Book Review: “Understanding China’s Health Transition in the 21st Century”

Igor Rudan, Kit Yee Chan, Harry Campbell, Yan Guo (2019, Editors): Elevation: Understanding China’s Health Transition in the 21st Century. Edinburgh: JoGH, pp. 1-509. ISBN 978-1-9999564-8-6

In the past four decades, no country has undergone a transformation as rapid, complex, and consequential as that of the People’s Republic of China. Its economic ascent has been widely chronicled, while its technological and geopolitical rise has been intensely scrutinized. Yet the profound epidemiological, demographic, and health-system transitions accompanying this national metamorphosis have received far less integrated scholarly attention. “Elevation: Understanding China’s Health Transition in the 21st Century” adresses this imbalance. Bringing together a substantial body of empirical and analytical work, this edited volume offers one of the most comprehensive syntheses to date of China’s evolving health landscape and its implications for global health.

Published as a curated collection of original research, the book compiles multidisciplinary analyses spanning health system reform, communicable and non-communicable diseases, maternal and child health, and China’s expanding role in global health diplomacy. The result is not merely a retrospective documentation of progress, but a forward-looking intellectual framework for interpreting health transitions in large middle-income nations.

China entered the 21st century after decades of sustained economic growth that reshaped living standards, infrastructure, and social determinants of health. The book’s opening sections situate health within this broader development trajectory, emphasizing that improvements in population health have been both dramatic and historically unparalleled. One striking example is the rapid decline in maternal and child mortality, enabling China to achieve Millennium Development Goal 4 well ahead of the 2015 deadline.

Yet the editors resist triumphalism. They frame China’s health gains as an inflection point rather than an endpoint. Economic modernization has triggered a classic epidemiological transition: infectious diseases have receded, while chronic non-communicable diseases (NCDs) surge. This shift is driven by population ageing, urbanization, environmental exposures, and lifestyle changes, including sedentary behaviour, tobacco use, and dietary transformation. The conceptual strength of the book lies in its insistence that these drivers are interdependent. Health outcomes are portrayed as emergent properties of economic policy, urban design, social protection systems, and demographic structure, rather than as isolated biomedical phenomena. This systems perspective elevates the book above descriptive epidemiology, positioning it instead within the analytical tradition of political economy of health.

The first major section examines China’s sweeping health-system reforms, particularly those launched between 2009 and 2012. These reforms were among the most ambitious ever attempted in a middle-income country, encompassing insurance expansion, primary care strengthening, essential medicines policy, and public hospital restructuring. A recurring theme is the tension between central policy ambition and local implementation capacity. While national leadership committed enormous financial resources, amounting to hundreds of billions of dollars, the success of reforms depended heavily on provincial and county governance structures.

The book’s analysis of rural health care modernization is especially revealing. The transformation of village doctors, successors to Mao-era “barefoot doctors”, into providers capable of delivering standardized clinical care, public health surveillance, and digital reporting illustrates both the scale of reform and the magnitude of the capacity gap it seeks to close. Such discussions underscore a key lesson: health-system reform is generational. Infrastructure and financing can be scaled rapidly, but workforce competence, governance culture, and quality assurance evolve far more slowly.

Among the book’s most policy-relevant contributions is its detailed exploration of China’s essential medicines reform. Historically, pharmaceutical sales constituted a major revenue stream for health facilities, creating perverse incentives for over-prescription and cost inflation. The reform package tackled this structural distortion through multiple coordinated interventions: centralized procurement, price controls, insurance reimbursement alignment, and the “zero mark-up” policy in primary care facilities. The scale of implementation is extraordinary. Insurance coverage expanded to over 90% of the population, while essential medicines lists were integrated into reimbursement systems nationwide. Still, the book does not shy away from unresolved challenges: quality assurance of generics, provincial variation in procurement efficiency, and the financial sustainability of facilities stripped of drug-sale revenues. These tensions illuminate the political economy of pharmaceutical reform as a structural reconfiguration of incentives across the health sector, rather than merely a technical exercise in pricing.

China’s success in controlling infectious diseases is often cited as one of the great public-health achievements of the modern era. The book traces this trajectory from mass mobilization campaigns of the Maoist period to contemporary surveillance systems leveraging digital health technologies. Analyses of respiratory syncytial virus, meningococcal disease, and other infections demonstrate China’s growing epidemiological research capacity. Systematic reviews and meta-analyses consolidate fragmented provincial data into national burden estimates, strengthening the evidence base for vaccine policy and prevention strategies. Equally significant is methodological innovation. Studies comparing mobile-phone data collection with traditional field surveys highlight China’s role as a testing ground for scalable, technology-enabled public-health surveillance.

Few domains illustrate China’s health transition more vividly than maternal and child health. Through targeted investments, expanded insurance, and community-based interventions, under-five mortality declined dramatically over two decades. The book situates this success within a constellation of determinants: female education, poverty reduction, immunization coverage, and rural health infrastructure. Importantly, the editors frame child survival as a development strategy, producing long-term demographic dividends and human-capital gains, rather than merely a humanitarian goal. This integrative framing aligns the book with contemporary global-health thinking, where survival, nutrition, and early development are viewed as foundational to economic growth.

If the first half of China’s health transition was defined by infectious-disease control, the second is dominated by chronic illness. The book’s most expansive section addresses this shift, documenting the epidemiology of cardiovascular disease, diabetes, cancer, chronic respiratory disease, mental illness, and neurodegeneration. The drivers are multifactorial: ageing populations, air pollution, dietary change, tobacco consumption, and urban lifestyles. Without intervention, the editors warn, China faces escalating burdens of dementia, stroke, obesity, and metabolic disease. The analytical depth here is notable. Rather than presenting NCDs as inevitable by-products of prosperity, contributors analyse prevention policy, risk-factor regulation, and health-system preparedness. The implication is clear: China’s future health trajectory will strongly depend on future policies.

A distinguishing strength of the book is its attention to data systems. China’s health transition has been accompanied by an explosion of surveillance infrastructure, ranging from mortality registries to longitudinal biobanks. Resources such as the Maternal and Child Mortality Surveillance System and the China Kadoorie Biobank have transformed research capacity, enabling large-scale cohort analyses and risk modelling. Digitalization of scientific literature and administrative datasets has further democratized access to evidence, integrating Chinese research into global knowledge networks. The book rightly positions this information revolution as a foundational enabler of evidence-based policy. Looking forward, the editors identify population ageing as China’s defining health challenge. Rapid demographic inversion, driven by declining fertility and rising life expectancy, will generate unprecedented demand for chronic-disease management, long-term care, and dementia services. Urbanization compounds this pressure. As hundreds of millions migrate to cities, exposure to pollution, sedentary work, and processed diets intensifies NCD risk profiles. The book’s policy prescription is unequivocal: prevention and primary care must anchor the response. Without a rebalancing away from hospital-centric care, costs could escalate to levels that threaten economic growth itself.

The final section broadens the lens beyond national borders, examining China’s emergence as a global health stakeholder. Topics include development assistance for health, medical teams in Africa, and the institutionalization of global health research within Chinese academia. This outward engagement marks a historical reversal: a country once defined by aid receipt now shapes international health agendas. The book invites readers to consider how China’s domestic health experience, particularly its rapid scale-up of coverage, might inform other low- and middle-income countries navigating similar transitions.

As an edited collection of a large amount of original research, the book inevitably faces challenges of thematic cohesion, with certain level of variability in chapter style and methodological depth that primarily reflects the diversity of contributing authors. However, strong editorial framing managed to mitigate potential fragmentation. The five-part structure, that spans from system reform to global engagement, successfully creates a logical narrative arc mirroring the stages of China’s health transition. The reliance on systematic reviews, national datasets, and policy analyses lends the volume substantial scientific credibility. For researchers, it functions as both reference compendium and analytical synthesis.

The book clearly privileges quantitative epidemiology and policy analysis over ethnographic or sociocultural perspectives. This leaves the reader with less insight into important and interesting issues such as patient trust, provider behaviour, and cultural determinants of care. Similarly, environmental health is acknowledged, particularly air pollution, but there will likely be opportunities to increase focus on this important area in the future editions. Also, the rapid pace of Chinese reform always carries a risk of rendering certain Chinese datasets becoming dated quickly. The authors underscore that health transitions of this kind of speed demand continuous analytical updating. Yet these possible challenges reflect the enormity of the subject, rather than editorial oversight. No single volume could exhaustively capture a transformation of this magnitude.

Where the book achieves its greatest impact is in its generalizability. China is not merely a case study, but rather a preview of what could be expected elsewhere over time. Many low- and middle-income countries now confront the same dual burden of infectious disease persistence and NCD escalation. China’s policy experiments, such as insurance expansion, essential medicines reform, and digital surveillance offer scalable lessons. Equally, its challenges, e.g., urban health inequities, ageing costs, regulatory complexity, and many others, serve very clearly as cautionary signals in this book. Thus, “Elevation” does an excellent job reflecting China’s journey while charting pathways for others.

In conclusion, “Elevation: Understanding China’s Health Transition in the 21st Century” is an ambitious, data-rich, and policy-relevant contribution to global health scholarship. It captures a nation in epidemiological motion: one that has compressed a century of health transition into a single generation. Its core message is both sobering and full of hope: health gains born of economic growth are neither automatic nor secure. They require sustained investment, institutional reform, and preventive vision. For scientists, policymakers, and global-health practitioners, this book offers not only documentation, but also an analytical toolkit for understanding how societies transform health at scale and what it takes to sustain those gains in the face of demographic, environmental, and fiscal headwinds. In an era where the future of global health will be shaped increasingly by middle-income giants, “Elevation” stands as essential reading: a landmark synthesis of the forces redefining population health in the 21st century.