Rapid transitions are occurring across China, but the leading health problems and the challenges imposed on the health system by epidemiological and demographic change differ between groups of Chinese provinces. Localised health policies need to be implemented to tackle the diverse challenges faced by local health-care systems.

All provinces in mainland China have made substantial strides to improve life expectancy at birth between 1990 and 2013. Increases ranged from 4·0 years in Hebei province to 14·2 years in Tibet. Improvements in female life expectancy exceeded those in male life expectancy in all provinces except Shanghai, Macao, and Hong Kong. We saw significant heterogeneity among provinces in life expectancy at birth and probability of death at ages 0–14, 15–49, and 50–74 years. Such heterogeneity is also present in cause of death structures between sexes and provinces. From 1990 to 2013, leading causes of YLLs changed substantially. In 1990, 16 of 33 provinces had lower respiratory infections or preterm birth complications as the leading causes of YLLs. 15 provinces had cerebrovascular disease and two (Hong Kong and Macao) had ischaemic heart disease. By 2013, 27 provinces had cerebrovascular disease as the leading cause, five had ischaemic heart disease, and one had lung cancer (Hong Kong). Road injuries have become a top ten cause of death in all provinces in mainland China. The most common non-communicable diseases, including ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and cancers (liver, stomach, and lung), contributed much more to YLLs in 2013 compared with 1990.

Following the methods of the Global Burden of Disease Study 2013 (GBD 2013), we have systematically analysed all available demographic and epidemiological data sources for China at the provincial level. We developed methods to aggregate county-level surveillance data to inform provincial-level analysis, and we used local data to develop specific garbage code redistribution procedures for China. We assessed levels of and trends in all-cause mortality, causes of death, and years of life lost (YLL) in all 33 province-level administrative units in mainland China, all of which we refer to as provinces, for the years between 1990 and 2013.

China has experienced a remarkable epidemiological and demographic transition during the past three decades. Far less is known about this transition at the subnational level. Timely and accurate assessment of the provincial burden of disease is needed for evidence-based priority setting at the local level in China.

The Global Burden of Disease Study 2013 (GBD 2013) analysis of causes of deathbenefited from a close collaboration with the China Center for Disease Control and Prevention and the Maternal and Child Health Surveillance System. In this study, we use the GBD 2013 analysis to examine trends for 240 causes of death for all 33 province-level administrative units in mainland China from 1990 to 2013.

GBD 2013 Mortality and Causes of Death Collaborators Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.

The differential trends and composition of disease burdens we have identified at the provincial level have important implications for the health system in China. There is an ongoing effort by the Chinese Government to reform the health-care system. Consideration of subnational trends will be crucial to tackle the diverse health challenges faced by provincial governments, and localised health policies will likely be the key for overall success at the national level.

To our knowledge, our study is the first ever systematic analysis of provincial level burden of disease in China. In this analysis, we took advantage of the largest demographic and epidemiological datasets assembled, including censuses, demographic surveys, the Disease Surveillance Points system, the Maternal and Child Health Surveillance systems, Cancer Registries, the newly established Death Registration System, Notifiable Infectious Disease Reporting System, and the National Surveillance System on Injuries. In addition to using the updated analytical tools of the GBD 2013, in order to fully utilise the data, we developed methods specific to this study, including China-specific garbage code redistribution and rural and urban weighting. We report high levels of heterogeneity in terms of both level and rate of change in both all-cause mortality and specific causes of death at the provincial level in China.

China has been undergoing tremendous demographic and epidemiological transitions during the past three decades. Although overall population health, as represented by under-5 mortality rates and life expectancy at birth, has been improving at impressive speed, increasing burden from non-communicable diseases and an ageing population have presented great health-care challenges for the country. Although such challenges are much discussed at the national level, relatively little is known about the subnational level in China.

Levels and trends of mortality separated by cause are a crucial starting point to understand health inequalities across provinces. To our knowledge, there have not been any systematic studies of provincial causes of death in China.Since the 1970s, there has been extensive analyses of variation between provinces, and even counties, for cancer death rates.Various causes of heart disease, suicide, and injuries have been studied for selected provinces.More comprehensive cause of death studies have been done for some counties and several provinces.Remarkably, there has been no previous comprehensive examination of levels of or trends in causes of death in China at the provincial level.

From 1990 to 2013 China experienced rapid economic growth, with income per capita increasing from 1664 RMB to 41 908 RMB,and life expectancy at birth increased by 8·5 years.Under-5 death rates dropped from 59 per thousand in 1990 to 13 per thousand in 2013 so that China had the second fastest annualised rate of decline of all nations.Rapid reductions in mortality have also been associated with a progressive shift in burden from infectious diseases to non-communicable diseases, increasing the demand for affordable access to health services. Rising income inequality has also increased policy attention on the challenges of health inequalities.Concerns have been raised that health inequalities are rising.

GBD 2013 Mortality and Causes of Death Collaborators Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.

The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The authors had access to the data in the study and had final responsibility to submit for publication.

For each quantity (eg, deaths, YLLs, and life expectancy), we report 95% uncertainty intervals (UIs). These UIs include uncertainty that stems from the sample size of data, adjustments to different sources of all-cause mortality, and cause-of-death model specification and estimation. Uncertainty from all of these sources is propagated into the final quantities of interest by taking 1000 draws from the posterior distribution of each component quantity of interest. We have been unable to quantify and include uncertainty in garbage code redistribution algorithms.

We used the GBD 2013 global age-standard population to calculate age-standardised death rates.The appendix (p 26) provides the detailed values. We followed the standard GBD 2010 methodsto compute years of life lost (YLLs) by multiplying numbers of deaths from each cause in each age-group by the reference life expectancy at the average age of death for those who die in the age group. The appendix (p 27) shows key indicators from the new GBD standard life table.

Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.

GBD 2013 Mortality and Causes of Death Collaborators Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.

We calculated the probability of death for three summary age intervals and the cause-specific contributions to each of these summary indicators for childhood and adolescence (0 to exact age 15 years), reproductive-age adults (15 to exact age 50 years), and middle-aged adults (50 to exact age 75 years). For each probability of death, we used the multiple decrement life-table methodto compute the probability of death from each cause and the overall contribution of each cause of death to the summary probability of death.

The methods used in the GBD 2013 for each cause of death have been described previously.The main method that we used is Cause of Death Ensemble modeling ( CODEm ).We captured the effect of natural disasters, such as the Wenchuan earthquake in Sichuan in 2008, with the methods described previously.Results for each individual cause of death with uncertainty were constrained to equal the estimates of all-cause mortality for a province-age-sex-year group using the CoDCorrect algorithm.

GBD 2013 Mortality and Causes of Death Collaborators Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.

GBD 2013 Mortality and Causes of Death Collaborators Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.

GBD 2013 Mortality and Causes of Death Collaborators Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.

We mapped the DSP special cause list that was used from 1992 to 2002 to the GBD cause list. We used the standard GBD ICD-10 mapping to the GBD cause list for DSP data (2004–07) and for the China CDC Cause of Death Reporting System (2008–12). The appendix (pp 14–24) shows this mapping. In the GBD 2013, causes that cannot be underlying causes of death (termed garbage codes) are reassigned to causes that can be underlying cause of death. For example, heart failure deaths are reassigned to the underlying causes of heart failure, such as ischaemic heart disease, hypertensive heart diseases, chronic obstructive pulmonary disease (COPD), rheumatic valve diseases, and non-rheumatic valve diseases. In China, for subnational data with ICD-10 detail, we used the same method for the mapping and redistribution of garbage codes as for other GBD 2013 ICD-10 detail sources in other countries. Some garbage codes were redistributed proportionally by geography, year, sex, and age, and others were redistributed using China-specific proportions generated through statistical methods. The appendix (p 25) shows the fraction of deaths assigned to ten classes of garbage codes in each province in 2008 and 2012.

Over time, a larger fraction of deaths have been registered in China through the expansion of the Disease Surveillence Point (DSP) system and provincial and county initiatives to increase cause of death registration. With the expansion of coverage, province aggregates might not accurately represent the distribution of the population between urban and rural areas in each year. For this reason, we have stratified the data preparation by urban and rural status for each county within each province ( appendix p 1 ). Within each province-strata, a higher fraction of in-hospital deaths might be reported than that of deaths outside of hospital because of the internet hospital reporting system. To avoid bias, we reweighted in-hospital and out-of-hospital deaths based on the age-sex-province specific fraction of deaths in and out of hospital in the DSP system. The appendix (pp 11–13) shows these percentages. DSP data have been used to establish these percentages because, in these communities, there is a concerted effort to identify all out-of-hospital deaths. Province strata death rates are combined to produce overall province death rates by weighting each strata by population in each age-sex-year group. Province death rates are rescaled so that all-cause mortality equals the estimated death rate in each age-sex-year estimated in the life-table analysis. Finally, we used the Bayesian noise reduction algorithm as described previouslyto deal with zero counts and small number issues for rare causes.

GBD 2013 Mortality and Causes of Death Collaborators Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.

Cancer registry data from Chinese provinces were selected for use in the cause of death analysis according to GBD 2013 quality criteria, which were reported previously.We incorporated data from 79 cancer registries, or 502 cancer registry-years (CRY) in our initial analysis ( appendix p 10 ). After quality review, 108 CRYs were dropped from our dataset because of implausibly high fractions (>80%) of all deaths due to cancers.

GBD 2013 Mortality and Causes of Death Collaborators Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.

Hong Kong has a long history of medical certification of death under colonial rule and this has continued after becoming a Special Administrative Unit. Hong Kong, for example, has reported cause of death data to WHO since 1955. Macao has reported to WHO only one year, 1994.

In the late 1990s, many provincial CDCs added their own expanded set of DSPs and some counties also collected data for causes of death. Starting in 2004, an internet-based reporting system was established so that nearly all hospitals in China report ICD-coded cause of death information to the China CDC. The combination of the expanded set of provincial and county community registration and the in-hospital mortality reporting is the China Cause of Death Reporting System. This has rapidly expanded such that by 2012, 4 million of 8·9 million deaths (not including Hong Kong or Macao) were recorded with death certificates and ICD-coded causes. The appendix (p 9) summarises the expansion of the total number of deaths recorded through the various systems, and provides a snapshot of the counties in China that reported number of deaths in 2012 ( appendix p 39 ). All but 28 of 2857 counties reported to the electronic system in that year.

The Maternal and Child Surveillance System developed a parallel system to record high quality cause of death data from a representative sample of communities. The National Office for Maternal and Child Health Surveillance was formed in 1996 to administer the population-based mortality surveillance for under-5 age groups and maternal causes in China. By 2006, data were collected in 336 sites ( appendix p 38 ).

The DSPs were established in 1978 and have been progressively expanded during the past 35 years. During each expansion, sites were selected on the basis of a multistaged stratified cluster sampling strategy. The appendix (p 37) shows the location of the DSPs across China at different stages.Within these sites, deaths in hospitals and the community are recorded and a standardised instrument is used to collect information from medical records and the deceased person's household. This information is then used by a local physician to assign a cause of death.

We used five main data sources that provide information about causes of death. Across systems, data have been reported using two versions of ICD-9 tabulations and one of ICD-10 ( panel ). These have all been mapped to the GBD cause list.

GBD 2013 Mortality and Causes of Death Collaborators Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.

The GBD 2013 model life-table systemused recorded provincial life tables from China (see appendix p 8 ) to inform the provincial age patterns of mortality, thus providing more accurate mortality estimates for 5 year age groups at the provincial level.Provincial level estimates have been rescaled to match GBD 2013 country level estimates.

GBD 2013 Mortality and Causes of Death Collaborators Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.

We systematically reviewed published and unpublished sources for all-cause mortality at the provincial level in China for the time period 1950–2013. Province-level estimates of under-5 mortality rate (U5MR) and adult mortality rate (probability of death between ages 15 and 60 years) are based on censuses, surveys, and surveillance systems ( appendix pp 2–7 ). We used spatiotemporal regression and Gaussian process regression to synthesise all available sources for U5MR and adult mortality.Throughout the entire GBD process, we have made every effort to synthesise different data sources using different estimation strategies, including Gaussian process regression. This allows for integration of data from multiple sources into one final estimate with uncertainty intervals. Additionally, the bias adjustment strategy as applied in the child mortality estimation process helps to generate consistent time-series estimates of U5MR based on multiple sources of data.

GBD 2013 Mortality and Causes of Death Collaborators Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.

The GBD 2013 Mortality and Causes of Death Collaborators describe in detail the GBD 2013 cause list, the systematic approach to collating causes of death data from around the world, mapping across different revisions and national variants of the International Classification of Diseases and Injuries (ICD), redistribution of deaths assigned to causes that cannot be underlying causes of death through garbage code redistribution, and the cause of death modelling approach used for each cause. One important aspect of the GBD framework is that cause-specific estimates are constrained to sum to demographic estimates of all-cause mortality using the CoDCorrect algorithm.In this report, we focus on specific issues related to the analysis of causes of death at the provincial level in China that were included in the GBD 2013 analysis. The units of analyses for this study are the 33 province-level administrative units, including Hong Kong and Macao Special Administrative Regions, all of which we refer to as provinces in this study. Because of the changes in provincial level administrative units since 1990, we have gone back to all original data sources to separate provincial level estimates for Chongqing and Sichuan, and Guangdong and Hainan.

GBD 2013 Mortality and Causes of Death Collaborators Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.

In 1990, 16 of 33 provinces had a major cause of child death (lower respiratory infections or preterm birth complications) as the most common cause of death ( appendix p 46 ). The most common cause was cerebrovascular disease in 15 provinces and ischaemic heart disease in two provinces (Hong Kong and Macao). By 2013, 27 provinces had cerebrovascular disease as the most common cause, five had ischaemic heart disease, and one had lung cancer (Hong Kong). In 1990, road injury ranged from the fourth most common cause of YLLs in Ningxia and Zhejiang to the 12th most common cause in Yunnan. By 2013 ( appendix p 47 ), road injury had become the second most common cause in Qinghai, Tibet, and Zhejiang and the third most common cause overall in China. The rise of ischaemic heart disease in relative importance is also evident in comparisons of the 1990 and 2013 orderings, with 24 provinces having it as the first or second leading cause in 2013 (up from nine in 1990). Trends in COPD have been quite different across provinces, rising in provinces including Ningxia, Gansu, Guizhou, and Sichuan, but falling in provinces including Hong Kong, Jiangsu, and Guangdong. Liver, stomach, and lung cancer have increased in importance in many provinces. Cirrhosis, which was in the top ten only in Tibet in 1990, was in the top 10 of 15 provinces in 2013.

The top 15 causes of death in China overall included three types of injuries (road injuries, self-harm, and falls) for men and two types of injuries (road injuries and self-harm) for women. Road injuries had a characteristic pattern whereby the death rates were more than 40 per 100 000 people for men in western provinces (Qinghai, Xinjiang, Gansu and Ningxia) and Hebei. The national age-standardised death rate due to road injuries for men and women separated by year from 1990 to 2013 suggests that rates might have peaked in 2005 and have since been in decline ( appendix p 45 ). Death rates for self-harm in women in 2013 ranged from 19·7 per 100 000 people (15·6–26·4) in Hubei to 2·1 per 100 000 people (1·5–3·4) in Tianjin. By contrast, in 1990, rates ranged from 49·9 per 100 000 people (35·2–63·1) in Hubei to 8·9 per 100 000 people (5·9–11·8) in Beijing.

Lung cancer is the fourth most common cause of death for men and women in China overall. Age-standardised death rates for lung cancer range from 7·4 per 100 000 people (5·8–9·0) in Tibet to 79·1 per 100 000 people (64·8–92·2) in Liaoning for men and from 4·6 per 100 000 people (3·6–5·9) in Tibet to 38·9 per 100 000 people (29·1–50·4) in Heilongjiang for women. For men, another cancer, liver cancer, is the fifth most common cause of death. Death rates for liver cancer in men range from 20·0 per 100 000 people (14·3–26·1) in Tianjin to 69·0 (54·4–83·8) in Guangxi. Another important cancer, especially in men, was stomach cancer, for whom the highest death rates were in Qinghai at 66·8 per 100 000 people (50·3–84·5).

For the third most common cause of death in China, COPD, death rates exceeded 100 per 100 000 people for men and women in a set of contiguous provinces in south and west China: Chongqing, Sichuan, Yunnan, Guizhou, Gansu, and Qinghai. By contrast, rates of death from COPD for both men and women were less than 50 per 100 000 people in a set of contiguous provinces in northeast China: Tianjin, Beijing, Jilin, Heilongjiang, Liaoning, and Hebei.

Age-standardised death rates for ischaemic heart disease range from 50·2 deaths per 100 000 people (95% UI 31·6–62·0) in Zhejiang to 218·9 per 100 000 people (159·3–267·7) in Heilongjiang for men and from 38·7 per 100 000 people (22·0–47·6) in Zhejiang to 165·8 per 100 000 people (126·1–205·0) in Heilongjiang for women. Although the ordering of death rates does not directly correspond with that of all-cause mortality, a relatively clear north-to-south gradient exists, with the highest rates in the North. The appendix (pp 43–44) shows the same information for 1990. Compared with 1990, for men, the age-standardised death rate for ischaemic heart disease in China nationally has increased and 25 of 33 provinces have seen an increase. For women, however, ischaemic heart disease death rates have fallen at the national level, although three of 33 provinces have had non-significant increases (Hebei 8·5% [–29·9 to 43·1], Qinghai 16·3% [–24·2 to 59·3], Gansu 38·6% [–29·1 to 102·1]).

Provinces are ordered by all-cause age-standardised death rate. Green cells show that the rate is significantly (p<0·05) lower than the national rate; red cells show significantly higher rates; and yellow cells show rates that are indistinguishable from the national rate. COPD=chronic obstructive pulmonary disease.

Age-standardised rates of death (per 100 000 people) for leading causes in China and its provinces for men (A) and women (B) in 2013

Figure 4 Age-standardised rates of death (per 100 000 people) for leading causes in China and its provinces for men (A) and women (B) in 2013

The table provides an assessment of deaths and death rates by cause for both sexes combined. The appendix (pp 28–36) shows the same results for men and women separately. Notable differences between rates for men and women include ischaemic heart disease, for which rates are increasing for men and decreasing for women. The overall (men and women combined) constant age-standardised mortality rates for ischaemic heart disease in the time period 1990–2013 might seem surprising because prevalence of most relevant risk factors are increasing. However, because of improvements to the treatment and control of high blood pressure and better access to various treatments related to cardiovascular outcomes, such a finding is reasonable. Constant and declining trends have been reported in many other countries.

GBD 2013 Mortality and Causes of Death Collaborators Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.

The number of deaths in China increased from 8·6 million (95% UI 8·1 million to 9·1 million) to 9·1 (8·3–9·8) million between 1990 and 2013 but the age-standardised death rate fell by 33·1% (27·7–39·4) during the same period ( table ). For the communicable, maternal, neonatal, and nutritional diseases, the number of deaths decreased and age-standardised rates fell by 74·1% (72·1–75·9). For non-communicable diseases (NCDs) overall, the number of deaths increased from 5·9 million (5·5 million to 6·3 million) to 7·9 million (7·2 million to 8·5 million; 33·5% increase [19·4–46·9]), but the age-standardised death rate fell by 25·7% (19·1–33·0). Among the NCDs, 43 of 79 causes had significant reductions in age-standardised mortality rates, including cerebrovascular disease, liver cancer, stomach cancer, and oesophageal cancer. We noted significant increases in age-standardised rates for liver cancer due to hepatitis C, prostate cancer, pancreatic cancer, mesothelioma, atrial fibrillation and flutter, interstitial lung disease and pulmonary sarcoidosis, and chronic kidney disease.

Deaths for all ages and both sexes combined and age-standardised death rates for 240 causes in China in 1990 and 2013 with percentage change

Table Deaths for all ages and both sexes combined and age-standardised death rates for 240 causes in China in 1990 and 2013 with percentage change

We estimated the probability of death for 33 provinces between birth and age 15 years for girls and boys, broken down into key causes during childhood and early adolescence ( appendix p 41 ). Probabilities of death ranged from less than 0·5% in Macao and Hong Kong to 5·1% (95% UI 4·5–5·7) for boys and 4·5% (3·9–5·0) for girls in Tibet. Figure 3 provides a similar province-level decomposition of the probability of death between age 15 years and exact age 50 years broken down by cause. For women, the probabilities ranged across provinces from a low of 1·2% (0·8–1·7) in Shanghai to 5·8% (4·6–7·0) in Tibet. For men, the range was from 2·7% (2·0–3·7) in Shanghai to 9·1% (6·5–12·5) in Guizhou. In nearly all provinces, road traffic injuries play an important part for men, as do ischaemic heart disease, cerebrovascular disease, and lung cancer, liver cancer, and other cancers. Tuberculosis is an important cause of death in Tibet and a few other provinces with high mortality. Cirrhosis stands out as a cause of death for men in Tibet, Qinghai, Guangxi, Yunnan, and several other provinces. Probability of death due to liver cancer was not only higher in men than in women, but also ranged widely across provinces, with the highest levels in men in Guangxi and the lowest in women in Shanghai. Between 50 years (exact age) and 75 years (exact age), three causes made the largest contributions to probability of death in most provinces: chronic respiratory diseases, cerebrovascular disease, and ischaemic heart disease ( appendix p 42 ). For China overall, these causes account for 44·4% (40·3–46·8) of the probability of death in women and 43·3% (42·1–44·6) of the probability of death in men.

For female life expectancy ( figure 2 ), the range in 1990 was from 57·4 years (95% UI 54·6–60·0) in Tibet to 78·8 years (78·1–79·6) in Hong Kong. Between 1990 and 2013, female life expectancy increased by between 3·9 years (−0·8 to 5·5) and 15·0 years (11·6–18·4), and in 2013 the lowest life expectancy was 72·4 years (70·5–74·3) in Tibet and the highest was 85·2 years (83·3–87·2) in Shanghai. The gap between the best and worst province narrowed from 21·4 years (18·7–24·3) in 1990 to 12·8 years (10·7–15·0) in 2013. This reduction of differences in life expectancy has been driven by falls in diarrhoea, lower respiratory infections, and other infectious diseases; neonatal disorders; maternal disorders; cardiovascular diseases; and chronic respiratory diseases. Large reductions in deaths due to self-harm (suicide) also contributed to increases in life expectancy in many provinces.

Life expectancy in 1990 and 2013 and change in life expectancy from 1990 to 2013 decomposed into the contribution of major groups of causes of death for each province for women

Figure 2 Life expectancy in 1990 and 2013 and change in life expectancy from 1990 to 2013 decomposed into the contribution of major groups of causes of death for each province for women

The appendix (p 40) shows data for men and women combined. For men ( figure 1 ), life expectancy in 1990 ranged from 55·2 years (95% UI 52·6–57·7) in Tibet to 74·1 years (72·1–76·2) in Shanghai, a gap of nearly 19 years (16·0–21·8). By 2013, the range was from 68·4 years (66·3–70·6) in Tibet to 80·2 years (78·0–82·7) in Shanghai, a gap of 11·8 years (9·3–14·5). In most provinces, reductions in diarrhoea, lower respiratory infections, and other infectious diseases (light brown bars) have made important contributions towards this improved life expectancy. Other major drivers have been reductions in neonatal disorders, cardiovascular diseases, chronic respiratory diseases, and neoplasms. Increasing numbers of transport injuries made negative contributions to the change in life expectancy during this period in several provinces, including Xinjiang, Guizhou, Shandong, and Hebei.

Life expectancy in 1990 and 2013 and change in life expectancy from 1990 to 2013 decomposed into the contribution of major groups of causes of death for each province for men

Figure 1 Life expectancy in 1990 and 2013 and change in life expectancy from 1990 to 2013 decomposed into the contribution of major groups of causes of death for each province for men

Discussion

China has made extraordinary progress to reduce child mortality and increase life expectancy. Despite huge progress for all provinces, the gaps between provinces remain very large. Cause-of-death patterns are also highly variable. The shift from infectious diseases to non-communicable causes is occurring in all provinces, with important local or regional variations. In view of the demographic trends in China, this shift is highly likely to continue with many health system implications.

On the basis of our results, we can divide China into five distinct groups. Shanghai, Tianjin, Zhejiang, Beijing, Hong Kong, and Macao have low mortality even by the standards of high-income countries: their regional averages for life expectancies are higher than those of the USA or South Korea. Tibet, Xinjiang, Qinghai, Guangxi, and Guizhou have levels of mortality that are more characteristic of low-income countries in South Asia; they also have the double burden of infectious diseases and neonatal causes and high levels of cerebrovascular disease, road injury, and stomach cancer. The remaining provinces of China can be differentiated on the basis of mortality levels for the four major cancers (stomach, lung, liver, and oesophageal), COPD, and the ratio of cerebrovascular disease to ischaemic heart disease. Jiangsu, Hainan, Guangdong, Fujian, Hubei, and Hunan have relatively high life expectancy and the lowest mortality rates due to ischaemic heart disease and cerebrovascular disease, but have much higher mortality rates due to either cancer or COPD. Most of the provinces in northeast China are in the fourth group, in which life expectancy is in the middle among all provinces and these provinces have higher levels of mortality due to ischaemic heart disease and cerebrovascular disease and the four major cancers. This group includes Shandong, Jilin, Liaoning, Shanxi, Shaanxi, Henan, Anhui, Hebei, Inner Mongolia, Heilongjiang, and Ningxia. The last group consists of five provinces that are mostly in the southwest part of China: Jiangxi, Chongqing, Yunnan, Gansu, and Sichuan. These provinces have lower than average life expectancy but low mortality from ischaemic heart disease and cerebrovascular disease and high mortality from COPD.

23 Xu G

Ma M

Liu X

Hankey GJ Is there a stroke belt in China and why?. 23 Xu G

Ma M

Liu X

Hankey GJ Is there a stroke belt in China and why?. 24 He J

Klag MJ

Wu Z

Whelton PK Stroke in the People's Republic of China. I. Geographic variations in incidence and risk factors. 25 He J

Klag MJ

Wu Z

Whelton PK Stroke in the People's Republic of China. II. Meta-analysis of hypertension and risk of stroke. , 26 Yong H

Foody J

Linong J

et al. A systematic literature review of risk factors for stroke in China. 27 Li N

Prescott J

Wu Y

et al. The effects of a reduced-sodium, high-potassium salt substitute on food taste and acceptability in rural northern China. , 28 China Salt Substitute Study Collaborative Group

Salt substitution: a low-cost strategy for blood pressure control among rural Chinese. A randomized, controlled trial. 29 Aiyagari V

Gorelick PB Management of blood pressure for acute and recurrent. , 30 O'Brien C

Bray EP

Bryan S

et al. Targets and self-management for the control of blood pressure in stroke and at risk groups (TASMIN-SR): protocol for a randomised controlled trial. , 31 Ebrahim S Cost-effectiveness of stroke prevention. 32 Liu M

Wu B

Wang WZ

Lee LM

Zhang SH

Kong LZ Stroke in China: epidemiology, prevention, and management strategies. Cerebrovascular disease remains the leading cause of premature mortality in China and in 23 of 33 provinces.We noted increased rates in the north and west of China, as did Xu and colleagues,but we also saw high rates in Guizhou, as did He and colleagues.Cerebrovascular disease mortality seems to be inversely related to income per capita, with the highest rates in the poorest provinces, with the exception of Yunnan, and the lowest rates in the most demographically and epidemiologically advanced provinces, such as Hong Kong, Macao, and Shanghai. Several studiessuggest that hypertension is the main determinant of high cerebrovascular disease levels in China. We estimate that China overall and 11 of 33 provinces for men and 18 of 33 provinces for women had significant reductions in age-standardised cerebrovascular disease death rates. The remaining provinces had no significant changes. Population-based strategies to reduce blood pressure through the use of salt substitutes are being studied in China.Treatment for high blood pressure is also a key strategy for controlling cerebrovascular disease, and studies have reported that these treatments are highly cost-effective.However, provincial data about the fraction of individuals with high blood pressure who are on treatment are not available. Liu and colleaguesargue that resources have been used for expensive and invasive procedures of unproven value for secondary prevention. In view of the prominence of cerebrovascular disease as a cause of death and the huge gradients across the country, China needs a cerebrovascular disease prevention policy focused on the poorer provinces with the highest rates.

33 Moran AE

Forouzanfar MH

Roth G

et al. the global burden of ischemic heart disease in 1990 and 2010: The Global Burden of Disease 2010 Study. 34 Popkin BM

Keyou G

Zhai F

Guo X

Ma H

Zohoori N The nutrition transition in China: a cross-sectional analysis. , 35 Du S

Lu B

Zhai F

Popkin BM A new stage of the nutrition transition in China. 7 Yang G

Wang Y

Zeng Y

et al. Rapid health transition in China, 1990–2010: findings from the Global Burden of Disease Study 2010. Rates of ischaemic heart disease in China have increased from 1990 to 2013 for men but decreased for women. Analysis of trends for ischaemic heart disease in China, as in most countries, is affected by the allocation of garbage codes (such as heart failure) to ischaemic heart disease. Trends in ischaemic heart disease in other countries are strongly affected by access to care; in many countries, death rates for ischaemic heart disease have fallen, despite increasing prevalence of key risk factors such as tobacco use and obesity.One explanation for divergent rates between men and women could be the high levels of tobacco consumption in men compared with women in China. Diet in China is also changing, with increased fat intake, increased total caloric consumption, increased meat consumption, and increased consumption of sugar-sweetened beverages.Changes in diet might be driving increases in causes such as colorectal cancer, pancreatic cancer, and diabetes. Continued change in diet and increases in obesity could contribute to a situation in the future whereby ischaemic heart disease levels will rise in women as well as men. Our current assessment of ischaemic heart disease is different from that reported by Yang and colleaguesat the aggregated national level. In addition to the use of substantially more empirical data about causes of death, compared with the GBD 2010, shifts in our modelling strategy, including analysis at the provincial level, and improved garbage code redistribution have contributed to the changes in both levels and trends of our estimates for ischaemic heart disease. Such shifts also exist for other causes of death, most notably COPD.

36 Li JY

Liu BQ

Li GY

Chen ZJ

Sun XI

Rong SD Atlas of cancer mortality in the People's Republic of China. An aid for cancer control and research. 37 Ng M

Freeman MK

Fleming TD

et al. Smoking prevalence and cigarette consumption in 187 countries, 1980–2012. 38 Shi J

Zhu L

Liu S

Xie W A meta-analysis of case-control studies on the combined effect of hepatitis B and C virus infections in causing hepatocellular carcinoma in China. 39 Ferenci P

Bernstein D

Lalezari J

et al. ABT-450/r–ombitasvir and dasabuvir with or without ribavirin for HCV. , 40 Gaetano J Benefit-risk assessment of new and emerging treatments for hepatitis C: focus on simeprevir and sofosbuvir. 41 Shen L

Shan YS

Hu HM

et al. Management of gastric cancer in Asia: resource-stratified guidelines. 42 Fock KM

Katelaris P

Sugano K

et al. Second Asia-Pacific Consensus Guidelines for Helicobacter pylori infection. 43 Asaka M A new approach for elimination of gastric cancer deaths in Japan. China has high rates of cancer mortality, especially for lung, liver, stomach, and oesophageal cancer. Within China, marked local variation in prevalence of these cancers was reported in the 1973–75 National Cancer Mortality Survey.Our findings at the provincial level suggest that complex patterns remain that are not simply a function of socioeconomic development. Some fraction of all four cancers can be related to tobacco consumption, with population attributable fractions greatest for lung cancer, oesophageal cancer, liver cancer, and stomach cancers. Prevalence of daily smoking in men was 45% in 2012 and 2% for women, suggesting the huge potential to reduce cancer levels through reducing tobacco consumption among men.The role of hepatitis B and hepatitis C is well recognised for liver cancer.Liver cancer is a particular problem in Fujian, Heilongjiang, Sichuan, Guangxi, and Henan. In national surveys, coverage of the third dose of hepatitis B vaccination for infants was 93·4% in 2006, and 96·7% in 2013. New highly effective treatments for hepatitis C have introduced another strategy for reducing liver cancer mortality in China.The new treatments, however, are currently extremely expensive. Screening and eradication of Helicobacter pylori infection is recommended for groups who are at high-risk for stomach cancer.However, the cost-effectiveness of H pylori screening in low-risk groups is not conclusive.A new screening strategy in Japan used a test-and-treat approach to H pylori infection for individuals of all ages and endoscopic examination for people aged 50 years and older.China has launched early detection and diagnosis programmes for several gastrointestinal cancers in most provinces. The efficacy of such programmes needs further investigation.

44 Zhang X

Xiang H

Jing R

Tu Z Road traffic injuries in the People's Republic of China, 1951–2008. 45 Hu G

Baker T

Baker SP Comparing road traffic mortality rates from police-reported data and death registration data in China. , 46 Ma S

Li Q

Zhou M

Duan L

Bishai D Road traffic injury in China: a review of national data sources. 47 Wang SY

Li YH

Chi GB

et al. Injury-related fatalities in China: an under-recognised public-health problem. Our study identified road injury as a leading cause of premature death in China. Police data suggest that, at least since the early 2000s, traffic fatalities have been declining;other sources have suggested stagnant (according to DSPs) or increasing (according to urban vital registration data) rates.The relative constancy of rates over time during a period of extraordinary increase in motorisation suggests that fatalities per vehicle have fallen substantially. However, wide differentials in age-standardised road injury rates have persisted, with poorer western provinces continuing to have much greater death rates than do richer provinces. Most road injury deaths are among pedestrians and motorcyclists. Studies have shown that effective and often inexpensive interventions such as seatbelts, helmet use for motorcyclists, traffic separation, traffic calming, and drunk driving interventions have low levels of implementation in China overall.In view of the prominent role of road injury, efforts to scale-up the implementation of a package of these effective and low-cost strategies could have substantial benefits for health in China overall and help to reduce inequalities between provinces.

The general pattern of 60–90% reduction in the age-standardised death rates for infectious diseases from 1990 to 2013 did not apply to HIV. In fact, we noted that age-standardised death rates have increased significantly during the period in 32 of 33 provinces. A more detailed examination of trends by year shows that HIV is falling in Macao, Henan, and Tibet, but was still increasing in 14 of 33 provinces during the period 2005–13. Antiretroviral therapy has been scaled up substantially but estimation of the true magnitude of the epidemic and access to treatment remains difficult.

48 Lopez AD

Murray CCJL The global burden of disease, 1990–2020. 10 Yip PS

Law CK

Law YW Suicide in Hong Kong: epidemiological profile and burden analysis, 1981 to 2001. , 49 Phillips MR

Li X

Zhang Y Suicide rates in China, 1995–99. , 50 Phillips MR

Liu H

Zhang Y Suicide and Social Change in China. 51 Zhang J

Ma J

Jia C

et al. Economic growth and suicide rate changes: a case in China from 1982 to 2005. , 52 Wang CW

Chan CL

Yip PS Suicide rates in China from 2002 to 2011: an update. 53 Mann J

Apter A

Bertolote J

et al. Suicide prevention strategies: a systematic review. , 54 van der Feltz-Cornelis CM

Sarchiapone M

Postuvan V

et al. Best practice elements of multilevel suicide prevention strategies: a review of systematic reviews. , 55 Dong X

Chang ES

Zeng P

Simon MA Suicide in the global Chinese aging population: a review of risk and protective factors, consequences, and interventions. Murray and Lopezcalled attention to extremely high rates of suicide in Chinese women in the GBD 1990 study. Several studieshave reported extremely high levels of suicide, especially in young women in rural areas in the 1990s. Explanations have been multifactorial, with mental illness accounting for less than two-thirds of suicides, by contrast with higher proportions in Western countries. Our results show that age-standardised rates varied profoundly across provinces in 1990 and in 2013, but rates have fallen in all provinces, with reductions ranging from 36% to 81%. Despite the progress, rates reach as high as 19·7 per 100 000 (15·6–26·4) in Hubei, although they were as low as 2·1 per 100 000 (1·5–3·4) in Tianjin. Studies have attributed the decrease to rising economic status, female labour force participation, urbanisation, and possibly increased access to health care.Because progress occurred in nearly all provinces, the variation in female suicide rates remains tenfold across provinces. Age-standardised rates for men are now higher than those for women in all 33 provinces. With suicide a top ten cause of YLLs in 12 of 33 provinces, active intervention strategies are still needed, despite the progress driven by socioeconomic development. Recommended policy steps, such as identification of high-risk individuals, restriction of access to means of suicide, basic mental health services, and social support networks might need to be strengthened in the most at-risk provinces.

56 Salvi SS

Barnes PJ Chronic obstructive pulmonary disease in non-smokers. Despite continued high levels of tobacco consumption by men, COPD has fallen substantially as a cause of death in both sexes. The profound secular trend in men and women can only be explained by a prominent role for factors other than smoking that have been falling in recent decades. Other key determinants of COPD might include exposure to household air pollution, ambient air pollution, history of tuberculosis, lower respiratory tract infections in childhood, and poverty.Other risk factors for COPD reported in China include physical inactivity, low educational attainment, and being underweight. In view of the importance of COPD as a cause of death in China, the reductions are welcome. Learning from provinces or communities in which reductions have been the largest might provide insights into how to accelerate progress in other populations.

2 GBD 2013 Mortality and Causes of Death Collaborators

Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. 57 Fu Z

Dong J

Guo B

Liu S

Li J On the issue of correcting pulmonary heart disease coding. This study has several important limitations. First, all the limitations outlined in the GBD 2013cause of death analytical approach apply here; notably, although uncertainty intervals include uncertainty from sampling and non-sampling error, model specification, and model parameter estimation, they do not include uncertainty in garbage code redistribution algorithms. Second, we assume that, within each of the 60 province strata, the available in-hospital and out-of-hospital data are representative of that subpopulation in each time period. We judge this assumption to be reasonable since regions that reported low numbers of deaths were excluded in the analysis. Third, the quality of certification and coding as assessed through the fraction of garbage codes varies substantially across provinces and has substantially improved over time. The quantity and quality of data available in the most recent years are much greater than they were around 1990. Time trends, especially in poor high-mortality provinces such as Tibet, are affected by the redistribution of garbage codes. This is the reason for the differences in coronary heart disease death trends between the GBD 2010 and GBD 2013 studies. Fourth, debate continues with respect to garbage code redistribution for pulmonary heart disease in China. In GBD 2013, we used a rigorous analytical strategy combined with up-to-date ICD-10-coded cause of death information from the cause of death reporting system of the Chinese CDC. As a result, 48% of pulmonary heart disease was redistributed to COPD and 42% to ischaemic heart disease in GBD 2013. Other studies about redistribution of pulmonary heart disease in China have largely been based on small, urban, and non-representative populations.Further investigation using field data from China would be welcomed to help to elucidate this subject. Fifth, as with all cause of death analyses based on death certificates, important national biases might exist in the way physicians complete death certificates or assign death based on available information for deaths outside of hospital. Differences in the quality of data entered into the surveillance point system in different years could affect the accuracy of the estimated trends in causes of death. Sixth, we applied the new relational model life table systems to estimate provincial life tables. Although we have empirical life tables from China that are of high quality after adjustment for incompleteness, we still do not have observed life tables from censuses at the provincial level. Site-level life tables from the DSP system are generally more volatile and assessment of their completeness is difficult.

China in epidemiological terms is not one nation, but five: rapid transitions are occurring in all of them, but the most important health problems and the challenges imposed on the health system by demographic and epidemiological change are different. Tracking levels of mortality by age–sex groups and cause will be crucial for the health system to respond to these diverse needs in a timely fashion. Rapid expansion of cause of death registration from 0·6% in 1991 to 44·7% in 2012 (excluding vital registration in Hong Kong and Macao) shows that complete registration could be implemented in China in the near future. The value of this resource in tracking health in the different Chinas would be immense.