researchers. Results: Twenty distinct studies met the inclusion criteria. The two most common types of CHW-led NCD-related care were diabetes and hypertension management (n = 7) and mental health care (n = 7). Thirteen studies discussed the barriers and 16 studies reported facilitators. The most common barriers included lack of support (n = 6), lack of resources (n = 4), and heavy reliance on technology (n = 4). The common facilitators included an integrated health system (n = 9), community and patient trust (n = 5), high quality training (n = 5), and CHWs' capacity (n = 5). Fourteen studies mentioned training content, while only eight described detailed procedures and duration. Conclusions: This review suggests that trained and supervised Chinese CHWs had the capacity to provide grassroots NCDs preventive interventions. In order to increase the generalizability and sustainability of such programs, studies with robust designs are needed to explore the effectiveness of CHW-led programs, and the intervention strategies to improve the practice of CHWs in various settings.

Delivery of public health services by community health workers (CHWs) in primary health care settings in China: a systematic review (1996-2016).

BACKGROUND: Community Health Workers (CHWs) have been widely used in response to the shortage of skilled health workers especially in resource limited areas. China has a long history of involving CHWs in public health intervention project. CHWs in China called village doctors who have both treatment and public health responsibilities. This systematic review aimed to identify the types of public health services provided by CHWs and summarized potential barriers and facilitating factors in the delivery of these services. METHODS: We searched studies published in Chinese or English, on Medline, PubMed, Cochrane, Google Scholar, and CNKI for public health services delivered by CHWs in China, during 1996-2016. The role of CHWs, training for CHWs, challenges, and facilitating factors were extracted from reviewed studies. RESULTS: Guided by National Basic Public Health Service Standards, services provided by CHW covered five major areas of noncommunicable diseases (NCDs) including diabetes and/or hypertension, cancer, mental health, cardiovascular diseases, and common NCD risk factors, as well as general services including reproductive health, tuberculosis, child health, vaccination, and other services. Not many studies investigated the barriers and facilitating factors of their programs, and none reported cost-effectiveness of the intervention. Barriers challenging the sustainability of the CHWs led projects were transportation, nature of official support, quantity and quality of CHWs, training of CHWs, incentives for CHWs, and maintaining a good rapport between CHWs and target population. Facilitating factors included positive official support, integration with the existing health system, financial support, considering CHW's perspectives, and technology support. CONCLUSION: CHWs appear to frequently engage in implementing diverse public health intervention programs in China. Facilitators and barriers identified are comparable to those identified in high income countries. Future CHWs-led programs should consider incorporating the common barriers and facilitators identified in the current study to maximize the benefits of these programs.