1. the Background and Purpose of the Health Policy Study

INTRODUCTION

1. The Background and Purpose of The Health Policy Study In 2000,World Health Organization in Western Pacific Area adopts the scene analysis to study health policies of local memberships in planned groups. The main purpose is to help the membership’s health policy legislator and policymaker detect the problem which is present during health sector’s reform extensively by collecting various materials (including digital data) both inside health system or outer. So we can solve those problems timely. In the same time, we are desirous that the survey will help the leaders, policy makers to use the present materials and data to improve their management. We want our health reform to achieve those objects: health sectors provide high quality service; the people possess more equitable, effective service; and people’s general level of the health will be increased continuously. To base on the purpose of survey, this survey will be carried on in three provinces in China (Zhejiang province, Guangxi province and Shaanxi province) in the second half of 2001.The contents of survey is make up of three parts. Part one: politics, economy and society problem; Part two: Health System; Part three: the development of health sector; the detail is presents in the questionnaire and survey table. The method we used is both integrated qualitative and quantitatively analysis. Investigator and professional collected the material and data widely in provincial government, Provincial Statistics Bureau, Provincial Department of Finance and so on. We have an individual interview with the leaders and staff when necessary. According to the material we gathered to analyze the comprehensive situation (investment, process, produce, influence and outcome); next we analyzed the positive and negative influence, which is caused by politics, economy, culture and reform measures. We also printed the investigated results and analysis reports for different levels of provincial leaders to consult when they made a strategic decision.

1.1. Health Policy Analysis

1.1.1.To construct the frame of health policy problem How to bring society health problem and health care problem into health policy procedure and turn into health policy problem? What is health policy problem? Which analysis is to be used to solve health policy problem? What fundamental condition is needed when we establish health policy procedure?

1.1.2.To establish and adopt health policy scheme What are the fundamental principles when we establish health policy scheme? What is the target when we achieve the health policy program? How to set up the scheme that can be selected? How to optimize the selected health policy scheme? What benefits groups direct or indirect influenced the process of health policy scheme establishment? How to pass through and issue health policy scheme?

1.1.3.To bring health policy into practice

1 What conditions are needed when we want to carry out health policy effectively? What measure we adopted during health policy takes effected period? What ‘s the influence that resulted from those measures?

1.1.4.To assess the health policy effect Which standards should be followed to assess the influence and effect of health policy’s practice? Who is assessment the result of health policy? What is the result of health policy assessment? We should carry out and develop health policy continuously or revise, adjust and abrogate it?

1.2.The Factors Related to Health Policy Analysis

Health policy analysis includes so many contents. The following factors are more important.

1.2.1.The target of health policy Health policy target is the objective that policy maker want to achieve by setting up and carrying out health policy. It may be some benefits or certain condition. Health policy target is very important for health policy establishment. We select a correct aim, then establish working draft, carry on cost-benefit analysis, and confirm an action plan. On the other hand, health policy target is so complicated. There are clear and definite single target also diversification incompatible target, long-term target and short-term target, quantification target and non-quantification target. With regards to policymaker, it’s difficult to confirm health policy target. The reason is that health policy target is so ambiguous that policymaker didn’t know what is the target on earth. Health policy is so obscure when policymaker masked their intention deliberately. Health policy is so incompatible because various groups including government department want resort it to achieve their own benefits. For those reasons, health policy target analysis is the main factor of health policy analysis.

1.2.2. Preparing selected scheme Prepare selected scheme is a proposal referred to policymaker to choose, also called draft. It may be specific health policy, tactic or action plan. Health policy analyst provides scheme to policymaker after seeking, choosing, checking and taking steps. At the same time, they design scheme in many ways to against omit. There are some principles will be established while choose the drafts. We get rid of some draft that is not conforming to rules in order to easy to selected. Furthermore, that draft is to be demonstrated and decided the final action scheme.

1.2.3.The power of the health policies The analysts of the health policy need to compare the outcomes resulted from the implementing of the optional schemes with the possible costs needed and in turn predict the efficacy of the health policy. Two kinds of comparing methods can be used in analyzing process. One is to subtract the cost from the outcome. If the difference is plus, it will be showed that the outcome of the health policy is greater than the cost of it. If the difference is negative, that the outcome of the health policy is less than the cost be showed. Thus the expected effect of health policy will be worked out. The other is to divide the possible outcome by the predicted cost. The

2 quotient is exactly the expected efficiency of the health policy. Besides economic outcomes and economic efficiencies, there are non-economic outcomes in efficacy of health policies. Adding the non-economic effect to the economic outcomes and efficiencies, the expected efficacy of health policies would be worked out.

1.2.4.Standards of health policies The standards of health policies are a kind of rules or scales used to rank the optional schemes in a certain order so as to give priorities to the preceding ones. The standards of health policies would affect not only the selection of the optional schemes but also the evaluation of the health policies. The standards of health policies lie on the concepts of value of decision-makers. Analysts of health policies should not choose the standards of health policies for the decision- makers but establish suitable standards of health policies according to the priorities of subjective values of them and then rank and compare the optional schemes according to the standards of health policies.

1.2.5.Models of health policies The core of health policy analysis is to find or formulate a model that can predict the executing process of the selected scheme. If the scheme for action of health policy has been selected, the task of the analysts of health policies will establish a formula, or a model, through which we can be informed what steps will be involved, what effects will be resulted in and to what extent the goal will be reached in the executing process of the health policy. The formulation of models of health policies needs special skills as well as creative thoughts.

1.3.Procedure of Health Policies Analysis

The process of health policy analysis can be divided into five phases relatively such as goal interpreting, scheme seeking, effect predicting, model formulating and scheme evaluating.

1.3.1.Goal interpreting The goal of health policy analysis is not assumed by analysts of health policies, but affirmed by decision-makers. The tasks of analysts of health policies are listed below. Firstly, they should analyze the problems concerning health policies that lead to the goals of health policies. Secondly, the controversial items associated with the goals should be analyzed. The third, the goals affirmed should be interpreted. At last, various factors and relations included in the goals of health policies should be assumed and analyzed. Since the information of the goals of health policies is continuously increasing, analyses of goals must be done repeatedly.

1.3.2.Scheme seeking Seeking for the optional schemes of health policies is the precondition of the schemes comparing. Scheme seeking involves three aspects. The first is to analyze the optional schemes brought forward by decision-makers. This process usually needs repeating for several times. The second is to arrange the optional schemes have been listed according to the criterion. Based on the above two steps, the third is that analysts of health policies should try to find or to design all possible schemes, and do their best to make the schemes exhaustive and new schemes exclusive

3 from original ones. In this phase of analysis, analysts of health policies must ensure three kinds of jobs. The first is to acquire as more information as possible. They should go to great lengths to exploit, collect, distinguish, screen and deal with information. The second is to take advantages of outer minds in widest scope. They can consult specialists of related subjects and absorb their opinions according as the content of the health policies. The third is to make actual investigations to acquire sensory knowledge of the issues and circumstances of health policies so as to avoid the disjoint of the optional schemes from the facts.

1.3.3.Effect predicting On the bases of thorough studies of finite optional schemes of health policies, analysts of health policies must predict the future outcome of each scheme according to its content and character. The job of predicting can be performed as following steps. Firstly, seeking and stipulating the concrete conditions of the implementing of the schemes of health policies. Secondly, predicting possible situations occurring in the processes of implementing of the schemes and their probabilities. Thirdly, investigating the intervening means of dealing with the adverse situations in the process of implementing of each scheme and their positive and negative effects. The fourth, ground on the former three steps of analysis, working out possible outcomes of schemes for action of health policies.

1.3.4.Model constructing Formulating the models of health policies is greatly correlated with predicting the outcomes of them. The aim of model formulating is to make more precise and intuitive prediction of the outcomes of optional schemes of health policies. Suitable models can be formulated only with the guide of the prediction of health policies. Forms of models of health policies formulated could be various. The simplest forms are those of diagram demonstrations and tables. More complicated and subtle forms are math models such as algebra formulae, differential equations and computer programs etc. Model formulating of health policies is not only a kind of skills, but a process of systematically thinking and creatively designing. Model formulating of health policies must comply with certain regulations. First of all, it must be known that the goal of model formulating is not the model itself. Model formulating needs to conform to the ultimate objectives that direct the executing process of optional schemes of health policies. On this account, model formulators must enhance communication, dialog and consultation with executors of health policies. Next, models formulated must be brief and clear and should not be too complicated or too elaborated. It must be considered to save time, labor and money when model formulating. The third, the implementing of health policies is a systematic project so that it is impossible to formulate models for each links or step. Model formulating should focus on the most necessary sectors or links of the implementing of health policies.

1.3.5.Scheme evaluating The purpose of scheme evaluating is to make the schemes for action decided ultimately by decision-makers so as to complete the policy making process. The foundation of scheme evaluating is to set up the standards of health policies, which could be one or several. The

4 precondition of scheme evaluating is the outcome predicting and comparing of optional schemes health policies. Analysts of health policies rank all the optional schemes in the order from the best to the worst according to the standards of health policies and the predicting results obtained in former phases. If economic profit or efficiency is considered as criterion, the ranking of optional schemes can be performed in two ways. One is to equalize the profits or efficiencies and rank optional schemes in the order of ascending costs. The other is to equalize the costs and rank optional schemes in the order of descending efficiencies. If social justice is considered as criterion, the ranking of optional schemes can also be performed in two ways. One is to equalize the satisfaction rate of the public or the protecting degree for weak population and rank them in the order of ascending costs. The other is to equalize the costs and rank them in the order of descending rate of satisfaction of the public. The five links or phases of health policy analysis are not isolated but associated with each other. In actual process of analysis, these links are often overlapping, penetrating, repeating and periodic.

2.Achievements of Health Promotion in Shaanxi Province Since the founding of the People’s Republic of China, Shaanxi Province has implemented the Party guiding principles of health work under the leading and support of the provincial Party committee and government. The countryside has firmly been taken as the focal point of health work, and great effort has been made to provide basic health services for the people. Rapid progress and marvelous achievements have been made, which contribute greatly to protect and improve people’s health, and promote economic and social development of Shaanxi province. Before the founding of the PRC, the health services in Shaanxi were very backward. There were only four general hospitals, one isolation hospital and one maternity hospital, in which there were 226 doctors and 455 hospital beds. The most advanced medical equipment at that time were three X-ray machines. Besides there were some people practicing medicine in private hospital, individual clinics and some Chinese herbal medicine shops. Many kinds of infections diseases and endemic diseases broke out every year. The average life span was only 40 years old. Since the founding of the PRC, specially after the year 1978，every aspect of health service construction has been developed greatly and the health service network at three levels of province-town- countryside has been shaped basically under continuous striving and close attention paid by provincial Party and government to the public health services. By the end of 2000 there had been 5572 health organizations, which was 36.40 times more than those in 1994 and 96857 hospital beds and 163905 public health workers, which was separately 73 and 39 times more than those in 1949. The three chief health indexes reflect the social development — maternal mortality rate, which has dropped from 15000/million to 570/million. The infant mortality rate (IMR) from 290‰ to 21‰ and life expectancy, which has risen from 40 years old to 70.3 years old — have gotten up to the average level of developing country. The rural health construction has been strengthened constantly. Since the founding of the RPC, it is regarded as the key-point of health development all along in Shaanxi province, where health network at three levels of county-town-village has been established and developed. Buildings of inpatient department and ambulant clinic have been built in the hospitals at county level successively while dispensaries were sited in all towns. After construction and reorganization

5 for years running, the proportion of the rural areas covered with health organizations, in which there’re 54793 public health workers, has gotten 89.78%. The popularizing of various medical treatment systems in whole province and the development of basic hygienic work have strengthened peasants’ concept of health so greatly that the hygienic habits were forming little by little and the basic hygienic work has been up to scratch in 94 counties. Since 1978 the investment in the health construction in the key counties has been up to 4.50 million RMB each year. 216 focal projects in 70 counties were constructed, which improved the basic hygienic condition in a batch of health organizations at county level. Successively 270 million RMB was invested in three aspects of the rural health services construction (rural dispensaries, quarantine stations and maternity clinics). The standard of “one nil and three aspects of coordination” (without houses in hazard and the coordination of houses, staffs and equipment ) has been reached in 1419 rural dispensarie,89 county quarantine stations and 89 county maternity clinics, after repairing houses in hazard of more than 280 thousand square meter, building houses of 579 thousand square meter and equipping 5819 medical machines. Every year Health Department of Shaanxi Provice sends 50 working groups and 250 doctors to the rural area of the north and the south Shaanxi to support and improve health services constriction in poverty regions. Marvelous achievement has been made in prophylaxis and health care. Organizations of prophylaxis and health care of maternity and childhood have been founded in all counties, and the branches of prophylaxis and health care organization are basically founded in towns and villages, in which necessary apparatus are equipped with and the monitoring and preventing measures of epidemic have been developed. Provincial patriotic public health campaign was developed, knowledge of health care was popularized and comprehensive measures of prophylaxis and treatment, such as inoculation, planned immunization and medication, were carried out. As a result, the morbidity and mortality of all kinds of infectious diseases were decreased from 1312.42/100 thousand and 201.69 per 100 thousand to 204.52 per 100 thousand and 0.24 per 100 thousand respectively and some fatal infectious diseases and endemic have been effectively controlled. From mid of 1950’s, after the extermination of smallpox, other serious infectious diseases such as the plague and cholera were also effectively controlled in their breaking out and spreading. The incidence of measles, diphtheria, black fever and leprosy and other infectious diseases greatly decreased, especially the prevention of hemorrhage taking the top position in the whole country and no wild poliovirus being found in recent 6 years. Great effort was taken in the prevention of endemic disease. For example, nearly all table salt was added with iodine. Keshan disease was further controlled. The Kaschin-Beck disease was in steady situation. Leprosy patients in 50 counties were well controlled. Nearly 160,000 projects of fluorine protection were accomplished, with the 78.2% population saying good-bye to high fluorine water, bitter water and water from cellars. In 1996, five-year campaign against endemic diseases in shaanxi and 32- county-in-serious-situation-provention plans were fully carried out, and by the end of this century the threaten of endemic diseases will generally be eliminated. Health care of woman and child was strengthened with new method of delivery being popularized and 224 hospitals being entitled with infant-loving hospital through the whole province. Campaign of patriotic health is in the process of great development. From the beginning of 1960’s, all previous sessions of Shaanxi Party Committee and Government have paid great intention to and strongly supported the patriotic health campaign. Branches at all levels have been founded and amplified. The guideline is to get mobilized, pay attention to hygiene, reduce disease,

6 improve health conditions. The other guideline is to be organized by government, managed by the local, coordinate department, mobilize the public, rule with science knowledge, supervised under the society. All levels of patriotic health organizations closely surrounded the central assignments by Party and government in all periods and continuously carried out tasks of these campaign, such as prevention of diseases and elimination of pests, “two controls” (control water and feces) and “five improvements” (improve wells, latrines, pigsties, stoves and, environment hygiene), health education, promotion of condition of dirty, disorder and mistake, creation of sanitary city and so on, which made the important and historic achievement in changing the sanitary conditions in city and village, eliminating diseases ,changing custom, protecting and improving people’s health levels and promoting the construction of spiritual and material civilization. By the end of 2000, in 80% cities and 56% village of the province the health education is popularized, of which five cities, Xi’an Baoji, Xianyang Hanzhong, Hancheng , are entitled as national sanitary city and nine counties are rewarded as provincial sanitary county, especially Liquan County being honored as national sanitary county by National Patriotic Public Health Committee. The Weiyang and Yanta District in Xi’an and the Qingdu District in xianyang are entitled as the district of tap water popularization in rural area by Nation Patriotic Public Health Committee and Department of Public Health. The number of the people benefiting from this reform has reached 2,325,080,000, 84.41% of rural population, in which 9.68 million, 35.29% of rural population, are drinking tap water. The number of the oven-changed-family is 1.95 million and of lavatory -changed-family is 2.54 million, 37.04% of the rural population. The rate of harmless waste management reached 28.79%. The Hanzhong City and the County Fengxiang are entitled as National Paradigm City in popularization of national clean lavatory program. Chinese medicine construction has made marvelous achievement Shaanxi is one of the original regions of Chinese herbal medicine, which is named as the place without waste plants and the place having excellent doctors. However before the liberation there were no formal Chinese medicine clinics, research and education organizations so that Chinese medicine was at the edge of becoming extinct. After the foundation of PRC, the CP and government pay more attention to Chinese medicine. In Nov 1954, the first session of herbal medicine conference of Shaanxi was held. In 1955 three Chinese herbal medicine clinics and one hospital of Chinese medicine were established in Xi’an, which is regarded as the new chapter of the history of Shaanxi Chinese herbal medical history. In 1956 and 1959,Chinese medicine Research office and college of Chinese medicine in shaanxi province were founded in succession, which was a symbol of the Chinese medicine is in the right track. After the year 1978, the reform and development of Shaanxi Chinese medicine were getting more vital. Chinese medicine is arranged as one of four strategy local-points of health services projects of Shaanxi by the provincial Party committee and Shaanx government and the conference developing Chinese herbal medicine was held, in which the seventh five-year-plan on Shaanxi’s Chinese medicine development project was established. Thus Chinese medicine began a rapid development. By the end of December 2000 there are 178 organizations of Chinese medicine have, 10,548 hospital beds and 22,682 staff. In every county there is more than one Chinese medicine clinics. The aim of prevention and treatment of disease with two means of Chinese medicine and western medicine has been reached in village. The number of employees and hospital beds of Chinese medicine hospitals in Shaanxi separately rank the seventh and twelfth in our country. The Affiliated Hospital of Shaanxi Chinese Medicine College is in the range of seven importantly constructed hospitals countrywide, and 6 other

7 hospitals were regard as the national paradigm hospital by National Chinese Medicine Administration Department while 7 hospitals are provincial paradigm. In the whole province, 3 Chinese medicine hospitals awarded as Three-level/First-order Hospital ，one Chinese medicine hospital awarded as Three-level/Second-order Hospital and 21 hospitals as Second-level/First- order Hospital sine 1978. 167 Science and Technology Advancement Prizess in Chinese medicine have been awarded, of which one is at national level, 24 at provincial level and 149 at the level of Shaanxi medicine. The research of bolbostemma paniculatum (Maxim.) franquet in shaanxi Chinese Medicine Research College was taken as one of the tackled key studies in national ninth 5-year-plan. The development of Chinese herbal medicine resources, the research in receptors of Chinese herbal medicine and the arrangement of the ancient books of Chinese medicine with computer all are leading in the nation. Medical industry developed greatly. Before 1949, the base of medical industry was extremely weak. There were only Northwest Chemical Pharmaceutical Factory, West China Pharmaceutical Factory and Northwest Health Stuff Factory and a few Chinese herbal medicine workshops. Only 10 kinds of pills and 20 kinds of Chinese herbal could be produced at that time. The total industrial output value was only about ten thou Yuan. After the foundation of PRC the development of medical industry was paid more attention. For meeting the needs of people’s health protection, medical industry has been developed rapidly. After scores years of construction, development in medical departments has been made. A system including medicines, medical appliances, and so on has been established to the full, which has been the important portion in the economic development of Shaanxi. Education and research in Medicine have been developed rapidly. A layout of medical education of primary, middle and advanced rank and scientific research network have been set up though 50 years effort. The guiding principle of running a school in multiplex ways, different styles and models was persisted in firmly. At present there are 4 advanced colleges of medicine, 12 secondary schools of medicine, 20 secondary vocational schools of medicine and 52 schools of further education of medicine in counties, in which there are 20,884 students, which was 50 times of those in 1949. The completed and integrated medical research system, including 5 research institutions and 44 subsidiary bodies, has been set up. Some research projects, such as research institution, research capability, experiment situation and technique ability have been leading in the nation or world. 167 achievements have been made, of which there are 30 national prizes, 303 provincial prizes. In the fields of social medicine, molecular biology new achievements are continuously obtained. Xi’an Medicine University won the Clause-swards Prize in the research of the incidence mechanism of KeShan disease. Department of Health in Shaanxi organized research institutions to coordinately research in epidemic hemorrhagic fever (EHF) and made marvelous achievements that 22 prizes of all levels has been awarded. The research of Shaanxi People’s Hospital in dent-lag bolt won the forth Prize of National Invention . The Forth Military Medicine University has been in the leading position in two aspects, cardio-blood vessel cage and the treatment of Parkinson’s syndrome. Reform of public health continuously goes deep. With the gradual reform in politics and economics in china, the public health under the old system of planned economy have not adapted to the increasing requirement of public health. Since the beginning of 1980’s, the reform of public health gradually has been taken into the schedules of all health institutions. There ‘re three important stages in the process of reform. In the stage one the old hospital management system of

8 exclusive running hospital was broken and the new system that hospitals are managed in various styles has been established to settle the public problems in medical diagnosis and treatment under the guideline of multi-management by nation, collectiveness and individual. In stage two the price system of health services and the system of labor forces, personnel and distribution were reformed. In hospital the system of business accounting management at two levels has been followed out to solve the problem of equalitarianism. In stage three the management style of responsibility with comprehensive purpose was spread and the reform of management and operation system was developed. Nowadays all levels of health institutions have adopted the new management style that reinforces vitality and vigor of health institutions greatly. In the reforming of township hospitals various reforms in running hospital are spread popularly in different ways. The hospitals belonging to public property can be managed to be individuals, the hospitals managed under the contract or mortgaged to be others. Another way is that the hospitals are managed in joint with town and township enterprises .The experiment of health comprehensive reforms in Chengcheng County arranged by Shaanxi Health Department has got the achievement in a certain stage. The local legislation has been speeded up. In order to reinforce the function of local medical legislation in managing public health and to take every health work in the track of legal management. Shaanxi government and the Party committee paid great attention to local medical legislation. Taking the socialistic legal system as the foundation, the local legislation has been speeded up greatly. By June 1999, there have been four local rules by the Party committee of Shaanxi and six regulations by the provincial government. The provincial problems of supervision and management have been settled to meet the needs of the public health reform and development in Shaanxi Province. International communication of health is gradually vital. Under the reform and opening up policy, the academic exchange in health affairs, such as exchanging and cooperation with Japan, USA, Belgium France, Singapore and Sudan, has changed, which contributed to the improvement of medical research ability in shaanxi and the support to the third-world countries. By the end of 2000, shaanxi Health Department has entertained 7546 friends specialized in medicine over the world. 3215 academic lectures, speeches and operation demonstrations have been held and the total number of attendees is 14494. In order to understand each other deeply, about 1556 specialists and scholars went abroad attending the academic meetings, training and visiting. According to the arrangement by Health Department, from April 1971 to the end of 2000, 24 batches and 595 doctors were sent to Sudan as medical support teams. In recent 30 years medical support teams help the foreign countries with the great trust on their shoulders and with the intention that gaining honor for motherland, taking Norman Bethune as an medal, they made many moved and praised deeds, and also are honored by Sudan government. President and vice president of Sudan meet them several times. They also won the title as non-movement ambassadors. The work of gaining foreign investment achieved a lot. Since 1989, Shaanxi Health Department fully uses the local health resources and enlarges the scale of opening and cooperation. They also strive to widen the ranges of investment and take measures to attract, develop and make use of international health resources. There ’re four-loan projects from World Bank in turns, which are the project of regional health development, project of woman and child health, branch project of immunology of disease prevention and branch project of Chinese basis health service projects and the total investment in which is 42.28 million RMB. Since 1993, a

9 amount of work has been carried out on making full use of the loans from the foreign countries. There were 9 projects invested by the foreign countries such as Austria, USA, Israel, Spain, Finland. The total money is 16344 thousand USA dollars. The above investment is nearly 0.573 billion RMB, 0.394 billion from foreign countries, 0.179 billion from Chinese local government. All investment was mainly used in the health promotion in the rural and poverty-stricken areas so that the development of the health undertaking in aided areas was improved greatly. The promotion of spiritual civilization makes a new improvement. Since the reform and opening-up policy began, leaders of the party and the government administration of all levels in Shaanxi pay great attention in spiritual civilization construction in health service. We strengthen the education of medical ethics and professional ethic as well as to take many activities, such as learning from the models like Gao zhi, Ma zhengfeng and Zhangjimei. At the same time, the contribution prize of health in Shaanxi and the Prize of Norman Bethune and the Prize of medical ethics were set up. Many units and individuals were honored these prizes. In the nature disasters and accidents all doctors and nurses in the high sense of profession and duty, regardless of death and tiresome, accomplished every assignment effectively. Mary effective measures are taken to solve the problems existing. Since 1991, six surveys have carried out and the satisfactory rate reaches over 85 percent. Shaanxi Health Department were awarded 3 times as the best administration unit by Shaanxi Party Committee and the Government. From Dec 9, 1996 to Dec 12, 1996, the Center Committee of CPC and State Council held the first National health conference after the foundation of PRC and the regulation of Resolution to Reform and Development of Health Services of the State Council of Party Central Committee were announced. From March 30, 1997 to April lest, 1997. CPC Committee of Shaanxi and the Government held a meeting as to learning the spirit of the conference. At the same time, the Opinion of Shaanxi Province Party Committee and Government on Following out the Resolution was also announced. This meeting is an important milestone in the history of public health in Shaanxi which guides us to a new direction, ascertains the quality, position and function of the public health and gives us a steady foundation to develop new situation of the public health.

3.Main Discoveries of the Research There are also some problems needed being noticed and solved except the great achievement.

3.1.Unreasonable arrangement of health resources Health resources excessively remain in cities, while the basic health support in countryside is weaker. There are 6.2 hospital beds pre thousand people in city while the ratio in countryside is only 1.6. The number of skilled medical workers is 8.9 per thousand people in city while 2.2 in village. The problem of co-existence of lack and wastage of health resource gets sharper and sharper. Especially in some big cities, the organizations of health are mixed up and the functions are unclear. All these problems lead to the lack of advantages in regional health resources.

3.2.Lower total health investment and unreasonable structure Government investment was inadequate and the heavier health burden of the private. From 1995-1999, the total health cost was 4% in the GDP, which is lower that 4.82% the average rate in the nation. In 1998, the total cost per person was 179.12 RMB, extremely lower than 302.58 of the national level.

10 The expense in health budget reduced from 23.85% in 1995 to 19% in the total health cost in 1999 while the percentage of health work in the total cast reduced from 8.72% in 1995 to 8.40% in 1999, which reduced from 3.41% to 2.52% in the provincial financial expense. The proportion of social health cost in the total fast also reduced year after year. The properties of private health expense in the total cuts increased, reached 50% in 1996 while 63% in 1999. The proportion for disease treatment in total cost is bigger than that of prevention and health maintain.

3.3.Low quality and inadequate health resource in impoverished counties The population there is 500,000. According to the rules of financial aid to health institution by Shaanxi CPC committee and government, the rate is not less than 60% of personal wage. In center and village public health clinics the rate is 100% in north Shaanxi, 80% in south Shaanxi and 60% in middle plain of Shaanxi. However, the policy of full financial aid to prevention is not in well process. Many fundamental institutions in oversized region lacks of equip rent. The village public health clinics there have no normal equipment such as X-ray machine B-microwave machine and electrocardiogram. They diagnose by stethoscope, sphygmomanometer，and thermometer or by one pillow and three fingers. Many such regions are in high risk of endemic and epidemic disease. These health problems have been main factors restricted the economic development in these regions.

3.4.Sharp increase of the expenditure for health care The speed of treatment fee is far above the rate of social-economic development of and people’s income. From 1988 to 2000, fee to see doctor in a clinic per person increased from 5.10 to 67.18, 13.16 times the former. The inpatient fee per person increased from 206.40 to 2333.43, 11.29 times the former. In 10 years from 1991-2000, the outpatient fee per person increased by 21.73%, the fee of in-patient by 20.07%, while, the rate of GDP is 12.43 and personal income is 12.94%(Fig.1).

11 3.5.Disorder in production and circulation of drug There are altogether 200 chemical pharmaceutical factories, but most of them are small and in low level, there are too many enterprises with bad reputation and too many illegal conducts in drug circulation, which result in the excessive increasing of drug price.

3.6.Unreasonable compensating system and twisted behavior of medical services Financial aid, charge for medical service and price difference in drugs are three aspects in medical compensating. Nowadays, financial aid takes less proportion not more 30% in wage. From 1991 to 1999, the GDP and atonal financial expense were increased 2.97 times and 2.46 times respectively, while the health expense was only increased 1.73 times. The proportion of health expense of financial expense is 2.27% in 1991 and 1.79% in 1999. When wages, management fee and prices of medical product are increased, most of technical service charge is still lower, which can’t compensate the cost. Thus the health organization can only get the compensation from drag sales, inspection of medical equipment and new-special programs, which make the health service twisted.

3.7.Improper policy of medical prices Improper policy of medical prices can’t form flexible price mechanism according to the cost. Price level was made in 1992, except the charge registration in-patient diagnosis, nursing and machine inspection in regulation according to the level in 1996 and 1998, other 95% of medical services are still unchanged. The high technology service price is far beyond the real cost so that stimulates overly purchasing and over-use these devices. however, outpatient and in-patient fee is approach lower than cost, which result in the profit lost so that this service is used least. Because of the effect of social-economic development, the cost of medical service is

12 changed: There are 2040 prices adjusted before 1992 are less than 40% of present price. In order to survive in the market, the hospitals have to gain profit through resolved charge, repeated charge and illegal charge, which has been a social problem.

3.8.Bad equality Generally speaking, health resources in Guanzhong, including Xi’an, Baoji, Xianyang, Tongchuan and Weinan, are higher than that in north and south of Shaanxi. Quantitative analyzing equality situation of health resource in population and comparing the doctors, nurses and berth with Tony Coefficient draw a conclusion that the equality of doctor distribution is good, that of bed is next, while that of nurses is bad(Fig.2).

From 1995 to 1999, the ratio of hygiene expenditure between city and village is 1:0.34, 1:0.37, 1:0.35, 1:0.29 and 1:0.25. The survey of health service shows that the rate that those who should see doctor and hospitalize but not to do is increasing, what’s more, the ratio of village is higher than that of city. Medical burden gets heavier. The poor people in city and peasants in poor region are still in poor condition partially, it is occurred usually that person becomes more and more poor because they can’t afford the medical expenses if he is ill(Fig.3).

13 3.9.Low efficiency. From 1988 to 1998, the per patient cost of treatment in general hospitals in Shaanxi has a tendency of increasing while utility rate and turnover rate of hospital bed have a tendency of decreasing. The number of times of one doctor making diagnosis and give treatment per day decreased from 5.8 to 2-3, which is greatly lower than the standard workload of 10-16 .The utility rate of hospital bed rapidly decreased from 96.8% in 1988 to 55.1% in 1998, decreasing 5.5% every year. At the same time, the bed turnover rate decreased from 24.8 in 1988 to 15.8 in 1998, average decreasing rate is 4.4%.