World Bank Document
PHN Technical Notes GEN 18
This paper is for distribution within the World Bank Group only. Public Disclosure Authorized It should not be cited in any external publication.
THE WORLD BANK Public Disclosure Authorized
HEALTH SECTOR ISSUES IN SHANDONG PROVINCE (Peoples Republic of China)
1983
Public Disclosure Authorized April
Population, Health and Nutrition Department Public Disclosure Authorized
* This paper is one of a series issued by the Population * * Health and Nutrition Department for the information and * * guidance of Bank staff working in these sectors. The * * views and opinions expressed in this paper do not neces- * * sarily reflect those of the Bank. * GEN 18
ABSTRACT
This document provides an update and a review of the health sector in China through a detailed analysis of Shandong Province. Shandong may represent the average in China without distortion associated with extreme per U capita income levels or high urbanization rates. Its agricultural output per capita is slightly above national average; its industrial output per capita is 87.3% of the national average; and its distributed collective income per capita represents 95% of the national average.
The medical service organization and utilization, training of health manpower and cost and finance of health expenditure from brigade to province are reviewed and illustrated, in addition, with a case study of Qufu county. It is a county of great historical and cultural significance -- the birthplace of Confucious.
This leads to the discussion of emerging health issues as a consequence of improvement of health care delivery, improvement of population coverage together with social-economic changes since liberation. New demands on health service facilities, training and health management are emerging as a result of the "epidemiologic transition," population changes and agricultural reform. Finally, it discusses how the health officials propose to address these issues and whether the cost for implementation of the new policies are feasible.
This paper is Supplementary Paper No. 9 to World Bank Report No. 4664-CHA, "The Health Sector in China".
Prepared by: Andre Prost, PHN; Jacques van der Gaag, DRD; John Krister, WHO Nicholas Prescott, PHN and Mary Young, CON
April 1983
NOTE
This case study was prepared on the basis of a visit by the authors to Shandong Province from October 1 to 15, 1982, duriig the course of the World Bank's Rural Health and Medical Education mission to China. TABLE OF CONTENTS -
Page INTRODUCTION
CHAPTER I. Population and Family Planning...... 2
CHAPTER II. Medical Services Organization and Utilization...... 4
CHAPTER III. The Outcome of Health Care Services: Disease Situation and Epidemiological Picture...... *.12
CHAPTER IV. Training of Health Manpower...... 21
CHAPTER V. Case Study on Qufu County*...... 31
CHAPTER VI. Costs and Financing...... 41
CHAPTER VII. Issues and Health Priorities in a Changing Environment.... 0.... 0 ..... 0..0.0...... 46
- Issues related to population changes
- The changing financial environment
- The changing epidemiological pattern
- Lingering problems
- The pressures on the referral system
- Issues in training
- Issues in health mangement
The equity issve and the One-third Countries Program
CHAPTER VIII. Government Policies and Planning.....o...... 54
REFERENCES
TABLES LIST OF TABLES
Within text: Page
Table A. Population in Shandong Province...... 2 Table B. Distribution of X-ray Sets in Shandong Province...... 8 Table C. Enrollment in Shandong Medical College...... 23 Table D. Qufu County Demographic Indicators for Selected Years...... 31 Table E. Main Agricultural Productions, Qufu, 1957-1981...... 33 Table F. Health Sector Shares of Government Expenditure; Yexian and Qufu Counties...... 41
Following Text:
Table 1 - Health Manpower and Facilities in Shandong as Compared to Nationali Figures in China, 1981 Table 2 - Health Personnel and Facilities in 1981; Distribution-. by Prefectures and Municipalities Table 3 - Utilization of Selected Hospital Facilities Table 4 -.Outputs of Health Services Table 5 - Water Supply Table 6 - Communi.able Diseases: Cases Reported, Mortality, Incidence per 100,000 Population Table 7 - Achievements in Control of Communicable Diseases in Yexian Table 8 - Prevalence and Intensity of Ascariasis in Selected Areas of Shandong Province Table 9 - Immunization Schedule in Rural Areas of China Table 10 - Relative Frequency of Cancer by Site; Comparison of Shandong with China Table 11 - Age-Adjusted Cancer Mortality Rates per 100,000 Population; Comparison of Shandong with China Table 12 - Anthropometric Survey in Qingdao Municipality Primary Schools, 1946 Table 13 - Anthropometric Status of Rural and Urban Children-and Youth, 1979 Table 14 - Anthropometric Status of Female Children and Youth, Shandong Provinze, 1979 Table 15 - Food Prices-and Rations in Yexian City, October 1982 Table 16 - Birth Control Situation of Twelve Communes in Qufu County, 1981 Table 17 - Agricultural Production Situation in Qufu County, 1981 Table 18 - Qufu County Health Facilities and Staff, 1957-1981 Table 19 - Qufu County - Staffing and Utilization of Commune Health Centers, 1981 Table 20 - Qufu County - Incidence of Reported Communicable Diseases Table 21 - Qufu County Hospital - Distribution of Diagnosis in 3,627 Inpatients Admitted during 1981 Table 22 - Qufu County Hospital - Ranking of Death Causes in 133 Deaths during 1981 Table 23 - Immunizations Delivered in Qufu County Tables, continued:
Table 24 - Consolidated State Expenditure on Health: 19.75-1982 Table 25 - Distribution of Consolidated State Expenditure on Health per Capita by Municipality and Prefecture, 1981 Table 26 - Functional Shares of Government Expenditure of Health Table 27 - State Expenditure on Health in Yexian and Qufu Counties Table 28 - Sources of Finance for Government Expenditure on Health in Yexian and Qingdao Table 29 - Health Insurance Expenditure in Selected Areas Table 30 - Rural Cooperative Insurance: Brigade Level Data, 1981 Table 31 - Comparison of Revenues and Expenditures in Selected. Hospitals Table 32 - Average Patient Charges in Selected Hospitals Table 33 - The One-third County Program (37 Counties) INTRODUCTION
Situated in the east of China, Shandong province covers an area of 153,300 square kilometers. The census on July 1, 1982, was 74,419,054, making it the third most populated province in China. The average population density is 485 inhabitants per square kilometer, with 1,020 inhabitants per square kilometer of arable land. Shandong is one of China's oldest cultural centers and the birth place of Confucius.
Shandong province is divided into nine prefectures, four municipalities under provincial authority, five cities under prefectural authority, 106 counties, 2,093 people's communes and 86,143 production brigades. /1
Shandong province is composed of mainland and a peninsula extending into the Yellow Sea. It has hilly and rolling land in its middle south -and the peninsula, and flat land in its western part which belongs to the Great Plain of eastern China. Topographically, Shandong reaches 1,540 meters above sea level, at Mount Tai, and drops to more than 50 meters below.sea level in northwest and southeast. The Yellow River (Huang He) flows 617 kilometers across the northwest Shandong plain and empties into Bohai sea. Winter is long and dry. Rainfall is concentrated during summer time. Severe droughts plagued Shandong province during historical times. Effects of the most recent drought, in 1980, were alleviated by the huge number of dams and reservoirs recently built for water conservation and irrigation.
Shandong has 7.4% of mainland China's population; 90.5% of the population live in rural areas. The gross value of agricultural output in .the province was 7.8% of the national total in 1979. The value of agricultural output per capita is just above national average, 101%. From 1952 to 1979, agricultural production grew at an average 3.2%,per year. Wheat and corn represent the main crops, with additional yields of peanuts, vegetables, and apples. The Province does not produce rice.
The gross industrial output in Shandong province was 6.5% of the national total in 1979. The value of industrial output per capita-as--a percentage of the national average is only 87.3%. Industrial production increased 11.5% per year between 1952 and 1979.
The distributed collective income per capita was 81.5 yuan in 1979. This amount represented 95% of the national average.
These indicators adequately reflect the relative position of the province in the country. Shandong ranks as the 18th richest province among the 29 provinces, municipalities, and autonomous regions.of China. Shandong may represent the average in China, or something very close to the average, without distortions associated with extreme capita income levels, or high urbanization rate. This makes Shandong province suitable for a case study aiming at a better understanding of the health sector in China.
/1 List of administrative units and official pinyin spelling of names are recorded in "The Administative Divisions of China" 1980.. -2-
CHAPTER I: P-, LATION AND FAMILY PLANNING
POPULATION
The total population of Shandong Province in 1981 was estimated at 73,948,000; there were 37,498,000 males and 36,450,000 females. No age/sex distribution is available. The population per prefecture and municipality is given in Table 2. The census on July 1, 1982, was 74,419i,054, with two cities, Jinan and Qingdao, each exceeding 1 million inhabitants.
The birth rate in 1981 was 16.48 per 1,000; the death rate 6.47 per 1,000. The 1981 rate of natural increase (RNI), 10.07 per 1,000, was considerably lower than the RNI in 1970, but exceeded the 1980 figure. The post-war baby-boom and the increasing number of women at marrying age was mentioned as the explanation for this reverse in the trend. No population predictions were given. The mobility of the population is very low, as in most places in China. Less than 1.5% of the population changes residence every year.
Table A. Population in Shandong Province
Total Population Birth Rate Death Rate RNI Year (millions) (per thousand) (per thousand) (per thousand)
1964 55.52 25.3 1970 33.89 7.34 26.6 1975 21.56 7.53 14.0 1978 71.60 10.3 1979 72.32 10.8 1980 72.96 13.91 6.39 7.5 1981 73.94 16.48 6.47 10.1
Source: Shandong Province Statistical Bureau.
FAMILY PLANNING
In 1979, of the 1.4 million couples with one child, 20% had a one-child family certificate. In 1980, of the 1.8 million couples with one child, 40% had certificates. And in 1981, of the 2,237,000 couples with one child, 1,565,910 couples -- an impressive increase to 70% -- had certificates. In 1981 there were 1.21 million births 1/, of which:
799,250 were first children (65.9%); 311,200 were second children (25.7%); and 101,700 were third children (8.4%).
I1 The number varies from 1,210,924 (total) to-1,212,150 (sum of the parts). ~i~u~abnanuoagiss (k)k: Ui.
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There is no legal province incentive or disincentive structure for one-child families in Shandong province, but the following were suggested: for holders of one-child certificate, 5 yuan per month until the child is 14 years old; free schooling up to middle school (included); no paid maternity leave and hospital cost reimbursement for the third child.
Of the 9.527 million married couples with the wife below 49 years of age 1/, 7,327,400 (85%) practiced birth control, using the following methods:
60.4% IUD 8.0% Sterilization, Men 17.0% Sterilization, Women 14.6% Other (Oral, Condoms, etc.).
The data on family planning participation in rural communes in Qufu county, presented in Table 16, are an example of the high level of participation in the program. Provincial authorities consider birth control to be an average of 95% effective. Failures result in induced abortions. Contraceptives are not available for unmarried men and women. Pregnant unmarried women can get free abortions (no questions asked). The total number of abortions was 333,148 in 1981, equivalent to about 1 abortion to every four live births.
FAMILY PLANNING FINANCING -
Total expenditures on family planning were 23 million yuan in 1981. The number does not include minor contributions from the brigades and communes in the form of food supplements and reimbursements for travel costs for pregnant women. It also excludes 400,000 yuan worth of condoms provided by the central government.
The total province budget is distributed to the prefectures. The prefectures pass it on to the counties. The distribution is on-a-simple per capita basis: 30 fen per person.
The province purchases 4,000,000 IUDs per year from the central government -(10 fen each). In addition to the 20,000,000 condoms it receives free of'charge from the central government, the province buys 30,000,000 more, for 2 fen each. These contraceptives are distributed according to the requests of the counties. A county can also request more money from the prefecture if the 30 fen per capita is insufficient.
1/ The age bracket of 15-49 years was mentioned, but the legal marriage for women is 20, for men 22 years. Late marriage is being advocated. Estimated average age of marriage: 22-23 for women, 24-25 for men. -4-
CHAPTER II: MEDICAL SERVICES ORGANIZATION AND UTILIZATION
The organizational structure of medical services in Shandong, similar to that of other provinces, is parallel to the political structure, The basic level is the brigade health center (rural or industrial brigade) run by barefoot or rural doctors. The next level is that of the commune health centers, which are staffed by full-time medical personnel, and offer more sophisticated equipment and inpatient departments (with typically 20 - 30 beds). At the top of the "three-tier system" is the county (or municipality) health bureau which is responsible for the county hospital (typicallly 150-180 beds), the county epidemic prevention station, the county maternal and child health center, and the county training school. County health bureaus report to Prefecture bureaus, which report to the Provincial Bureau of Health. Each of these administrative levels operates institutions which parallel the county-level ones: epidemic prevention stations, MCH services, medical schools, and hospitals. In addition, province and prefectures may operate other health institutions such as an office of pharmaceuticals or specialized hospitals.
The provincial bureau of health is responsible for planning and health services development in the Province, and was, until recently, responsible for all financial and budget matters. However, the 1981 fiscal decentralization introduced major changes in allocation and utilization of funds giving counties a much larger degree of autonomy. Previously, allocation of funds occured at the Provincial level, which resulted in a strong centralization of the decison making process. The relations between the Ministry of Public Health and the Province are not fully understood at this stage, but seem to consist in the giving of general guidelines and the handling by the Ministry of institutional coordination issue,s.
INFRASTRUCTURE AND PERSONNEL
The overall infrastructure of health services in Shandong is as follows:
- 2,560 hospitals of all categories, including 2,060 commune health centers (in 2.093 communes), and specialized hospitals for cancer (2), tuberculosis (1), pediatrics (1) and maternal-child care (5).
- 117,970 hospital beds, i.e., 1.6 per 1,000 population - Among these beds, 50,520 are in general and county hospitals, and 52,689 in commune health centers. Shandong ratio hospital bed/population is significantly lower than the national average for China (2.2 beds/1,000 population) (see Table 1).
- 151 county-level epidemic prevention stations reporting to the provincial station.
- 142 maternal and childhood centers, with 574 beds for observation.
- 90% of the 86,143 brigades operate a health center. Other brigades are small size units which benefit from services delivered in a neighboring more important brigade. XiNAME: Shandong/ss (R)P: U5
-5-
Facilities are operated by a total of 178,495 medical personnel (2.4 health workers per 1,000 population) Distribution per category is as follows:
- 31,717 senior western doctors, trained in provincial or state medical colleges (5 years)
- 24,429 assistant western doctors trained during three years in secondary medical colleges and county health schools
- 4,130 senior traditional doctors of Chinese medicine
- 6,704 assistant traditional doctors
- 2,269 senior western pharmacists
- 996 senior traditional Chinese pharmacists
- 3,541 head nurses (certified)
- 24,825 nurses ("middle level")
- 1,152 laboratory and X-ray technicians
- 1,332 other technicians (drug quality control, water supply control, pollution monitoring ... )
- 75, 898 lower level staff, including junior technical staff, and maintenance staff
- 1,502 other staff (drivers, unskilled workers).
In addition to these permanent personnel, part-time staff operate brigade health stations, devoting at least one-third of their time to health activities. They are:
- 154,788 barefoot and rural doctors /1
- 220,400 rural mid-wives and birth attendants.
Table 2 indicates the distribution of health units, hospital beds and health personnel in the 13 prefectures and municipalities reporting to the provincial health office.
/1 A detailed survey on rural doctors is reported in a companion paper by M. Young, "The Barefoot Doctor: Training, Role, and Future", Health Sector Issues in China, Supplementary Technical Paper No. 12. EXTNAMEz Shandong/ss (R)P: 06
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On the average, population to manpower ratio are as follows:
- 731 population per technical health personnel, i.e., 1.4 technican per 1,000 population
-, 2,063 population per senior physician (western and Chinese medicine), i.e., 0.48 senior physician per 1,000 population
- 1,193 population per auxiliary technical personnel (including assistant doctors)
- 627 population per hospital bed, i.e., 1.6 bed per 1,000 population
- 4 beds per nurse
- 2.4 physicians (senior and assistant) for 1 nurse. This ratio is very high, implying that certain tasks which could be per- formed by the nursing staff are presently performed by assistant doctors.
- 478 population per barefoot doctor. Shandong has over 10% of total barefoot doctors existing in China; therefore the provincial ratio is better than the national average (714 population per barefoot doctor).
- 335 population per rural birth attendant.
The physician to population ratio is adequate, even though below the national average of 1,233 population per senior physican. A proportion of the senior doctors did not receive full training in medical colleges, but only ad hoc post-graduate training since cultural revolution.
The number of stomatologists is not reported in a separate category. The mission was informed that Shandong province has-ar - particularly low ratio of 1 stomatologist per 350,000 population. The average ratio for China is 1 per 150,000 population. However, this number excludes assistant dentists who operate most of commune and counties dental facilities. The situation is likely .to change since a faculty of stomatology was established in March, 1977, in Shandong medical college (5 years training).
Table 1 compares the situation in Shandong to national averages. Table 2 shows the distribution of health facilites, hospital beds and health personnel in the 13 prefectures and municipatities reporting to the provincial health office. The distribution is uneven. Weifang, Dezhou, Linyi and Heze prefectures have lower health personnel to population ratio. In all the prefectures, the bed to population ratio is below the national average. Municipalities only are within a normal range. Heze and Linyi prefectures are espechally poor.in hospital beds. !ATNAME: Shandong/ss (R)P: 0/
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UTILIZATION OF HEALTH SERVICES
The utilization of existing facilities is relatively high in Shandong. The province is densely populated, so villages are situated within relatively short distances from commune health centers.
Outpatients clinics are crowded. County hospitals and major commune health centers receive an average 400-500 patients per day. Smaller commune health centers receive from 50 to 200 patients per day. The utilization of both outpatient clinics and barefoot doctor visits seems to increase with average incqoe of the population. Table 4 shows that in Qufu county, relatively poor, commune health centers provide less than 1 visit per inhabitant annually, and barefoot doctors 3 to 4 visits per inhabitant. On the other hand in Yexian, where average income is often two times higher than Qufu income, commune hospitals deliver 2 to 5 visits per inhabitant annually, and barefoot doctors often 7 to 8 visits. Aggregated figures indicate that in Qufu county, the population of the 3 brigades visited benefits from 4.5 to 5.5 medical visits per -inhabitant annually, assuming that they share an equal part of visits delivered at the commune and county levels. In Yexian, the population of the four brigades visited benefit from 7.5 to 14 visits per inhabitant and per year.
The occupancy rate of hospital beds is high. A sample of 233 hospitals in the province indicates an average 90% occupancy rate (Table 3). Figures in commune and county hospitals visited vary between 50% and 90%. The average duration of stay shows larger variations. From an average 10.2 days in general hospitals, duration of stay increases to 62.4 days in specialized hospitals. Similar variations are observed in commune hospitals (Table 3): centers with relatively poor equipment have a tendancy to refer a large number of patients to the county hospital; on the other hand, major commune centers receive patients referred by neighboring communes.
Referal is an increasing concern. Provincial authorities indicated that referal from commune to county level facilities exceed- 30% of inpatients. This figure is consistent with observations by Bank mission members. Touzhao commune health center, which has been upgraded in recent years to serve 4 neighboring communes, received 62% of its inpatients from other communes. No information exists on outpatient referal. Barefoot doctors indicate that 2% of patients are referred to commune centers. However, self-referal of patients is increasing. Higher income in rural areas and general socio-economic development result in a demand for better health care that cannot be met by barefoot doctors and poorly equiped commune centers. As a consequence, county hospital deliver elementary care for relatively simple cases which could have been handled at commune level. For exampl2, about 40% of outpatients in Qufu county hospital are self-referred. The upgrading of both technical skills of the health personnel and quality of equipment are urgently needed at commune level to release the increasing burden on county hospital. 'XTNAMF: Shandong/ss (R)P: 08
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TECHNICAL EQUIPMENT PT7RURAL FACILITIES
The mission did not review in detail the technical equipment of. hospitals. A general observation is of old material, sometimes obsolete, with t exception of facilities recently upgraded as part of the one-third counties program.
Application of X-ray technology is routine in all hospitals, including commune centers. The 2,800 health units in the province share 4,170 X-ray machines, i.e., 0.56 per 10,000 population. Most of them are 20 or 30 years old, and many of them do not deliver doses higher than 30 milliampZres, which is not sufficient for most of standard diagnostic procedures.
Ta le B. Distribution of X-ray Sets in Shandong Province:
NUMBER NO X-RAY MACHINES
Provincial Hospitals 6 59 Prefectural Hospitals 54 257 County Hospitals 171 446 Specialized Hospitals 162 352 Factories - Mines- 347 579 Commune Health Centers 2,060 2,244 Others ? 233
2,800 4,170
Estimates of frequency of X-ray application by type of examination are as follows (number of exams per 1,000 population).
1976 1977 1978 1979 1980
Fluoroscopy 125 152 297 216 229 Radiogram 15 15 16 18 27
Predominant use of fluoroscopy is partially due to lack of films and plates, and to attempt to reduce the cost of radiodiagnosis, but also to insufficient power of existing machines.
There are about 5,000 technicians in radiology. Chronic exposure to radiation is an important issue that needs to be strictly monitored.
Sterilizing devices deserve spetial attention. Few facilities are equipped with %odern autaclayes. In most facilities and hospital wards, sterilization of instruments, syrin:gues, needles, is made by boiling. This technique does not meet the minimum technical standards for safe use of the material. -9-
PREVENTIVE ACTIVITIES - EPIDEMIC PREVENTION STATIONS AND MCH SERVICES
Shandong health services operate 151 epidemic prevention stations, most of them at the county level. They are in charge of monitoring and keeping records of communicable disease; organizing immunization campaigns; establishing safety criteria for water supply and air pollution, and monitoring them; monitoring,food hygiene; organizing prevention of occupational hazards in factories mines and industrial plants; monitoring school health; and training health staff in these activities.
County and other lower level stations seem to devote most of their time to communicable diseases control, organization of immunization campaigns, and training rural staff. Some capacity for chemical and physical monitoring of air, water, and food is provided, but in many cases appears inadequate for the volume and variety of tests needed. These analysis, and reF,earch on similar topics, are handled by the central station in Jinan. Even school health, occupational diseases, and general sanitation of environment seem very minor concerns in rural counties.
The system of epidemic prevention stations has achieved a great deal since liberation in successfully controlling "communicable disease". It needs now a reorientation towards other goals. The strict definition of . tasks, and their distribution into several vertically organized services,. prevent epidemic prevention stations to broaden the scope of their acitivities. For example, tuberculosis is not reported to epidemic prevention stations, and together with cancer and cardio-vascular diseases is under internal medicine services. Stations are in charge of industrial health hazards, but have no connection with services providing care for -occupational diseases. Stations plan and organize the logistics for vaccine distribution, but delivery is the reponsibility of barefoot doctors and MCH services. Therefore, epidemic prevention stations have little role in improving immu'nization techniques and procedures except through training courses. They record the total number of immunizations given, but they do not know anything about age-distribution of immunized children o-r-coverage of the target groups. Also, they do not carry out epidemiological surveys to assess the efficacy of vaccines (sero-conversion, tuberculin reaction).
The changing epidemiological pattern, the increasing importance of chronic diseases, the persistance of lingering problems in a few infectious diseases, the recent emphasis on occupational hazards, make necessary the establishment of an epidemiological evaluation network. Epidemic prevention stations should initiate these new activities, which are of utmost importance for the next decade.
Maternal and childhood services are in charge of family planning service delivery, prenatal and obstetrical care, and surveillance of infants and children. They are staffed with dedicated and competent specialists. Successful control of births (see Chapter 1 above on population) is associated with surveillance at regular interval of married women under 60 years of age: as a consequence, genital infections and gynecological disorders are identified and cured. Training and supervision -10-
of rural birth attendants have resulted in a nearly complete coverage of deliveries: 98% of them are made under the supervision of health personnel. As a result, neonatal tetanus and maternal mortality are exceptionally low (see below Chapter.3).
REPORTING SYSTEM
There is no systematic reporting of medical information in Shandong health services except for communicable diseases. Administrative information (number of beds, staff, number of retrainees ...... ) are aggregated at the prefecture health bureau. Only total numbers are communicated to provincial authorities who do not have a detailed breakdown of figures. Hospital acitivites (number of impatients, outpatients, average duration of stay) are monitored locally, but data are not aggregated neither analyzed at higher levels. Very poor analysis is carried out on epidemiological and technical information: hospitals establish a list of diseases in inpatients, and maintain records of proportion of patients cured and dead. However, no analysis is made of diseases diagnosed in outpatients, although individual records are kept in the outpatients wards. No indication is available on accuracy of diagnoses, even in inpatients: comparison between initial diagnoses at admission and final diagnoses at discharge is lacking. As a result, health services cannot provide indications on the most frequent ailments, on disease patterns in the population. All statistics are hospital biased.
Causes of death are seldom certified by health personnel (less than 5%). Deaths are reported to police stations who maintain records of resident population. Corpses are incinerated and incineration stations keep track of numbers only. As there is no legal time allowed for birth registrations, children who die in the early infancy may have not been registered and infant mortality was probably underestimated. However, tight controls associated with the one-child family policy (registration of pregnancies, planning of births among work unit members) will certainly result in a quasi-complete registration of births. It will also result in a complete registration of infant deaths as parents will not wish a loss of time in being recorded as eligible for a new pregnancy.
Twenty-eight communicable diseases are reported to epidemic prevention stations. Sixteen of them no longer occur in Shandong. Barefoot and rural doctors are responsible for sending a written.report to the county station every ten days, even if no case was identified during the period. No information was available on the number of reports received during 1981 in the two counties visited. Therefore, no assessment of the accuracy of the reporting system is possible.
Communicable diseases which are not included in the list of twenty-eight are not reported to anti-epidemic stations. Some of them are not reported at all: e.g., chicken pox, rljella, mumps, tetanus. Other ones are surveyed by specialized institutions or by different health departments; tuberculosis, leprosy, filariasis and schistosomiasis were removed from the mandatory reporting list in 1980. There is no system for monitoring chronic diseases (cardio- and cerebro-vascular, cancer) and no population-based surveys are carried out at provincial level. 1Y-11-
As a general conclusion, reporting tasks are shared by several specialized departments of the health services and very little communication channels exist to assemble aggregated figures. Many diseases are not reported, and the absence of population based surveys make very difficult the establishment of an epidemiological picture in the province.
WATER SUPPLY
One of the tasks of the province's epidemic prevention station is the control of drinking water. Every half month, samples are taken from cross sections of the Yellow River to carry out analysis on water quality.
Table 5, constructed from information given in Jinan, reveals a large gap between rural and urban areas in terms of the quality of drinking water. Assuming that all drinking water in urban areas is 100% safe, the table implies that about 23.5 million people in Shandong (32%) have drinking water that meets safety criteria. Of these people, about 18.3 million live ini rural areas. Thus 48.6 million people in rural areas (73% of the rural population) have substandard drinking water.
One of the problems is a high fluorine concentration in various areas. About 5% of the rural population has access to high fluorine drinking water only. However, clinical manifestations of fluorosis are now * exceptional. -
The government provides funding for installation of water systems in the cities. Communes and brigades are responsible for expenditures on water installation in the rural areas. There is an estimated annual requirement of 3-4 million yuan to be spent to solve the severe water shortage in the mountainous and littoral regions. - 12 -
CHAPTER III: THE OUTCOME OF HEALTH CARE.SERVICES: DISEASE SITUATION ANL> EPIDEMIOLOGICAL PICTURE
The improvemet of health care delivery and the improvement of population coverage together with the economic and social changes introduced since liberation, have been associated with dramatic changes in the health status of the population of Shandong province. Mortality rate decreased to a low level, reported as averaging 6.47 per 1,000 population in 1981. Infant mortality rate decreased to 10 per 1,000 in Jinan city, 11.28 per 1,000 in Yexian, and 14.3 per 1,000 in Qufu county in 1981. Neo-natal mortality rate in the province represents 60% of infant mortality. It was only 8.56 per 1,000 births in Yexian and 9.8 per 1,000 births in Qufu in 1981. Both infant mortality and neo-natal mortality are underestimated. Children under 1,500 grams of weight are not reported as birth, but as abortions, and children dying in early infancy are likely to be omitted if death occurs before birth is reported. Maternal mortality rate, which is one of the best indicators of obstetric services quality, was 1.12 per 10,000 deliveries in Qufu, and no fatality associated with delivery was observed in Yexian in 1981 (as compared with 3 per 10,000 in 1980). Some major endemic diseases have been eradicated since liberation. Plague and cholera have not been reported since 1949. Small- pox was eliminated in the early 50's. By 1963, typhus, relapsing fever, and venereal diseases were reported to have been wiped out. Kala-Azar was eliminated in 1972. Diphteria has not been reported since 1976. Yexian statistics-provide an example of the magnitude of achievements over the last 20 years (Table 7). Twelve communicable diseases are still prevalent in the Province (Table 6). However, the case fatality rate is in each case lower than 1%.
NUTRITION 55ATUS
The estimated 1980 daily per capita nutrient availability in Shandong is 2,482.4 Kcal, 67.1 grams of protein, and 70.8 grams fat (Piazza, 1983). These figures are slightly higher than the national averages which are 2,295 Kcal, 58.2 grams of protein, and 40.4 grams fat.
Data concerning the heights and weights of children at different ages provide a useful indicator of the environment affecting child development. Either inadequate nutrient intake or high prevalence of infectious diseases (particularly gastroenteric can lead to growth faltering, and differences in average growth rates between different populations thus signal differences in nutrition and disease patterns. The mission obtained two sets of anthropometric data from Shandong. The first, and by far the best, shows 1979 data from a large sample of rural and urban school children; (Table 13) displays these data. Table 14 graphs the 1979 data concerning female height against percentile curves developed from a sample of U.S. children. The figure shows the average of urban Shandong school children to remain at about the 25th percentile of U.S. norms, whereas rural school children are growing far more slowly -- between the 3rd and 10th percentiles. It is perhaps worth noting that urban growth in Shandong (aged 18-25) had the second highest average heights and weights of urban youth among the 16 provinces surveyed in the 1979 survey; only - 13 -
Beijing was 1 higher. / Actual differences between rural and urban areas may be understated by the comparison in Table 14, because the drop-out rate from rural schools is higher than for urban ones, and studies-from elsewhere in China suggest that stunted children tend to have higher drop-out rates.
Table 12 contains data from a 1946 anthropometric study of school children in one city of Shandong, Qingdao. The data in that table suggest that young children were little worse off in 1946 than in 1979; children at puberty and older appear, however, to be markedly better off at present. While the 1946 urban females have the same height at age 12 - 13 as the 1979 rural females, by age 16 - 17, the 1979 children have achieved substantial catch-up growth, whereas the 1946 rural' children have fallen even further behind the norms. Because diarrhoeal disease prevalence is typically much lower for older age groups than for young ones, the -improvements at older ages between the immediate postwar year of 1946 and 1979 probably represents increased food availability.
IMMUNIZATION
Table 6 indicates that diseases susceptible to immunization are under control in Shandong province. Diphtheria is no longer reported. The prevalence of poliomyelitis and encephalitis B have been reduced to very low levels (1 per 100,000 population or even less). -Pertussis and measles, still deserve special attention -- especially measles, which has recently shown a marked increase in some rural areas. (Jinan city medical services claim, however, that only sporadic cases occured in the city since 1976, either in non immunized children, or imported from other places in the province.)
78 million person/doses of vaccination were delivered over the province in 1981 against 10 diseases according to national schedule (Table 9). Smallpox immunization was stopped in October 1981. The lack of adequate cold chain resources in rural areas has led to a centrally planned immunization program, with vaccinations delivered usually once a year for each type of vaccine, during campaigns of one to several days organized at the county level. Dates are arranged well in advance,- barefoot doctors and brigade health centers designate the eligible children accotding to a detailed census register, and children who do not report for immunization are sought through home visits. Vaccines are sent by county authorities in ice-boxes and must bf delivered within 2 days. A typical 1981 calender is as follows (from Tongp!m brigade in Yexian):
- January 1 and 23: poliomyelitis I, 2 doses; - February: poliomyelitis II and III, 1 dose (same children); - April: diphtheria, booster dose for primo-vaccinated children; - May and June: encephalitis B, 2 injections, 1 month interval; - August, September, October: DPT, 3 sessions; and - November: measles. - For BCG vaccine: in January, April, June and October, immunization of 0-3 months old infants boin since the last session. In May, booster injection to those eligible.
j See References: Research Group for the Study of the Physique of Chinese Children and Youth. --14-.
Provincial authorities claim that 98% of eligible children are adequately covered. Records of eligible and immunized children kept at brigade health centers confirm this high coverage in places visited during the mission. Epidemiologists in Beijing acknowledge that immunization coverage in Shandong is among the highest in China. The absence of mobility of the population and the tight control at the brigade level make such achievements possible. In Shandong, as in most of China, priority is not given to complete the initial set of immunizations within the first 12-15 months of life. Few immunizations are effectively provided during the first year of life. Moreover, the practices of a single annual campaign for each type of vaccine, and of the administration of a single vaccine per campaign, delay in many children the date of effective protection. This delay is even greater in children who cannot receive the immunization for medical reason (about 10%) and who are registered for the next session, one year later.
No study has been carried out on sero-conversion rates after immunization in Shandong province except for BCG in Jinan city (see Chen Zheng-ren et al., 1982). However, several research institutes in China have initiated such quality control measures, with support from WHO and UNICEF.
Influenza has been recently introduced in the vaccination program. The coverage of the population varies from county to county. Several virology laboratories have been established in the province to monitor the .circulation of the virus.
TETANUS
Tetanus is not reported to epidemic prevention stations and no hospital statistics have been computed. Initial vaccine is delivered between 7 and 12 months of age, and a single booster shot at age 2, according to the national plan. Such a schedule is likely to result in a low level of protection .in adults, and therefore in a significant number of cases amongst agriculture workers, horse and cattle keepers, and--manure workers.
The average incidence of neo-natal tetanus in 1981 was 0.25 per 1,000 birth for the whole province. In the two counties visited, incidence rate was 0.11 per 1,000 births in Qufu, whereas no case has been reported in Yexian since 1977.
FECAL-BORNE DISEASES: DYSENTERY, TYPHOID, HEPATITIS
The situation of typhoid and paratyphoid fevers is unstable. Average prevalence was reduced from 40-50 per 100,000 population in the late 1950's to 10 per 100,000 or less actually. However, outbreaks still occur in rural areas. Immunization is delivered to risk-groups (horse and cattle keepers, manure collectors), as deionstrated in Qufu county where 37,000 received vaccination in 1981, the first campaign undertaken within --he last'three years. -15-
Hepatitis, on the contrary, is very stable, with an average incidence rate of 45 per 100,000 people. Most of the cases are due to infections with A virus. The Shandong Medical College Faculty of Public Health recently studied the prevalence of B virus in a 2,000 population sample aged 20 to 49 in the vicinity of Jinan city. 5% of them had been in contact with B virus (unpublished data). Liver cancer, strongly associated with hepatitis B virus infection, is not a major problem in Shandong.
Dysentery is reported on clinical symptoms: frequency and nature of stools, and mainly presence of blood in the stools of patients. No laboratory examination is performed. Incidence is actually stable, 300 per 100,000 population. Improvement cannot be expected without additional efforts in sanitation hygiene, and better control of water supply. Amoebiasis is not documented actually as a causal factor of dysentery. Pre-liberation surveys (Winfield and Chin, 1939) recorded the presence of Entamoeba histolytica in 13.8% of 4,618 stools examined,. with similar infection rates in urban and rural samples. The persistance of high rates of infection with Ascaris (see below) raises doubts on the disappearance of Amoebiasis as many similarities exist in both transmission patterns. Giardia and other intestinal protozoa are probably less common (4%, according to Winfield and Ta, 1939)-.
FILARIASIS
Shandong is one of the fifteen provinces in China infected with filariasis. Only Wuchereria bancrofti is found, exclusively transmitted by Culex pipiens pallens during the summer months (June-September). Culex pipiens constitutes more than 90% of mosquito populations in villages; it is a domestic, indoor resting species, which principally breeds in the manure pits, latrines and wells./ 1
Mass surveys conducted between 1955 and 1958 indicated that the disease was prevalent in 74 counties in the province with a total number of about 2.5 million infected people. Prevalence rate was as high-as 30% in some of the 14 hyperendemic counties, all located in southern Shandong. Clinical symptoms were present in 5 to 10% of the population in these counties. Entom)logical surveys showed that 17% to 50% of mosquitoes were infected, of which as many,as 16% carried infective larvae.
Mosquito control was carried out through fumigation of winter resting sites of the adults, and spraying fuel oil during spring and summer in larvae breeding sites. Mass treatment was conducted with diethyl-carbamazine (DEC) since 1958 in hyperendemic counties (1,100,000 patients treated) and since 1970 throughout the province. Provincial authorities indicate that altogether 1.8 million patients were detected and treated with DEC. Over 90% of them became negative after 3 courses. In addition,, prophylactic treatment with DEC medicated salt at a 0.3%
/1 Additional information on filariasis in Shandong provided in Zhong, H.L. et al. (1981), Wang Zhong-san et al. (1982), Ma Gui-hou (1979), Wang Zhao-jun (1979), and Shandong Institute of Parasitic Diseases (1979 and 1981). ibL" L .A&4L :)i1L1LLU4116/ b6 1 \ )r; 10
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concentration was given to the whole population of hyperendemic areas for a period of six months, with a total of 18 million people covered.
As a result of integrated control measures (entomological control, treatment of patients, prophylaxy), the prevalence of microfilariae carriers dropped to below 1% in most of the counties. Data provided in Jinan indicate that the prevalence of filariasis in the province decreased from 100 per thousand population in 1970, to 28 in 1973, and to 0.5 since 1974. The present number of cases is estimated at about 50,000, most of them concentrated in a single county.
As an example, 22.2% of the population of Zouxian (Jining prefecture) was infected in 1958. In 1979, 2 microfilaria carriers were detected among a population of 25,920 in two villages. During the same survey, -in Te'ngxian and Zouxian, from 8,995 persons formerly positive, the microfilaria rate was 0.14% upon reexamiriation, and 0.36% in 274 individuals who had missed the reexamination and were traced out. At the same time, 33,004 female C. pipiens were trapped. Three of them only, collected from the same house, were infected. These results were confirmed in 1980. No microfiloria carrier was identified in 2,073 persons, including 353 previously positive cases, living in six Zouxian villages, which were surveyed with the most sensitive method available (blood fitration technique).
ZOONOSIS
Leptospirosis is virtually absent from Shandong. No human cases were recorded by the provincial epidemic prevention station during recent years. Possible sources of infection are carefully monitored and samples are studied in the central laboratory of the provincial anti-epidemic station in order to detect any circulation of Leptospira in the environment.
Rabies has also been eliminated. Sporadic cases may occur, but no data are available.
Anthrax is said to be prevalent in sheep in Shandong and represents a threat to human communities. Recent figures on human cases were not available.
KALA-AZAR (Leishmaniasis)
Shandong province was, before liberation, one of the major areas of China infected with Leishmaniasis. Kala-azar was present in all the 106 counties with higher incidence south of the Yellow River. In 1950, an .estimated number of 210,000 people were suffering from the disease, representing an average prevalence rate 525 per 100,000 population (assuming the total population of the province to be about 40 million people). The distribution of the disease was parallel with the distribution of the vector Phlebotomus sinensis, which has a long life cycle (one'generation per year) and a short period of activity from May to August. (See Wang Zhao-jun, 1979.) z4iNiuir,. wanaong/ss t K)k' Li
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Integrated control was carried out since 1956, using indoor application of insecticide (DDT or gamexane) and treatment of patients with "a stibium preparation locally manufactured by the Shandong Sinhua Phaimaceutical Company. By 1958, prevalence rate was reduced to 3.5 cases per 100,000 population, and by 1969 to 0.1 per 100,000 population.
Provincial health authorities claim that Kala-azar has been eradicated since 1972. Although the sample size is unknown, it was indicated that intradermal test with a Leishmania antigen failed to demonstrate a positive reaction in any people under 15 years of age receiving the test, while in 1962 the positive rate was above 20% in the same group of population.
MALARIA
Shandong province is situated on the northern limit of the Chinese central plains malaria endemic area. The disease is relttively unstable, with Plasmodium vivax as the only reponsible parasite. Transmission season lasts for 3 to A months, with a peak from August to October, and with Anopheles sinensis as vector. Outbreaks of malaria epidemics often occurred before liberation. After liberation, the disease was considered under control with incidence rate below 1 per 1,000 population. /1
In 1960, however, the number of malaria cases in Shandong rose to' about 2 million, as a result of major floods. Another increase in incidence rate occured in the early 1970's. According to provincial statistics 3,235,610 cases were reported in 1971, indicating an average prevalence of 49 per 1,000 population. The number of cases recorded then decreased to the present figure of about 70,000 cases (Table 6) with an average prevalence of 1 per 1,000 population. The number of cases for 1981 might be much lower since 30,000 cases only were recorded during the first nine months. In 1979, from 26,564 blood examinations performed in patients with fever, 3,033 (=11.4%) were positive for P. vivax.
Control measures include treatment of cases with a daily course of 1.2 grams of chloroquine over 3 days in combination with primaquine for 8 consecutive days; two courses at a 3-month interval of a combination.of pyrimethamine with primaquine to all people with history of malaria in the preceeding year; mass prohpylaxy with pyrmethamine in heavy endemic areas; aerial spraying of rice fields with insecticides.
Control of malaria in Shandong is difficult. Methods for successful vector control are still lacking and the density of Anopheles sinensis is still high in many regions. Prolonged parasite latency make difficult the detection of human cases, and therefore the elemination of the source-of infection. Incidence of malaria was recently estimated at 0.1 to 1.0% in. the southern half of the province, and below 0.05% in the north and eastern coastal area. Surveys show very little differences among age groups. Malaria is in principle eliminated from Jinan city 'sinc 1975.
/1 Information on,malaria provided in Wang'Zhao-jun (1979), Huang Sengi (1980), Zhou Zu-jie (1981), and Shandong Institute of Parasitic Diseases (1979). -18-
No resistant strain of Plasmodium has been recorded from Shandong. Anopheles resistance to current insecticides was not documented, although it appeared in other parts of China.
OTHER PARASITIC DISEASES
Very little hookworm infestation has been reported from Shandong Province (Cott et al.,1926)T. Reports show scattered cases, almost entirely of the subclinical type. An extensive survey in Yantai prefecture in 1923 (Grant et al., 1926) reported 363 positive cases from an 890 rural population sample (40% prevalence); however, the lack of clinical consequences and the absence of disease associated with the low intensity of infestation led to the conclusion that hookworn was not a sitificant public health problem and did not deserve special attention. Surveys in urban areas, Yantai, Jinan, and Jining, always indicated that the importance of hookworn was negligible or practically nil. The study of local conditions suggests that the insignificance of hookworm as a public health problem since preliberation time is due to adverse climatic conditions, especially the long cold winter and the slight rainfall, which leaves only a short moist period each year suitable for hookworm transmission.
Tridhuris is exceptional (less than 0.5% of sampled population). Ascariasis is widespread with infection rates higher than 70% in rural areas. Prevalence in urban areas is much lower./ 1 The changes which occured since liberation in sanitation and management of human excreta did not result in any reduction of both prevalence and intensity of Ascariasis infection, as suggested in Table 8.
Schistosomiasis does not exi,t in Shandong. Paragonimiasis (human lung fluke) does not exist either, although one location is recorded on a map available in the Beijing Tropical Institute. The parasiology department of the Shandong Medical College says that intermediate hosts are not present in the province. Clonorchiasis (liver fluke) is scattered through the Province, with 13 documented locations. The absence-of raw fish in the diet has made transmission to man quite exceptional in most places and so, it is not a public health problem. Surveys recently conducted in two suburban counties of Qingdao municipality indicate an average prevalence rate of 2 to 3% in the population (personal communication). Fasciolopsis sp. is recorded from one focus in the 0Wuth-western part of the province.
LEPROSY
Leprosy is not a major problem in Shandong. 51,255 patients have been registered since 1949, including existing patients at that time. 36,001 were cured; 12,005 died; 893 moved; 2,356 are presently under treatment, indicating a low prevalence rate of 3.2 per 100,000 population. The proportion of lepromatous cases was not reported.
/1 Information on Ascariasis and Trichiuris is provided in Cort and Stoll (1931), Winfield (1934, 1937a-and 1937b), Winfield and Chin (1938), Scott (1952, pc95 sq.) - 19 -
TUBERCULOSIS
Tuberculosis is still a major concern. The total number of cases treated in 1981 was 351,671 (prevalence 4.8 per 1,000 population), but there is no systematic screening of the population in search.of new cases. In 1979, a sample of 67,811 people was examined in 50 places selected at random, 38 of them in rural areas an 12 of them urban. A total number of 330 patients was identified, 159 of them already under treatment and another 171 newly diagnosed. The final report (see National Tuberculosis Survey, 1982) indicates that standardized prevalence rates in Shandong are 4.55 per 1,000 for TB morbidity (compared to an average of 717 in China), and 1.34 per 1,000 for positive smears (compared to an average of 1.87 in the country).
Another indication is provided by a screening of 464,115 people in Yexian in 1976-77. 5,759 tuberculosis patients were identified (i.e., 12.4 per 1,000 population). This number, related to the 1977 population of the county, is consistent with the figure of a 7 per 1,000 prevalence rate provided by the health authorities. The reduction of tuberculosis prevalence in Yexian in 1981 appears to be the result of the absence of screening since 1977 rather than a true decline in incidence.
Finally, in Qufu county, the total population of a rural brigade (about 1,300 people) was examined by fluoroscopy in 1982. 9 cases of tuberculosis were detected, indicating a prevalence of 6.9 per 1,000 population. In Qufu, as in former-sample studies, it does not seem that TB diagnosis as confirmed by X-ray film or sputum examination.
These limited surveys indicate that tuberculosis is certainly underestimated in Shandong. Surveillance programs are not systematically carried out, even in collective risk groups, such as schools or mines. Tuberculosis is not monitored by epidemic prevention stations,,but is under Internal Medicine services which lack basic logistics, adequate staffing, and authority to carry out regular surveillance and preventive activities.
Initial BCG immunization is given to newborns within the first 3 months of life (4 sessions per year in every brigade). Booster-Ainjections are given at age 3, 7, 10 and 14. Intradermal tuberculin tests administered in Jinan city to children who had received BCG vaccine within the first three months of life resulted in a 84.5% conversion rate. (No indication was provided on sample size and age group surveyed. See Chen Zheng-ren et al., 1982.) Investigation on the immunological status of the population after vaccination is essential as the locally produced BCG, which is not lyophilized, seems to have a short duration of potency.
CARDIO-VASCULAR DISEASES
Prevalence of hypertension is within the limits of the average rate in China. In 1979-1980, a sample of 97,481 people over 15 years of age was surveyed in 3 prefectuies and 2 muncipalities./1 4,992 (5.12%), had blood pressure over 160/95 mm Hg. Results in Yenta and.Heze prefecture samples were close to the average (3 to 6%); results in a rural sample of Zaozhuang municipality were lower than the average (less than 3%), whereas results in Linyi prefecture and Jinan city were significantly higher (6 to' 9%).
/1 See Geng Guanyi (1981), and Wu Ying-Kai .et al. (1982) INAVI : Shandong/ss (R&)P: zU
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Coronary heart diseases account for about 10%'of patients admitted to county hospitals, and for one-third of the deaths in these facilities. As indicated in other parts of China, there is a tendancy in Shandong for an increasing frequency of coronry heart diseases which replace cerebro-vascular diseases as the leading circulatory disorder. Shandong Medical Colleges Faculty of Public Health carries out a research program on risk factors. High levels of cholesterol and triglycerids in blood are associated with increasing risk, but findings do not differ tom results of similar studies in other parts of China and other countries.
There is no systematic screening for high risk individuals in the population and no preventive program.
CANCER
Cancer is the third cause of mprtality in Shandong, accounting for 12 to 15% of hospital deaths and probably 9% of death causes in the general population (Atlas of Cancer Mortality, 1979). The 1973-75 national cancer mortality survey recorded in Shandong death rates of 69.1 per 100,000 population in males and 49.2 per 100,000 in females, representing approximately 9% of the 1981 mortality rate (647 per 100,000). These cancer mortality rates are significantly lower than the average rates for China, as indicated in Tablc 11. However, the mortality in males in 19 counties, and in females in 16 counties, is significantly higher than the national average in China. Higher mortality is especially related to stomach cancer (24 counties in the eastern part of the province), oesophagus cancer (16 western counties), cervix uteri cancer (northern region), and lung cancer (20 northern counties). Liver cancer and leukemia are highly prevalent in Qingdao municipality only. The mortality from breast cancer does not differ from the average rate in China. On the contrary, cancers of colon, rectum, nasopharynx, and lymphoma are less common than in other parts of the country (Tables 10 and 11).
No epidemiological record is available on the frequency of various types of cancer in the population. However, a survey of-95,-641 married women below 60 years of age in Qufu county between 1971 and 1981 recorded 74 cases of cervix uteri cancer (prevalence 77.4 per 100,000 women in this age group). As cervix cancer represents 26.8% of cancer sites in women (Table 10), this survey might indicate that about 3 per 1,000 adult women suffer from cancer, and slightly more adult males. However, this assumption is not purely speculative at this stage. Hospital records indicate that 110,375 patients with tumors were treated in 1981 (110,510 in 1980 and 99,151 in 1979), which represent a prevalence of 1.5 per 1,000 population and 2.5 per 1,000 population above 20 years of age.
MENTAL DISEASES
Mental diseases is an increasing concern for provincial authorities. The construction of a psychiatric hospital is planned over the next five years. A crude estimate at'the provincial level. is that serious mental disorders affect 5 per 1,000 population, i.e., about 350,000 patients in the province. - 21 -
CHAPTER IV: TRAINING OF HEALTH MANPOWER
AVAILABLE COURSES
Four levels of medical education are available in the province. They are:
(1) Undergraduate courses at the higher level mediz,l colleges, of which there are nine; one under the auspices of the Ministry of Public Health, namely Shandong Medical College, four provincial and four prefectural colleges. Courses are available for western trained physicians, pediatricians, stomatologists, public health physicians, pharmacists and traditional Chinese physicians. They are mostly of five years duration, sharing core preprofessional curricula. Student fees are met by the government and a living allowance is paid.
(2) Postgraduate courses for medical scientists and research workers as well as for clinical specialists are available at some of the higher level medical colleges in association with the affjtliated and teaching hospitals. These courses are offered at masters and doctoral levels and are of three or four years duration. Nominees for specialist training must normally have had at least three years experience after graduation and enrollments are approved by.the Ministry of Public Health, which provides grants for student support and teaching costs.
(3) Secondary level courses for assistant physicians, nurses, dental assistants, pharmacy assistants and health technicians are privided by the secondary medical colleges and county health'schools-. Courses are usually of three years duration and are open to graduates of junior middle schools.
(4) In-service training courses of varying duration are provided"^for almost all categories of health workers. The medicalcal res, county health schools, provincial, special and codinfy hospitals all take part in this work. A general principle of managemen' of such training is that higher level institutions accept responsibility for providing courses, lectures, practical training or providing mobile training teams as appropriate for staff belonging to lowec formations. Thus, a network of training is provided t mrnt a great variety of needs. Special mention should be made df the retraining of western trained medical staff of- the cultural revolution period, many of whom lacked formal trpainiag, and-,loi generally received only three-year courses from 'keleton faculties. Regular programs are provided for such personnel by the medical colleges, supported by television university ourses in preclinical sciences.
Finally, continuing the education of barefoot doctors is a Opec*al function of the rural hospital system and the county health schools. Courses of 6 months to 1 year duration are provided to supplement the primary thre -22 months or 6 months coutsps whicl/ möåt barefoot doctors originally received. Such courses, together with shvrte-r continuing education activities ýof the coilnty and commune hospital,, a', eesned to meet the Ministry of Public Health criteria for the new categcöry of rural doctor, in principle equivalent to a three-year trained heth o'r,,graduating from a secondary school. In practi,agä this trainiig, togthe i4Wthe wide practical experience of many barefoot doctors> has been successfiuilin allowing a high proportion of barefoot doctors in the province to -pasg de MOPH examination for certification as a rural doctor.
in,1981, a total mumbe-,of 10.500 students are enrolled in the 9 medical colleges and 12 000 in thieQ28 eondar- medical schools.
SHANDONG MEDICAL COLLEGE /
The Campus
The college was formed thirty years ago from three pre-existing institutions of higher learning, The serenity and attractiveness of the campus reflect the quality -'nd traditdons of its respected origins. However, the ekpnsion,-äf teaching has oveitaken the building resources and student facilities, notably for• laborato ly sp·acé, arover-crowded and' outdated. An exception is, the splendid new liburry,which houses a literal treasure in Chinese and for eign -language iitearture whIdh. has apparently survived the cultural revolution virtually urgcathed.
koaffiliated hospitàl and fou municipal teaching hospitals, totalling 2,258 beds, provide the clinicgl base 'for teaching. Unfortunately, the team was åble to visit 6nly the af filiated hospital, but it was apparent that many of tlhe wards and other clinical facilities are old and affected by city dust, pollution and noise.
The Faculties
There are f our fäculties in the college -
(a) Faculty of Medicine (b) Faculty of Public Health (c) Faculty of Stomatology (d) Faculty of Pharmacy.
Serving all of the faculties is a department,of preclinical scienc s. The two most receritiy established faculties are stomatology and pharmacy,, Stomatology is a particularly badly needed discipline since. while China has only one fully qualiÅed stomatologist per 150,000 population, Shandong province has a most '4äerse ratio of,1:350,000, most dentistry being carried out by dental assistants.
/l See Saint et al. (1981), and A eneralInt oduction of the Shandong Medical College (1982). ' XTNAME: Shandong/ss (kL)P: 24
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Enrollment
Candidates must be graduates of senior middle school, must pass an entrance examination and must be judged of satisfactory health and moral character. Det&lls of student intake are as follows:
Table C: Enrollment in Shandong Medical College
Class Total Students Enrollment 1981 Course Duration
Undergraduate 2470 430 5 years* Postgraduate 116 50 3-4 years Advanced Studies 200 200 1-1.5 years Part-time Students 412 100 4 years
3198 780
* Note: Pharmacy students 4 years; western medicine curriculum being extended to six years--Ministry approval awaited.
The annual full-time undergraduate enrollment includes 300 for medicine, 50 for public health, 30 for stomatology and 50 for pharmacy.
A particularly interesting feature of the intake for medicine is the small .class of 35 students taught completely in the English language. While this imposes a heavy strain on the teaching staff and requires some duplication of facilities, there is obvious value in a core group of young graduates completely literate in English, who can readily take advantage of overseas experience and who can communicate easily with visiting foreign scientists and physicians. While there seems to be no special elitism in selection or training of this group, their future assignments in the medical services will no doubt be weighted towards teaching positions. The English language course is one year longer than the general course..
The team was impressed with the alert and industrious qualities of the students they met during the visit.
Postgraduate students generally follow one of two streams, a clinical speciality or a postgraduate research program. Masters and doctoral degrees are awarded.
Curriculum
The curriculum in medicine generally resembles the traditional western medical school of twenty or thirty years ago with a well-marked vertical division between preclinical sciences and clinical teaching. TNAME: Shandong/ss (R)P: 25
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Preclinical Sciences. There are thirteen teaching and research departments including biology, physics, human anatomy and physiology, pathophysiology and biochemistry, pathology and microbiology, pharmacology and nuclear medicine, as well as foreign languages and physical education. Teaching is held at a ratio of 50% ledture to 50% practical work in the laboratory. Students work in groups of eight to ten dissecting the human cadaver, although supply of sufficient specimens is difficult. Generally the course appears to lack preparation for the sociological and psychological components of.modern medicine.
Serious deficiencies in laboratory and equipment and educational technology obviously exist. Teachers often drew the team's attention to the need for modern analytical, imaging and measuring devices of advanced type. However, the team thought that the most urgent requirements are for replacing and upgrading preclinical basic scientific and audio-visual aids as well as for clinical pathology resources, However, a decision on priorities will need to await a more detailed investigation of the teaching program and an inventory and evaluation of existing resources.
The Clinical Courses. Fourteen clinical departments provide the clinical experience for students. The teaching program follows the national curriculum laid down by the Ministry of Public Health, which also supplies standard teaching material. However, the college is free and does exercise some discretion in what is actually taught. Teachers seemed very much aware that much of the developments in medicine during the past two decades are incompletely taught or absent and are anxious to repair these deficiencies. In particular, the team was told by the college president that considerable national debate was currently taking place on the need to shift emphasis somewhat from the purely biological/scientific approach toward a somewhat psycho-socially oriented program. This was in consequence of the success of the one-child family program and the increasing importance of chronic and degenerative diseases in an aging population.
It was certainly noticeable that medical sociology and psychology, child development and gerontology and rehabilitation medicine were missing = from the teaching program.
Another deficiency was the absence of clinical pharmacology teaching; the team frequettly observed during field visits instances of polypharmacy and over-prescription, both of western and Chinese traditional drugs and the proportion of health care costs attributable to drugs was everywhere very high. Although we were unable to investigate the incidence of iatrogenic disorders, the presence of large numbers of potent drugs, including psychotropic, antibiotic, endocrinological, cardiac and others at all levels, including the brigade clinic and commune health center, suggests that more needs to be done to check indiscriminate prescribing and that the key to this is better teaching of the physician.
Perhaps the most notable absence of teaching other than the above was in the area of community medical, epidemiological and critical scientific thinking throughout the clinical disciplines. In modern medicine, these are essential for the professional guidance and evaluative capability of the individual doctor, who is now in command of both powerful and expensive and potentially very wasteful tools and methodology for diagnosis and patient management. - 25 -
Teaching Methods
Didactic teaching is the core of student learning experience although there is strong interest in increasing practical instruction in laboratories. Task-oriented instruction has not yet developed although an educational research unit has recently been established and is said to be exploring the introduction of learner-centered and problem-solving approaches. A very good audio-visual unit is available and the quality of film animation and video material produced is high; however, its penetration into all areas of the curriculum is very limited and could be greatly expanded. Individual self-learning materials also need considerable development.
As with problem-solving and audio-visual methods, student assignments, project work and elective courses have not yet developed. The educational research department should initiate staff training courses to promote use of these modern methods of teaching. Together with promotion of more effective horizontal integration between teaching departments, such courses would greatly improve development of student initiative. A consequence will, of course, be a need for increased spending on audio-visual equipment and consumables.
The team also noted, as have other visitors, the almost total lack of vertical integration between preclinical and.clinical studies or of horizontal integration between the many departments. Thus, lack of coordination of teaching between say, physiology, pediatrics, public health and other subjects, must seriously impair the student's understanding of his patient as a whole person or of the interrelationship of biomedical systems within the organism. Neither is there an introductory clinical course in clinical examination and in the relationships between the clinical and diagnostic armamentaria of the various disciplines as they relate to one another.
Research
Pure and applied research is undertaken by many institutes and departments of the college. To a considerable extent, operational study projects are assigned by the national and provincial governments and by major industrial instrumentalities (64 such projects were assigned to the college in 1982). A director of research supervises and coordinates the various projects; however, it was obvious during the team's visit that the same lack of coordination and integration between departments which troubled the teaching program inhibited the development of critical analysis of the research efforts. While senior staff complained of the lack of adequate advanced instrumentation, the team (and others) concluded that there were important unfilled needs for improvement of research design and acquisition of modern scientific methods and techniques. However, it was clear that the college was a most important resource in studying the current and future major health problems of the province and in training research personnel. Notable examples of such community involvement were seen in the-Public Health Department which operated an urban health care experimental program and was assodiated with epidemiological studies in the WHO collaborating center in Yexian. - 26 -
Library
The impressive library is housed in a new building having reading rooms, periodical areas, book stacks and*a printing unit for student texts. More than 300,000 books in six languages are housed on modern shelving, but many of the standard works are rather old, no doubt partly because of the long lag in acquisitions during the cultural revolution and the accumulated demands upon limited finance.
Similar comment may be mAde about periodicals, of which more than 1,000 are held, 600 of them in foreign languages. Many series are broken and some more recently developed clinical and scientific specialties are poorly represented or missing, particularly in-English, some of great importance, such.as molecular biology, genetics, oncology and immunology. It will be a difficult task to identify and collect the missing publications and issues.
The principal and very serious weakness of the library is the total lack of mechanical and electronic filing and retrieval, and all cataloging and searching are done by hand. This must to a large extent undermine the value of an otherwise fine collection. As the readership is heavy and. demands will inevitably increase, modernization of information management in' the library must in the team's view be a very high priority for additional funds.
It will also be advisable to associate the technically very competent but educationally weak audio-visual unit with the library so that the services can rapidly expand to provision of student slide/tape, display and programmed text resources and carrels. This will greatly improve student self-learning.
Future Plans of the College
The principal development objectives of the college were, first, to upgrade the quality of its graduates and improve preclinical science training and extend the medical course to six years to permit introduction-of-- important new courses; and, second, to 4grade and strengthen the Faculty of Public Health to improve the epidemiological and scientific skills of public health doctors who will man the increasingly technical anti-epidemic stations of the future as new problems of non-communicable disease, environmental pollution and chemical hazard develop.
New courses under consideration include medical psychology, community medicine, genetics, clinical pharmacology, molecular biology, forensic medicine, eugenics. Foreign language training is to be increased.
Some attention is being paid by the Department of Medical Education to earlier clinical experience and a more learner-centered teaching approach, and the worrisome problem of departmental integration was also being examined, at first for resource-sharing purposes. - 27 -
The upgrading of laboratories would enable students to participate more individually in practical experimentation. In particular, the college was anxious to add to the Faculty of Public Health modern equipment for occupational health studies and teaching as well as data handling equipment to strengthen teaching and research in epidemiology. A much-closer link would be forged in the future with the anti-epidemic stations, whic'hA would also need upgrading, to provide field teaching and research opportunities for students.
General Impressions
The college is a prestigious and scholarly institution, recovering rapidly from a long period of stagnation and intellectual isolation. Twenty faculty members have studied overseas in the past two years. Standards of entry have been restored and positions are highly competed for. Student intake is rising; new faculties of importance, especially stomatology, are being established; and an excellent library has ,been built.
The government's financial allocation has also increased (+30% from 1980-81).
There is strong interest in improving the quality of -graduates and in modernizing the curriculum and teaching, methods.
*The college is contributing to the retraining of doctors who were inadequately trained during the cultural revolution and is offering numerous other opportunities for in-service training of health service staff.
Priorities for Support
(a) A strong case exists for replacing and improving basic laboratory equipment for preclinical science training and for upgrading clinical pathology equipment in the teaching hospitals.
(b) The Faculty of Public Health also has a strong case f-o-r-additional laboratory equipment for occupational health, radiation and chemical analysis instrumentation and for microcomputer facilities for epidemiological studies and teaching.
(c) Library information handling and data retrieval equipment, preferably computer assisted, and extended improved audio-visual equipment and self-learning facilities need very urgent upgrading.
(d) The stomatology faculty has urgent needs for improvement of dental and maxillo-facial resources to enable it to expand its capacity to train stomatologists to meet the serious provincial shortage. This support should extend to an increase in dental hospital unit facilities, laboratories and research equipment. iL±Aiwii: hanacon'giss.t)k: /L O
- 28 -
QINGDAO PROVINCIAL MEDICAL COLLEGE
Established in 1946, the college was an offshoot of Shandong University, training only western physicians. Since 1979, a faculty of pediatrics as been established, its graduates being trained in preventive pediatrics to staff the maternal and child health services and children's wards of hospitals. The college has three separate campuses for premedical, preclinical and clinical sciences. The affiliated hospital of 541 beds has 983 staff including 15 clinical professors and 44 associate professors and 199 visiting staff. Seven other teaching hospitals are located in Qingdao (6),and Yentai prefecture (1). There are three branch colleges in other parts of the province.
Enrollment and Curriculum
The college has a five-year curriculum, with common core preclinical courses for both groups of graduates. Annual enrollment is 300 senior middle school graduates. Postgraduate students in the clinical specialties number 36 per annum. The total number of students in 1982 is 1,899, of whom a small number of undergraduates are still following a three-year course for assistant physicians.
The courses are the standard ones authorized by the Ministry of 'Public Health, but ail innovation in this college is a compulsory post-graduate, year-long residency.
Teaching and Research
The visit was too short for the team to visit all campuses and hospitals so no estimate could be made of teaching policies or problems. However, the team was told that clinical teaching was looking ahead to problems of a nuclear-family dominated China with an aging population.
The Department of Public Health indicated a considerable number of research projects in nutrition, occupational and environmental health-and locally highly endemic diseases, such as rhinoscleroma, hemorrhagic fever and certain hemoglobinopathies. A research committee advises the college president.
Student Assignment
The college aimed to produce a good general practitioner of medicine suitable for work in the rural areas. The teaching staff regarded the graduates as being similar in training and quality to those of Shandong Medical College for their assigned posts, which are according to the provincia, anpower plan. However, this year the first 5-year class since the cultural revolution will graduate after taking the national examinations of the Ministry of Public Health, previously available only to the core colleges so that a more objective assessment may be possible. -29-
Preclinical Facilities and Resources
The only campus visited by the team, preclinical sciences, demonstrated a similar lack of modern basic scientific and educational equipment to that seen at Shandong Medical College. However, a generally very good impression was obtained of the quality of instruction.
IN-SERVICE EDUCATION IN SHANDONG PROVINCE
In general, the MOPH principle that higher formations should take direct responsibility for retraining of lower echelons was well in evidence in Shandong province.. A very large amount of in-service training was reported at all levels, particularly at the county level, and involving a very high proportion of health staff.
Provincial and Prefectural Hospitals. The principal role of the larger referral hospitals was to provide short full-time courses or part-time courses for medical personnel of the county hospitals. Much of this training was refresher type and was especially directed to cultural revolution period trained practitioners, The latter usually also followed the television preclinical science courses. The larger hospitals also provkded lecturers and teaching teams to visit county hospitals on a more or less regular basis.
County Hospitals. All of the. county hospitals visited offered a regular in-service training program for members of their staff, including some form of case discussion, preparation of discussion papers on topics of current importance, self-study programs or secondment to referral or special hospitals for varying lengths of time. (See Chapter 5 on Qufu County Hospital program.) In addition, all provided opportunities for commune medical staff and sometimes barefoot doctors to attend training courses in the hospital,. Mobile teams also visited commune hospitals regularly for advisory, supervisory and teaching assignments.
Commune Health Centers. The main thrust of in-service training within the smaller commune health centers was mainly to train and retrain barefoot doctors. Members of the hospital staff also visited the production brigades at least quarterly for supervisory and in-service education purposes.
The County Health School. While the principal function of these schools is to train barefoot doctors, pharmacists, technicians and nurses de novo, the school is also responsible for providing retraining for barefoot doctors for periods of from 3-12 months in order to meet the MOPH requirements for the rural doctor's certificate. About two-thirds of Shandong's barefoot doctors have reached this standard. - 30 -
Epidemic Prevention Stations. The stations have important tasks in training barefoot doctors for their preventive activities in water and sanitation control, epidemic surveillance, immunization, pest control, food hygiene and environmental protection. The team was not able to, see these activities first hand. In addition, the epidemic pevention station conducts training of epidemic prevention field sanitation workers, health aides, patriotic sanitary campaign committees, manure collection workers, food handlers and the general public in hygienic practices.
The Maternal and Child Health Center. Responsibilities of the center include retraining of female barefoot doctors and midwives in modern hygienic childbirth and family planning technique. They,also'provide instruction for kindergarden teachers and child supervisors in preventive pediatrics. 0-31-
CHAPTER V: CASE STUDY ON QUFU COUNTY
Qufu County is one of the 40 counties chosen to be upgraded by the MOPH under the first phase of the present Rural Health Policy. This chapter reports on the data provided to the mission by the health officials in Qufu County during our visit. It appears that very little data is collected routinely. Systematic collection of information on all 12 communes in the county and 110 brigades in three communes was undertaken for this mission. A preliminary statistical analysis of these newly collected data is reported in a companion paper./1
Qufu is located in the Jining Prefecture, 105 kms south of the provincial capital of Jinan. The County is 35 kms from north to south and 25 kms east to west, with 895 square kms of surface area. The county is a flat plain with some hilly area and an occasional mountain. There are no major rivers. Qufu is 35 miles away from Yanzhou, a city with a major train link.
POPULATION
The County is divided into 12 communes and 1 township. It has 470 production brigades, 2,230 production teams, 116,000 households, and 517,035 inhabitants (1981). The average population density is 578 inhabitants/square km. 94%,are employed in agriculture, on less than 50,000 hectares of arable land. The average household size is 4.5 people. Table D summarizes demographic indicators for selected years and Table 17 gives the breakdown of information 'on rural population per commune.
Table D. Qufu County Demographic Indicators for Selected Years
Total Crude Crude Rate of Year Population Birth Rate Death Rate Natural Increase (per thousand) (per thousand) (per thousand)
1950 310,000 No Statistics
1957 363,837 37.10 17.10 20.0
1977' 499,336 15.23 8.53 6.7
1981 517,035 17.47 7.31 10.2
/1 See J. van der Gaag, Health Sector Issues in China, Supplementary Technical Paper No; 3, "Health.and Health Care in Qufu County, Shandong Province: A Preliminary Statistical Assessment". -32-
The population of Qufu city increased from 20,559 in 1953 to 38,300 in 1981 (86% increase). 93% of the population lives in the twelve rural communes, which range in size form 13,000 to 50,000 people. The birth'rate varies significantly among communes from 11.1 to 20.7 per 1,000 population, although the percentage of married women of child bearing age is rather astable, around 13%. Family planning is a priority task and follows the national guidelines. Data provided in Table 16 indicate that the percentage of birth control users ranges from 72 to 89%, with an average figure of 82.2%. Of these birth control users, 24% agreed to receive the one-child-family certificate, representing 20% of women of child bearing age. However, this perceitage ranges from 7 to 35%, a rather wide range in the application of this important aspect of population control.
Statistical analysis (see Van Der Gaag, op.-cit.) indicates that contraceptive use as such seems less important than the use of additional incentives (in casu, the one-child certificate) to control population growth. The number of one-child certificates does increase with per capita income, thus reducing the increasing effect of income on the birth rate. For iexample, Qufu data suggest that a 10% increase in per capita income would normally increase the birth rate about 2.5%; however, it will also increase the proportion of one-child certificate holders, thus reducing the expected increase of the birth rate to only 1.8%.
SOCIOECONOMIC STATUS
In 1981, the total County income was estimated at Y 227.63 million,of which Y 148 million (65%) was from agricultural'production and Y 79.62 million (35%) from industry. The average per capita agricultural income in the communes in Qufu county is Y 240. From 4 to 35% of this income comes from agricultural sideline activities. The richest commune has a per capita income of over Y 300, while the poorest has only Y 80 per capita (Table 17).
- Part of these differences may be explained by the availability of arable land, ranging from 0.84 to 1.78 mu per capita. Part is probably resulting from demographic characteristics as indicated by the labor force/population ratio, which ranges from 0.33 to 0.50. Also the productivity of land shows large variations, from 96 to 305 yuan per mu. So does the income/labor force ratio: from 241 to 695 yuan per worker....-
The major agricultural production is wheat. Pig raising is the major side-line activity. Table E,shows changes in agricultural production, as well as the decline in the availability of total arable land in the county between.1957 and 1981: -V33 -
Table E. Main Agricultural Productions, Qufu, 1957-1981
1957 1977 1981
Rice (50kg/unit) 1,576 52,060 14,807 Wheat (50kg/unit) 496,033 1,110,790 1,929,490 Other Grains (50kg/unit) 380,880 2,283,210 2,750,596 Pork (50kg/unit) - 127,850 281,345 Edible Oil (50kg/unit) 12,115 7,760 24,108
Total Arable Land: Md 816,051 729,290 716,700 Hectares. 54,431 48,644 47,804
1 mu 0.0667 hectare
Among the 116,000 county households, 13,350 (11.5%) use running water, and 102,740 (88.2%) use well water, of which 33,560 (32.6%) use hand pump wells and 69,180 (67%) use open wells. 315 households (0.3%) still use surface water from rivers or ponds. The total expenditure on water supply for 1981 in the Qufu township was Y 150,000.
The overall literacy rate above 12 years of age in Qufu County is approximately 70% on the average, with only 50% for women. There are 2,664 primary school teachers and 1,631 middle school teachers. 72,117 children are enrolled in primary school. (No data are available on the total number of children under 12 who are eligible.) On the-other hand, from 42,786 children under schooling age (7 years), 61% are enrolled in 532 kindergardens and nurseries.
THE STRUCTURE OF HEALTH SERVICES
The healths service structure follows the three-tier system./1 At the county level there are a county general hospital, an epidemic prevention station, a MCH center, a secondary training school, and a dzug control center.
Each of the 12 communes operates a commune health center, which includes curative services, an epidemic prevention division , and a MCH division.
438 production brigades, representing 93% of the total number of 470 brigades in the county, operate brigade health stations, with an average of 2.4 barefoot doctors per brigade, and with a pharmacy consisting of about 200 western drugs and 300 traditional herbs. 32 brigades of very small size did not establish their own station, and share services provided in other brigades. Industries operate 32 labor health stations.-
/1 A comprehensive description is provided in the report of the inter-regional seminar on primary health care, Yexian, 1982. q34-
Table 18 reports on the development of health facilities ahd staff betweei.1957 and 1981. There is 1 hospital bed available per 990 population in 1981, compared to 1 per 16,538 in 1957. The number of senior physicians increased from 2 in 1957 (Ratio: 1 per 181,918 population) to 139 in 1981 (ratio: 1 per 3,720 population). 55 of them work in the 12 commune health centers which have a total of 237 hospital beds.
A. The County Hospital
The Qufu County hospital is a general hospital. Its organization in 4 administrative departments, 7 medical departments and 9 technical units is typical of the organization in county level facilities:
Administrative Medical Nimber Technical Departments Departments of Beds Units
Medical Internal Medicine 50 Radiology Administration Surgery 50 ECG Finance Gynecology-Obstetrics 32 Emergency Room Nursing Pediatrics 34 Pharmacy Ophthalmology - ENT 10 Endoscopy Dermatology -- Surgery.(3 rooms) Traditional Medicine 10 Laboratory Physical Therapy -_ ITotal: 186 Supplies
The floor area of the buildings of the county hospital is 8,750 square meters, built on a 15,300 square meterpiece of land. The typical number of beds for county hospitals is 155, but this amount did not meet the needs of the Qufu population and was increased to 186.
The quality of the equipment is very poor. The two X-ray machines are 20 years old, one from 1960 and the other from 1964. Laboratory examinations are relatively simple. The pediatric ward has onejhomemade incubator consisting of ordinary lamps it a glazed container. The ophthalmology department has one slit lamp. There is one ECG machine, one anesthesia device, one respirator, one endoscope and one cystoscope.
The total number of staff is 271, includng 5 directors and deputy-directors, broken down by categories as follows: -35-
Administrative Staff: 18 (7%)
Workers: 31 (11%)
Technicians: 222 (82%) --of which: 53 doctors (1 director, 20 specia ts nd 32 senior doctors)`,
12 junior doctors (assistdts)
4 midwives
99-nurses (14 senior, 54 middle level, and 31 primary l4vel)
54 technicians (10 senior, 27 middle lpve, and 17 junior)
Utilization indicators are reported in Table 3, 3,627 inpatients were admi,ted to the hospital, with another 2,199 admissions for deliveries. Bed occupancy rate is relatively high (87%), indicating that every bed is occupied 320 days per year, with a turn-over slightly above 32 times per year. Average duration of stay is 10.1 days, with obstetrtC paiipqs staying an average of 4 days, and other inpatients 14 days. A totaltwrnberof 2,877 surgical'operations"was carried out 1981, of which 2,240 were)minor (in- outpatients) and 637 major (resulting in hospitalization),. ThRre was a 4 day waiting period for elective surgery in summer, and no waiting durin the rest of the year. The number of abortions was not indicated.
An average of 460 outpatients are visited every day, with a total number of 168,862 visits in 1981. It was indicated that 60% were referred by other health institutions, and that 40% were probably self-presenting themselves, i.e., not following the referral procedure via barefoot doctors and commune health centers. The county hospital has no regulation. to enforce the three-tier referral system nor procedures to limit self-referral. However, self-referring patients are not reimbursed thei; hospftal fees by the cooperative health insurance. The ratio of the utiation of western medicine versus traditional Chinese medicine is estimated to be 2:1. Each, patient received at least two drugs per visit.
The county hospital provides in-service training to its own staff and also to those from commune health centers. From 1977 to 1981, 144 staff members from commune centers were retrained in the hospital (duration, 6 to 12 months). 51 lectures were delivered by senior staff, either to people assembled in the hospital, or to commune health staff during special visits arranged in the field. 212 field visits were organized to train rural staff, to assist them in solving a technical or managerial problem, or to discuss specific issues. In addition, the county hospital sends every three months a mobile team to supervise selected commune hospitals and medical stations. "36-
This training effort is co#ple'Aented by a extensive,program of in-service training for hospital staff, themselves. The program includes self-study, scientific paper preparation, case studies, and preparation of staff to take higher level examinations. In addition, from 1977 to 1981, 56 doctors were sent to provincial or prefectural institutes for vocational training of 12 to 18 months durattqi&; staff participated in 27 short-term training sesgions organized in the prefecture or in the province,, and 14 lectures were delivered in the hospital by visiting doctors.
4. The Epidemic Prevention Station
The epidemic prevention station has 41 total staff, of which 31 is technical and 10 administrative. They provide guidance to lower-level staff at the commune and brigade level., They handle the communicable disease repdrting system, based on barefoot doctors' reports, provided every 10 days even,Af no case of disease has occur.d..' They also are in charge of school e, hygi labor hygiene in industry and agriiAture (including control of pestitides and medical check-ups-for workers), fgd hygiene, drinking water control, and sanitation. Many activfties are carried out very irregularly. Phy idai check-ups took place in 19,81 in only a few schols and in a mining plant where 300 people were visited4 The cop,ol of water quality consists of an examination three times a year of water sa'mples taken every 10 square kilometers.
The epidemic rv Aiion station is responsible for organizing immunization campaign{ and distrib g vaccines. 376,400 immunizations-were delivered.in 1981 by MCH servin, health stations, and barefoot doctors (Table:23). The target groupsare those designated by the Ministry of Heatlh in the national immunization schedul, (Table 9). Discontinuation 'of smallpox immunization was decided in November 1981. The composition of the target group eligible for influenza vaccination is not clear. Typhoid vaccine was delivered to kisk group's: horse and cattle keepers and people handling manure. BCG vaccine was also delivered, but data were not available.
It is not possible to estimate the coy,rage of the population. The epidemic prevention station claims that 100% of the target group is covered, according to the plan. Hpwever, no detailed .?esults are available, broken down by age-group, geogra,hical area, or ty"" of vaccine. There is-no survey of efficacy (s4tylogical conversion rate, 'hin tests, etc.), no evaluation of the strictness of the" maintenance of the cold chain, no monitoring of the immunization proceduie .,
C. Maternal and Child 'Health
The county MCH center supervises the MCH and family planning activities carried out,in the 12 cpmmunes. The staff carries out periodic surveys of womeA and qdhool age tildren. They also provide outpatient services in family planning, and preatal and well-child exams. The county MCH station is staffed by 2 senior physiciang' 6 assistant physicians, 1 nurse, 1 primary,Level health worker, and-6Administrative staff. There is a total of 4 senior physicians, 16 assistant physicians and 10 mid-level nurses who perform and organize the MCH activities in the County. An estimated proportion.of 98.5% of all deliveries is assisted by trained health staff. - 37 -
D. Commune Facilities
Each of the 12 communes in Qufu County operates -a health center with a commune hospital. Facilities encompass an inpatient ward, several outpatient clinics, a surgical department for minor operations (including abortion and sterilization), and'specialized departments for obstetrics, pediatrics, and-traditional Chinese medicine. They also have an MCH division and an epidemic prevention division. Most of them have standard technical equipment of one X-ray fluoroscope machine, one monocular microscope, elementary laboratory devices, and one surgical .table. Some of them also have an ECG and dental materials. This equipment is old and obsolete, but well maintained and operating. Sterilization of instruments is made everywhere by boiling. Table 19 summarizes typical activity indicators of commune hospitals in Qufu County.
The largest commune center has 42 beds. The average size of a commune center in 1981 was 19.8 beds, as compared to 15.7 beds in 1975. The number of beds per 1,000 population ranges from 0.18 to 1.21, with an average of 0.50. There is no "major commune health center" in Qufu county, serving neighboring communes as a referral center. All patients are referred to the county hospital. However, some communes are relatively far from the county city, and the establishment of upgraded major commune centers could meet the demand for better care and relieve the pressure on county level facilities. On the other hand, two commune centers located in the immediate vicinity of Qufu city (Shuyuan and Nislian) receive outpatients only and do not operate inpatient wards., Having only a few beds (5 to 7) for temporary observations, and overnight care, they refer all severe cases to the county hospital.
The period 1975-1981 has seen a large increase in the number of health workers, especially in senior and middle level workers (Table 18). The present ratio per bed is 0.26 senior level health workers, 0.79 middle level, and 1.23 junior level. The number of other personnel remained relatively stable at 0.36 per bed.
Present figures suggest that the number- of health workers per bed does not seem to have any effect on the amount of hospital care made use of. Statistical analysis indicates also that there is no significant relationship between income and the availability of health care facilities. -In other words, the highest ratios of health care facilities available per capita are not found in the richest communes. On the other hand, data suggest that an increase in per capita income results in an increasing number of inpatient days.
The 12 commune health centers handle almost 900 outpatients per day, 400 of which are referred from brigade health stations (Table 19). The total number of hospital admissions is 11,181, representing an annual average of 43 admissions per 1,000 population. Commune centers referred 2,500 patients to higher level facilities in 1981 (in most cases the county hospital). The analyses indicate that income has no significant impact on the number of referrals to higher l&vel care. On the contrary, preliminary information collected during the mission indicates that increasing income is probably responsible for increased self-referral and the by-passing of commune facilities. -38-
The "mriance in these health care utilization numbers is large: the admission iates range from 7.5 to 51 per 1,000 population, the mean stay from 2.8 to 7.4 days. However, the lowest rates are at the commune health centers with less than 10 beds (35% occupancy rate) which are, as we learned in the field, mainly used for observation and overnight care.
EPIDEMIOLOGICAL SITUATION
Communicable Diseases
Major communicable diseases are under satisfactory control in Qufu County. Plague and cholera have not been reported from this county since 1949. Smallpox was eradicated in the 1950s. The last case of Kala-Azar occurred in 1962. Diphtheria has not been reported sinre 1977. Venereal diseases are said to be eradicated.
Nine "communicable diseases " are still prevalent in Qufu County. Incidence rates strikingly decreased over the last decade (Table 20). For example, maiaria dropped from 200 to 2 per 1,000 population. The present level of control suggests that none of them is a public health concern at the present time. However, several of them remain a threat if control measures are reduced. Improvement in sanitation and water supply will help in reducing the incidence of hepatitis and dysentry and in eliminating typhoid fever.
The're were 490 leprosy cases diagnosed between 1949 and 1981,: 299 were cured, 157 died or moved, and 34 patients-are still being treated.
Tuberculosis is not regularly reported, since it is not included in the standard list of communicable diseases. County authorities iave no figures on the present situation. Sample X-ray examinations were carried out in 1981 in a mining plant (300 workers) and selected schools, resulting suspect in 3 cases. The population of one brigade (about 1,300 people) was examined in 1982, resulting in the diagnosis of 9 new cases. These data, although rather vague and scattered, may indicate that the prevalence of tuberculosis is not negligeable.
Prevention of tetanus is part of the immunization pro-gram; However, tetanus vaccination is scheduled only in children before the age of 2, without booster injections at a later age. Therefore, cases in adults are likely to occur, but no figure is available. Neonatal tetanus is sporadic in Qufu, with a low incidence of 0.11 per 1,000 deliveries in 1981.
Morbidity and Mortality
It is impossible to determine in Qufu which are the main causes of morbidity and mortalityi Barefoot doctors do not report the diseases they have treated, although at this stage they identify symptoms rather than nosological entities. Commune and county hospitals keep a register of outpatients they have received, but the data are not aggregated on a monthly or yearly basis except for numbers. - 39 -
There is no certification of the causes of death by medical professionals. Deatfis are reported to police stations' which keep a recor4af all residents, and corpses are incinerated. Less than 10% of deaths occur in county or commune hospitalsi For example, about 3,500 deaths were recorded in Qufu during 1981 (6.9 per 1,000 population), 133 of which were in the county hospital.
According to health staff at all levels (county, commune, brigade), the main cause of morbidity is digestive ailments (gastritis, hemmoragy, gastric ulcer, diarrhoea, abdominal pains), followed by respiratory diseases (chronic bronchitis, pneumonia, common flu), skin diseases, arthritis, and eye diseases (conjunctivitis). This statement is supported by the distribution of morbidity causes in patients admitted to Qufu County hospital (Table 21), although they represent only 2,15% of outpatients visited and thus produces a picture heavily biased. Intoxications deserve special mention. They represent 2.5% of hospital discharges and 6% of hospital deaths.' In Xiao Xue commune, average an of 20 severe cases are treated every year out of a population of 40,000. These intoxications are associated with insufficient care during pesticide spraying (especially in cotton fields) and could be prevented." Another important concern should be the pathological problems in neonates (before 1 month of age). They account for 5% of hospital discharges and 6% of deaths. The total neonatal mortality figure in the county is 9.8 per 1,000 births. The one-child policy supported by the government requires -that special attention should be paid to the provision' of better obstetric services and to the improvement of equipment in pediatric wards. Qufu hospital County has no equipment for neonatal reanimation and only a rudimentary homemade incubator. Better training of brigade birth attendants and earlier referral of defective infants could also improve the situation.
MCH services carry out systematical examinations of married women below 60 years of age. 95,641 women were examined from 1971 to 1981. Pathological defects were found in 19.3% of them. Most common diseases are cervicitis, salpyngitis, and menstrual disorders. One-third were easily cured. The observed prevalence of cancer of the cervix was 7.7 per 10,000 women examined.
Statistics on mortality in Qufu County hospital are reported in Table 22. They do not represent a true picture of mortality causes inl the general,population. However, they are consistent with data recorded in other parts of China (Shanghai county, Beijing municipality rural areas), and emphasize the satisfactory they control of infectious and communicable diseases in the County. Coronary heart and cerebro-vascular diseases account for one-third of the total deaths, and cancer for 12%, although they account together for 13.6% of inpatient discharges and certainly much less of outpatient visits. -40-
ISSUES
Key problems within the health system would appear to be: (a) the bypassing of the referral system; (b) poor supervision of the curative services provided by the barefoot doctors; (c) poor coordination between the preventive and curative services; (d) overutilization of drugs at each level from county to brigades; (e) lack of management data; (f) old and inadequate equipment; (g) lack of monitoring of immunization campaigns.
Qufu County has a great potential for upgrading, especially in the areas of management of health services, improvement of supervision at every level, design of a coherent in-service training program which puts lesser emphasis on individual promotion, renovation of equipment, and decentralization of county duties to upgraded key commune health centers.
Ih -41-
CHAPTER VI.' COSTS AND FINANCING
This section examines the level and allocation of'health sector expenditure by major sources of finance in Shandong Province, with specific reference to Qufu and Yexian Counties and Quingdao Municipality. These sources are: state expenditure on recurrent and capital inputs, state expenditure on the state health insurance scheme, enterprise expenditure on labor health insurance schemes, both compulsory and voluntary, expenditure by rural cooperative health insurance schemes, and sources which comprise urban cooperatives and private out-of-pocket expenditures.
STATE EXPENDITURE
Consolidated state recurrent expenditure on health in Shandong Province totalled Y209 million in 1981 (Table 24). This was equivalent to Y2.8 per capita or about 85% of the national average. The distribution of per capita recurrent expenditure between and within prefectures and municipalities is substantially uneven. Per capita expenditure in the urban municipalities as a whole averages Y3.5, more than one and one half times greater than the average Y2.2 in the riral prefectures (Table 25). Within these areas there are more extreme variations, from Y2.8 in Zaozhuang to Y3.9 in Quingdao Municipality, and from Y1.6 in Linyi to Y2.8 in Yentai prefecture., Per capita recurrent expenditure in both Qufu and Yexian counties is significantly lower than the average for their prefecture, at Y1.49 and Y1.57 only 65% and 58% of the average respectively (Table 27).
Recurrent expenditure on heaith in 1981 accounted for approximately 8% of consolidated state recurrent expenditure in the province. The lack of data on sector shares for previous years precludes a test of the hypothesis that fiscal decentralisation has adversely affected fiscal appropriations to the health sector in the province as a whole. The decentralisation reform was introduced*to prefectural level in 1980 and extended to county level in 1981 in Shandong. Data for Qufu and Yexian counties suggest that there is some variation in health sector shares but not that the trend is downward. In Qufu county the share declined only slightly from 10.6% to 10.1% between 1975 and 1981, compared to a significant increase from 5.6% to 9.1% in Yexian over the same period as indicated below: .
Table F. Health Sector Shares of Government Expenditure; Yexian and\Qufu Counties
1975 1980 1981 (%) YEXIAN
Recurrent Expenditure 5.6 6.5 9.1 Capital Expenditure 3.2 3.7 3.2
QUFU
Recurrent Expenditure 10.6 10.3 10.1 -42-
There is also variation in the sources of finance for fiscal outlays at local level. Before the decentralisation all state expenditures were allocated by the central government. Under the partial decentralisation in 1980, Qingdao municipality financed all recurrent health expenditure out of its own budget while in Yexian 87% expenditure was financed by appropriations from the provincial government and the rest from the prefecture. Under the full decentralisation of 1981 the Yexian county budget itself financed 82% of county-level recurrent expenditure by the state, the residual being financed out of the provincial and prefectural budgets (Table 28).
Recurrent state expenditure on health-is allocated principally to the subsidy of hospitals within the state sector. Hospital subsidies consistently receive a share in excess of 60% of the total (Table 26). Appropriations to urban district hospitals and commune health centers claimed 27% of the total in 1981. Urban hospitals are subsidized at a rate of Y1-2 per bed day utilized. Commune health centers-receive a subsidy equivalent to 60% of their staff salary costs, unless they are among the one-third of the Commune Health Centers owned by the government which receive a 100% salary subsidy. Higher level general and specialised hospitals at county, municipality or prefecture and provincial levels receive a 100% subsidy of salary costs. Appropriations to these hospitals claimed the single largest share of state expenditure in 1981, 39%. The share allocated to preventive servizes, including epidemic--prevention stations, immunisation; TB control and MCH stations was 14.3% in 1981, a slight decline compared to the 16.7% share in 1975. The share of subsidies to rural brigade level services, including subsidy of training 'and salaries of barefoot doctors and provision of simple equipment for brigade health stations, is very low and fell from 1.5% to 0.5% between 1975 and 1981, but is budgeted to rise to 4% in 1982.
Recurrent expenditure accounts for about 75% of all state expenditure on health in Shandong. Capital construction expenditure accounts for a further 9% or Y26 million in 1981 (Table 24). This is equivalent to YO.4 per capita, about half of the national average. Similar distributional patterns are evident in capital expenditures per capita both between and within provinces and municipalities as are found for recurrent expenditure - (Table 25).
STATE INSURANCE EXPENDITURE
State cadres employed at all levels of government, together with college students teachers and.certain other categories are provided with free health services by the state insurance scheme. Only primary members are covered: dependents receive no benefit entitlements. The level of financing for these insurance benefits corresponds to the level of employment of the beneficiary. At each level the scheme is administered by the Committee on Goverriment Insurance in the Finance Bureau. Both the administration and financing of the scheme is completely independent of the Health Bureau.
Expenditure on the state insurance scheme claimed 15.3% of total state expenditure on health in Shandong Province in 1981, the only one of the three categories of state h6alth expenditure to receive an increasing share -43-
(Table 24). While growth of ordinary recurrent and capital expenditure decelerated sharply in the 1980-81 period, state insurance expenditure accelerated from an average annual rate of 11% during 1975-80 to 19% in 1980-81.
Average insurance outlays per member were Y40.2 in Shandong Province as a whole in 1981, nearly fifteen times greater than overall per capita state recurrent expenditure on health (Table 24). Again the distribution of expenditure per member is somewfat uneven: Y35.7 in Qufu County, Y38.3 *n Yexian, and Y37.1 in Quingdao municipality (Table 29). These expenditure levels exceed the Y30 norm recommended by the Provincial Health Bureau. Counties which do not exceed the average receive a Y60,000 incentive payment from the Provincial Health Bureau (the premium is a lump sum independent of the extent of the cost saving). Only 10 of the 106 counties in the province qualified for this premium in 1981. No disincentives are in force to discourage expenditures which exceed the norm.
LABOR INSURANCE EXPENDITURE
Labor insurance expenditure strictly denotes expenditure'of the compulsory labor insurance schemes, under which regular employees of productive enterprises with more than 100 employees are provided with free health services, and their dependents are entitled to 50% reimbursement. More broadly, labor insurance schemes also include voluntary schemes organized by county collective and commune industries. Reimbursement rates tend to vary with enterprise profitability, probably averaging around 50% for primary members but reaching as high as 100% in some enterprises. These insurance schemes are financed by an allocation out of the enterprise welfare. fund, equivalent to some 2%-3% of the total wage bill.
Aggregate data on labor insurance schemes are not available for Shandong Province as a whole. Data for Qufu and Yexian counties indicate expenditures per member of about Y34 and Y40 respectively, very similar to expenditure per member under the state insurance scheme (Table 29). Expenditures per member are typically much lower for the voluntary insurance schemes, around Y31 and Y29 for the county collective industry schemes in Qufu and Yexian respectively, and Y20 and Y12 for the commune industry schemes in the same counties.
RURAL COOPERATIVE INSURANCE EXPENDITURE
Rural cooperative health insurance schemes are an important health financing device for the rural majority who do not have access to the formal state or labor insurance schemes.
The cooperative schemes are typically organized at. brigade level, thus providing only a limited pooling of risk and precluding any redistribution between rich and poor brigades. The insurance fund is usually financed jointly by lump sum annual prepayments both from the brigade welfare fund and from individual members, and provides some degree of reimbursement for brigade level and referral services. Salaries of barefoot doctors at brigade level are paid out of collective distributed income, not 'out of the health insurance fund. -44-
Within this general framework there are great variations in the specific characteristics of cooperative schemes even in small areas. Some: Cf these are documented in Table,30. Annual prepayments in Shandong appear to range from Y1 to Y3 per member, paid out of the brigade welfare fund with no ) complementary individual prepayment. Expenditures per member out of the cooperative insurance funds in Qufu and-Yexian Counties are broadly consistent with this range at Y1.9 and Y2.4 respectively (Table 29), very substantially lower than per capita expenditures for those insured under the formal insurance schemes. Benefit entitlements vary considerably under different schemes. Many cooperatives offer 50% reimbursement for drugs and services at brigade level, others as much as 100% and still others as little as zero. Schemes offering no reimbursement at brigade level usually sell- drugs at wholesale prices coupled with a registration fee or at retail prices without a registration fee. Reimbursement for referral services also appears to average around 50% but may vary from a higher rate down to zero. The most unusual format, observed in Tongpiyu brigade, (Chengguan Commune, Yexian) involved a Y 2.50 annual prepayment per member from the brigade welfare fund to finance brigade leveliservices, plus an additional YO.50 prepayment from the welfare fund paid directly to the Commune Health Center. In exchange, the Commune Health Center assumes the obligations of a health maintenance organisation, providing free referral services to brigade members and also paying the full cost of any referrals to the county hospital or higher levels.
PRIVATE EXPENDITURES
Consumers of health services face user charges at all levels of the health system. At brigade level, consumers may have to pay a registration fee (typically Y 0.05), a service fee for immunizations (typically Y 0.05) and the full cost of drugs, either at wholesale or retail prices. Of ccarse, the level and structure of these charges vary within the cooperative insurance system at the brigade level. At Commune Health Centers, and at county, prefectural and provincial hospitals, consumers have to pay the full cost of drugs along with fees for inpatient and outpatient services.
Drugs are typically sold at a markup of 15% over uniform national n wholesale prices for Western drugs and 30% for traditional drugs..User charges for hospital services follow standard guidelines established in each province by the Provincial Health Bureau in consultation with the Price Bureau. Outpatients pay registration fees of Y 0.1lper first visit.and Y 0.05 per revisit at the county level, and Y 0.15 and Y 0.1 at prefectural and provincial levels. Inpatients pay a bed-day charge plus 6urgical fees for operations.. Average charges in Shandong Province are Y 2.88 per bed-day, and Y 20, Y 10 and Y 5 for major, medium and minor categories of operations respectively.
Hospital pricing policy in Shandong Province does not appear to reflect either the average or marginal costs of providing hospital services. Indeed, it is commonly asserted in Shandong that revenue from user charges recovers only about one-fifth of the operating costs net of drug expenditures. Data for selected hospitals presented in Table 31.suggest that the level of non-drug cost recovery from fees is higher than that, although 0 -45-
in three of the four hospitals shown, total operating revenues (excluding salary subsidies) recovered only about 80% of total operating costs. There is a concern that hospital charges should be increased in order to cover costs, and the central Ministry of Public Health has raised the issue with the-State Council. To date, higher charges have been implemented only on a pilot basis in some hospitals and for beneficiaries insured under the government and labor health insurance schemes. This experiment can be expected to be quite uninformative since the demand of those,beneficiaries is completely inelastic with respect to price by virtue of their insurance status. Of much greater policy interest would be evidence on the price elasticity of demand for hospital services by rural cooperative insurance members who, in general, have to pay 50% of hospital costs.
Current pricing policies nevertheless result in hospital charges which are quite high relative to individual incomes. Average inpatient and outpatient charges (drugs plus fees) in selected hospitals are shown in Table 32.. Inpatient bills range from about Y 30 at Commune Health Centers to about Y 120 at a large prefectural-level hospital. These represent a range of about 10% to 50% of average per capita income for rural peasants and 4% to 16% of the average cash wag, of urban workers. Average outpatient charges are of course much lower, varying from about Y 1.5 to Y 1.3 (the Y 16 figure for Yexian County Hospital is anomalous). As shown it Table 31, drug costs typically account for much the largest share, between 60% and 80%, of the. total charges to patients and constitute the single largest source of finance for hospital expenditure. The extent to which these drug prescriptions are genuinely appropriate is clearly an issue of concern. The possibility that control of drug consumption could lead to sigAificant redictions of hospital expenditure without compromising its effecti7.eness merits further investigation.
Total private expenditure on health services*in Shandong Province is difficult to estimate accurately, even though its elements are relatively easy to identify. Household expenditure surveys, showing private outlays on health services are not available for Shandong Province. The lack of data on health services utilization by different insurance classes of beneficiary precludes an indirect estimate based on utilization data, average-charges and reimbursement rates. Nonetheless, some fragmentary estimates have been made for the Province. The Provincial Health'Bureau estimates an average expenditure on health of approximately Y 12 per person per year for persons enrolled in the rural cooperative insurance system. This estimate is reportedly based on an annual survey of about 10 million rural inhabitants. The figure includes both reimbursed and direct private expenditures. Assuming an average reimbursement rate of 50%, this would imply an average annual expenditure of Y 6 per capita. Estimates by the Health Bureaus in Qufu and Yexian counties imply per capita average annual outlays of Y 2.3 and Y 0.5 per capita respectively. These figures are substantially lower than the reported average for the whole province, but since the basis for the estimates is unclear, it is doubtful whether much weight should be given to them. -46-
CHAPTER VII. :SSUES AND HEALTH PRIORITIES IN A CHANGING (NVIRONMENT
Issues Related to Population Changes
The life expectancy in Shandong Province dramatically increased since liberaton, from about 40 years to the present figure of 63-65 years. Elimination of major epidemic outbreaks, eradication of several communicable diseases and reasonable control of the other ones, improvements in sanitation, better coverage of the population with preventive and curative medical services, and establishment of a primary health care network at the production brigade level, resulted in the addition of an average 20 years of life expectancy since 1950. As a consequence, health services face a changing morbidity pattern associated with the aging-of the population: increasing problems of senil 4ity, disabilities, chronic and degenerative diseases. The demand of medical services rapidly increases with aging after 45 years of age, as previously noticed in societies which have experienced a similar change in'population pattern. Health services have to adapt themselves to meet the new demand which requires more sophisticated and more individual-oriented care.
At the same time, China succeeded in reducing fertility. Crude birth rate decreased in Shandong from 40 per 1,000 population to the present figure of 16.5 per 1,000. As a result, the number of people in-younger age groups decreases strikingly, both in absolute numbers and relative * proportions of the entire populaton. In 1981, the most numerous age group is no longer the 0-4 years group, but rather the 15-19 and,20-24.years group. These changes in the age structure of the population they serve result in changing priority.activitiies for health services. At the same time, the outcome of these services is more difficult to measure: further reduction of mortality rates is likely to be slow and not directly related to investments in health care; the complexity of morbidity patterns associated with multiple causes and risk factors leaves little hope for major achievements in eliminationg or even control, of new diseases.
Recently, the one-child family policy suggested by the government resulted in a set of new priorities. The main task of health services is to ensure the families that this single child will be reasonably healthy. Thus, prevention of birth defects becomes a priority, with emphasis on pre-natal diagnosis and abortion for genetically defective embryos, with provision of better obstetrical services and pediatric care.
The Changing Financial Environment
Two major events have fundamentally changed the financial context in which the health sector operates throughout China, and consequently in Shandong Province.
The first is the recent fiscal decentralization reform under which a block grant government revenue sharing system operates with full decentralization of sectoral allocation decision at provincial, prefectural * and county levels. The decentralization was introduced to prefectural level in 1980 and extended to county level in 1981. Before the decentralization 47' -F
the central MOPH was able to recommend, through the State Council, the level of health expenditure by each ,province, prefecture and county. Now it exerts no direct quantitative control. Instead, its influence is exerted indirectly through rather general policy recommendations contained in directives issued by the State Council. In addition, there appear to be 'estrictions on the extent to wbich actual expenditure decreases in a sector are allowed, relative to pre-decentralization levels.
It was expected thwZ local decision makers would assign a lower weight to the health sector than their central counterparts, and therefore that the decentralization would have a negative effect on fiscal allocations to the health sector, at least in relative,if not absolute terms. Such an effect could potentially have serious implications for the health sector since the government budget finances approximately one-quarter of total expenditure in the sector. Although data with which to ,ake an empirical test,.'f this hypothesis are not available for China as a whole, the qualitative evidence suggests, that the reform has had a mixed impact: positive in some regions and negative in others, especially in the poorer areas. For example, health sector allocations are reported to have declined in Shaanxi Province. .
Data for Shandong Province also demonstrate mixed results. On the one hand, there has been a secular increase in absolute levels of recurrent and capital government expenditure on health since the mid-1970s. On the other hand, the rate of growth decelerated sharply in the early 1980s: from about 11% per annum during 1975-80.to less than 4% in 1980-81. More micro- level data for the same periods reveal: in Qufu county a stable health sector share of recurrent expenditure (about 10%) accompanied by a sharp decline in the annual growth rate from 10% to 4%, indicating a decline in overall budgetary growth; in Yexian a marked increase in the health sector share of recurrent expenditure from 6% to 9%, but not sufficiently to prevent a decline in the annual growth rate from 14% to 11%, again indicating a constraint on overall budgetary growth; in Qingdao municipality the annual growth rate of recurrent health expenditure decelerated markedly, from 20% to 7%.
The second major reform has been the introduction in-19-79-of the production responsibility system in the rural sector. This is believed to have two implications important for the health sector. One is that the new incentive structure has generated a substantial increase in rural incomes and hence in the demand for health services. The other is that the weakening of collective organization in the rural sector has also weakened the mobilization of collective resources to finance provision of basic needs. Reports from some areas suggest that brigade welfare funds have collapsed, that cooperative health insurance schemes have-been abandoned, and that large scale resignations of barefoot doctors have taken place because the responsibility system has raised the opportunity cost of work as a barefoot doctor above the 'level which collectives are willing to pay for their services.
Shandong province has experienced a dramatic increase in rural incomes under the responsibility system. Distributed collective income per capita rose 54% between 1979 and 1981, from Y 82 to Y 126. Evidence in other -48-
less developed countries indicates that the income elasticity of demand for health services is at least unitary, so that rising incomes can plausibly be expected to induce a proportionally higher demand for health services in China. Specifically, it is expected that rural inhabitants will increasingly ' bypass the lower quality services provided by barefoot doctors and refer themselves to higher quality, higher level health units. The need to stabilize the primary barefoot doctor level by 'rading their skills to middle-level standard and to improve the quant7 and quality of services at commune and county hospital levels-in response to these new demands arising out of the economic reform was consistently perceived as a major policy issue by provincial and county health authorities.
Contrary to other reports, the rural cooperative health system in Shandong Province appears to be relatively stable. Some 90% of brigades have a cooperative brigade health station and insurance scheme, principally financed out of brigade welfare funds. Suggestions of a decline in the number of insurance s6iemes or their membership are scarce (in Heze prefecture only). Barefoot doctors appear to be relatively well remunerated, typically earning a workpoints income significantly greater than the average in the brigade ranging between Y 280 and Y 480. There is., however, some perceptioh of a modest threat to the retention of barefoot doctors which has induced the provincial grvernment to pay a small salary supplement of Y 2 to 3 per month to barefoot dotors in relatively poor brigades, as well as subsidizing provision of basy medical equipment and supplies for brigade health stations.
The Changing Epidemiological Pattern
The success of prevention and control of communicable .diseases resulted in a total change in mortality and morbidity patterns during the last 15 years.
In the 1960s, infectious diseases were still the major cause of death4 In 1973-75, respiratory diseases were the leading cause, accounting for 15% of deaths nationwide (118 per 100,000 population), whereas infectious diseases ranked sixth with 8.5% of reported deaths (64 per 100,000 population). In 1981, circulatory system disorders accounted in-Shandong for about one-third of deaths, with an equal share of cerebrovascular and coronary heart disease, and cancer ranks third with about 10% of deaths. Communicable diseases have disappeared from the list of the ten leading causes of mortality, and Table 6 indicates that since 1977 the casel fatality rate in this category never reached 1% of reported cases.
At the same time, morbidity reports demonstrate two clear patterns. One is the persistence of a large amount of mild diseases which can be handled.successfully by non-specialized physicians without any 1,sophisticated material: conjunctivitis and mild eye-nose-ear ailments, 'common infectious diseases, skin diseases, minor*injuries, diarrhoea. -They probably represent a majority of outpatient visits. The other is the emergence of an important number of chronic ailments: stomach ulcers, gastritis, colitis, bronchitis, chronic respiratory diseases, cancer, and cardiovascular disease. They represent a substantial proportion of 1the demand for health care, and a majority of inpatient admissions in local hospitals. oThese types of diseases require adequate diagnosis, long-term treatment and regular surveillance. ATNAME: shan/c/,//ss (R)Pt (P
None of the emerging leading causes of morbidity and mortality are likely to take rapid benefits from any preventive or social program. Risk factors associated with cancer diseases are .largely unknown. Prevention is, therefore, a long-term prospect, even when some risk factors are established such as liver cancer (highly associated with hepatitis B virus and the intake of aflatoxine), and lung cancer (associated with smoking habits, though 50% of lung cancers in China occur in non-smokers). The redetion of cancer mortality will result from screening of population groups at risk early diagnosis, early referral, and early treatment. Cardiovascular diseases are not different. Risk factors are associated with salt consumption, fat in the diet, but also sugar intake, the smoking habit, and stress. Moreover, they usually follow a long period of high blood pressure. rThus, morbidity and mortality reduction require screening procedures in the population, early diagnosis, treatment and follow-up of individuals raith increased blood pressure, and secondary prevention.,,
Lingering Problems
Despite the general improvement of the epidemiological situation, further efforts should lead to better control of lingering problems.
The first one is the need for improved sanitation. There are large .discrepancies between urban and rural areas-for provision of safe water. 85% of the urban population is served by public distribution systems meeting the safety criteria set up by the,epidemic prevention stations. Less than 30% of the rural population is served by devices meeting the same criteria. General sanitation deserves further attention at the village level. Barefoot doctors receive no incentive for sanitation work and manure utilization should be more carefully controlled for hygiene implications. Both measures are essential for further reduction of dermatitis, typhoid, hepatitis A, dysentery and diarrhoeal diseases.
The second one is tuberculosis. Prevalence in Shandong, based on self-reporting patients, is about 490 per 100,000; this is likely to be highly underestimated. The efficacy of BCG immunization has been often questioned. Screening of population groups is seldom carried out. A more coherent and systematic approach is necessary, including measures-such as tuberculin conversion rate surveys under 15 years of age, determination of groups at risk in urban and rural population with establishment of subsequent surveillance, general screening of the population at fixed intervals, introduction and generalization of microscopic examination of sputum at commune levels, establishment of referral procedures for suspect and confirmed patients, and establishment'of a coherent reporting and surveillance system through the epidemic prevention stations.
The Pressures on the Referral System
According to provincial authorities, the proportion of patients referred from commune to county level facilities exceeds 40%, although data provided in Table 19 indicate that the proportion of referrals is about 20%. The increasing number of chronic diseases, debilitations, and severe complications of aging are likely to increase this proportion becaSse health technicians at the commune level lack both skills and equipment to face more difficult problems in diagnoses and therapeutics.. -50'-
Moreover, he rising income in the population increases the demand for better health care. Patients now frequently prefer to lose the benefits of collective insurance systems and to vigit directly the county physicians. Table 19 indicates that in Qufu County An average proportion of 55% of a-ommune health center outpatients are not referred by brigade.health posts. This percentage ranges from 20% in Nanyang commune to 70-80% in Shuyuan and Xiao xue communes.
Both trends result in an increasing pressure on county hospitals and outpatient facilities which have to provide services for a broad range of ailments that could have been handled at lower levels. This new pattern tends to jeopardize the three-tier system. It calls for an urgent rehabilitation of commune health centers, or for the creation of some key-commune reference centers, with better equipment and improved technical skills of the medical personnel so that they can meet and satisfy the demand.
In addition, surveillance of chronic disorders and screening procedures for early diagnosis of cancer and cardio-vascular diseases cannot be successfully handled at the county level where health facilities serve a too important-population. They cannot be handled either at the brigade level where rural doctors will always lack sufficient competence and equipment. It seems that the focal point for action in Shandong Province is now the upgrading of commune health centers and the establishment of the so called major commune health centers" serving three or four communes.
Issues in Training
Issues related to formal training in medical colleges were reviewed above in Chapter 4. In addition, a large amount of in-service training is carried out at all levels, with every institution being responsible for increasing the skills of staff working at lower levels. This program is implemented through formal t ining courses (1 to 6 months), practical training during temporary as(44gfidents in higher level facilities, lectures given at county or provincial levels for rural staff or given in rural areas by visitin',staff, self-study,programs awarded with a degree after compliance withpovincial standards, caesitudy and discussion.
The mission_feels that, although the number of people involved is quite large, the goals, of the in-service training program are vague and insufficiently defined. Basic medical sciences and general scientific knowledge constitute the core of the learning process which is not specifically task-oriented.' Final?y, the motivation is the possibility of individual p;omotion rather-than the improvement of services delivered to the population.
Supervision proceps ii an essential component of Primary Health Car, delivery for imprpving skills f lower-level workers. The procedure exiia in the areas th6tthe missio2 vislt ed in Shandong. County hospital physic ians', officers,f the edunty health bureaus, visit thh commune facilities *at 'regular intervals of time, However, very little is known on the nature of the sw 1.ilata. In the absence of evaluative procedures, quaJ4ty control is not available, but outcome is probably rather l6 Supervisors shoul iecei-qt specific preparation to increase the efficacy of the process. 6 -51-
Medical colleges are isolated from medical staff working in the- provinces. The single existing link is the system of refresher courses offetked to physicians already engagpd"14n medical practice. However, these courses are academic and oriented towards basic sciences. Medical colleges could also play an important role in iiiitiating field studies in which college staff would coll4horate with local physicians in county hospitals and rural areas. These collaorative studies would increase the research capability of the colleges, Vould reduce the academic tendancy of teachers who would have to face realities, would help t1je county'health services to .better meet the needs of the masses,and would increase the skills of health personnel through collaborative studies of prattical problems. The challenge for medical colleges at the provincial level would be their ability to play,a leading role in helping the health services address the major issues of the next decade. Improvement in technology and scientific knowledge would not only lead to higher quality dare in referral institutions, but would also serve as a tool for increasing population-based aptivities.
Issues in Health Management
Chinese authorities are aware of the need for strengthening management procedures in the health sector. WHO already agreed to provide support and to organize several workshops for managers. The main issues in Shandong Province are as follows:
(a) The need for establishing standard procedures for nursing care in inpatient wards, laboratory examination, organization of emergency rooms, includiig a standard list of drugs and material and immediate avaiability of emergency equipment. As a result, many tasks could be assigned to nurses rather than to doctors or assistant doctors. The ratio of 2.4 physicians per nurse should be reduced, allowing higher level staff to devote more time to clinical and medical tasks. It can be considered, for purposes of compariR6n, that assistant doctors are performing tasks usually devoted to nurses in other countries. Therefore, in Shandong Province, the ratio would be 1.6 nurse and assistant doctor per physician. In other countries, the usual ratio is higher, with, for example, 2.8 nurses per physician in Hong Kong, 3.in.Japan, and 4.5 in Indonesia.
(b) The need for a more rational utilization of sophisticated equipment. A collaboration between several hospital departrits could result in a sharing of those expensive devices which cannot be fully utilized by each of them. This would avoid duplication of equipment and result in important savings in the budget.
(c) The need for increasing the quality of basic equipment, such as X-ray machines and sterilization sets. Most of them cannot meet adequate safety standards.
(d) The need for a reduction of drug utilization. There is strong evidence of polypharmacy and overprescription as well as of a high rate of drug misuse in the Province. Even at brigade level, the -52-
team observed very well stocked pharmacies with a large Variety of 'traditional remedies and more than'one hundred types of western drugs, both for oral and injection use, including intravenous preparations. Many of these were potent phychotropic, antibiotic, endocrinological and cardiac drugs, excessive or inappropriate use of which canobe dangerous or cause indesirable side effects. Some of these are undoubtedly necessary for meeting prescriptions issued by commune health centers or county hospital doctors. However, the quantity"and variety of provision raised serious questions of the appropriateness of medical education tn clinical pharmacology and toxicology, and the high cost of such apparently excessive drug provision is also a matter for concern because of its impact on health economics.
(e) The need for other cost containment studies, especially for improving selectivity criteria for interventions, and for reducing the average duration of stay in inpatient wards.
(f) The introduction of professional quality control as both a management and training tool. There are no analyses of the accuracy of &.agnosis and the proportion of them which have been confirmed or revised after hospital stay; no discussion among physicians of the accuracy of chemotherapy in relation to the proposed diagnosis; no research on iatrogenic and nosocomial infections and ailments, their prevention, and their consequences on the duration of hospital stay and health expendi-ture; no information'on surgical-deaths and the proportion attributed to the disease itself or to interventions (infection, anesthesia).
(g) The removal of convalescent or chronic patients from top category hospital wards into less expensive sections of the hospital or into special departments. For example, the lack of any physical medicine services in hospitals results in a congestion of internal medicine departments with patients suffering from paralysis, senile disorders, or other ailments requiring rehabilitation and nursing care rather than curative services.
The Equity Issue and the One-Third Counties Program
Shandong Province is a densely populated region where no area is really underserved. 90% of the 86,143 production brigades have a health post. The remaining 10% consists of small,brigades benefiting.from health services delivered in a nearby and more important brigade.
However, income is not evenly distributed in rural counties. Lower income areas have achieved less significAnt progress in health. Facilities are often older, or smaller in these communes. Many of them need repairing and upgrading. The quality of health care provided in poorer counties does not meet the demand of the population, and utilization of health services is usually lower. According to the principle of self-reliance, progress is slow because communities should be able to support part of the investments and to afford a substantial proportion of the operating cost. zst LiAL Ij I b CJ) v
-53 -
The provincial health-bureau has identified 35 counties and 2 urban districti to participate in the national program for the improvement of one-third of the counties (Table 33),. They are distributed in all the nine prefectures and four municipalities. 14 of them have been included in the first series to be upgraded by the end of 1983. 21 of them should be upgradedduring the period 1984-1990. It seems that provincial authorities *paid greater attention to keeping a balance between the nine prefectures than to meeting health-related criteria for selecting underserved counties.
There is no evidence in Shandong of major discrepancies between urban and rural areas. The number of health facilities of quality is greater in urban areas, but it is claimed that they deliver an important proportion of services to rural people self-referred or referred by commune centers.
Per capita expenditures of the different insurance schemes provide an indication of relative inequity (Table 29). The- government insurance spent in 1981 an average of Y 40 per member enrolled (Table 24). The Yexian commune industry insurance system spent only Y 12 per member. And the Qufu county brigade cooperative insurances spent only Y 1.9 per member (Table 29). These figures are not directly comparable: reimbursements vary from 100% for government employees to 80% or 50% for communes and brigades; government officials usually benefit from different "standards" and they are older on the average; some insurance schemes include dependents which ar not accounted for in this computation. However, these figures indicate that some selected groups more frequently utilize health care services and higher quality services. Table 4 also suggests that utilization of health services increases with per capita income. The average annual number of outpatient visits is 4 to 5 per person in Qufu county brigades that the mission visited. The average is 7 to 14 visits per person in the significantly richer Yexian. TNAME: shan/d/8/ss (R)P. 01'
- 54-
CHAPTER VIII. GOVERNMENT POLICIES AND PLANNING
Priorities and Planning at the Provincial Level
Health officials, both in the health bureau and in medical college, are perfectly aware of the new constraints and of the issues they will confront during the next decade. They know that an aging population and successful control of communicable diseases will result in an increasing number of chronic diseases. Higher income in rural areas will increase the demand for better health care and increase the pressure on the referral system. Addressing these issues will require the improvement of curative services, especially at the commune level, the upgrading of most rural facilities and the upgrading 6f technical-skills of the health personnel. Health sector management needs improvement, with new priorities in public health, epidemiological surveillance and reporting system, and increasing needs of technology and specialized care.
Shandong province"officials have set up a policy framework based on the national policy of China. It is not yet solidified and worked out in detail, nor has it yet been approved by the Ministry of Public Health. Also, the implementation of the proposals may be delayed after 1985, present target date of the plan. The main proposals are as follows:
1. To reduce the incidence of communicable diseases by 50%: Some of them will be eliminated wherever it is feasible. 100% of the target population will be immunized against eight diseases: poliomyelitis, diphtheria, tetanus, pertussis, tuberculosis, measles, encephalitis B, and influenza./l In addition, typhoid and meningitis vaccines will be delivered to selected groups.
2. To provide safe drinking water to 60% of the population: This requires transformation of old piped wells, quality control of pump-wells and establishment of running tap water systems.
3. To strengthen the technical standards of the primary health care delivery system: The final objective is that all minor health problems should be taken care of within the commune, either-at brigade or commune level. Commune hospitals should refer less than 30% of their patients to county level facilities.
4. To increase the skills and training of health personnel: Most barefoot doctors should be retrained and upgraded to rural doctors. Middle-level staff will also be upgraded after training. The target is to retrain 50% of county health workers. The goal is to strengthen middle-level and high-level categories of personnel.
5. To increase by 35,000 the number of health workers in the province: The present ratio of 2.3 barefoot and rural doctors per 1,000 population should increase to 3 per 1,000. Additional staff is required in high-level and technical positions.
/1. The first six diseases on this list are those included in the World Health Organization's Expanded Program of Immunization (EPI). -55-
6. To upgrade'and develop urban health services: 300 new health units, consisting mainly of outpatient clinics, will be established in neighborhoods, factories and enterprises.
7. To increase by 12,000 the number of hospital beds: Most of them will not be allocated to general hospitals, but to specialized services. The plan emphasizes-the needs of pediatrics, obstetrics, occupational diseases, psychiatry, and traditional Chinese medicine.
8. To implement the national program of improving facilities and health care delivery in one-third of the counties: Shandong province has selected 37 counties to participate in this program (Table 33). The first group of 14 counties scheduled for 1979-82 will implement the program by 1983. A second group of 8 counties will participate in 1984-85, and a third group of 15 counties in 1985-90.
9. To strengthen MCH services, with provision of additional equipment and retraining of staff: The one-child policy results in giving high priority to protection of pregnant women, early referral of high risk patients, and to prevention of birth defects through prenatal diagnosis and early abortion.
10. To upgrade the collective health insurance system in rural areas: Increasing coverage of risks may result from increasing individual and collective contributions according to brigade farming style and responsibility system. The health bureau may assist this development with provision of training and salary subsidies.
Other programs will also be initiated during the same period, in relation to chronic diseases, early diagnosis and treatment of cancer, research on environmental risk factors, anti-smoking campaign.
Provincial authorities have already set up tentative targets for the next period, likely 1986-1990, but did not work out a detailed ranking of priorities. Possible targets are additional numbiers of 20,000 beds,.40,000 health workers, and 1,200 health units (outpatient clinics.)
Costs and Feasibility of Implementation
An aggregate estimate of the incremental investment and operating costs of the 1983-85 and 1986-90 plans described above does not appear to have been prepared by the Provincial Health Bureau.
An indirect estimate of the probable range-of these costs can, however, be made on the basis -of two of the plan's components: the one-third counties project and the proposed expansion of hospital bed capacity.
The average investment cost per county under the one-third counties project in Shandong province is estimated by the Health Bureau at approximately Y 1.6 million, of which Y 1 million is for capital construction - 56 -
and Y 0.6 million for new equipment. However, experience so far indicated that actual costs are about 30% higher than this estimate, i.e., about Y 2.1 million. This is close to the county average of Y 2 million giv&n as a tentative estimate for the whole country by the Ministry of Public Health. Thus a figure of Y 2 million will be used here as an indicative planning figure. According to the implementation plan outlined previously this yields the following phasing of expenditure requirements:
Period Number of Counties Total Expenditure Annual
1979-83 14 counties Y 28 million Y 5.6 million 1984-85, 8 counties Y 16 million Y 8.0 million 1985-90 15 counties Y 30 million Y 6.0 million
The expected investment cost (capital construction plus equipment) of proposed hospital bed capacity expansion can be estimated.on the basis of the standard cost per bed of Y 10,000 used in Shandong Province. This yields the following investment expenditure requirements:
Period Number of Beds . Total Expenditure Annual
1983-85 12,000 beds Y 120 million Y 40 million 1985-90 20,000 beds- Y 200 million . Y 40 million
Since the one-third counties project includes hospital bed expansion, its costs would presumably be a subset of.the total for new hospital beds. Thus, the latter estimate of Y 40 million per year can be taken as the minimum requirement.
The central government offers no direct subsidy of capital construction or equipment costs. Thus, resources to finance the proposed investment plan have to be mobilized within the province "'- at provincial, prefectural and county levels. In principle, these expenditures.should be shared between these different levels of government. The provincial government itself has allocated, and will continue to allocate, Y 5 million per year to assist with financing implementaton of the one-third counties project, of which Y 2 million for capital construction and Y 3 million for equipment. This amounts to an average of Y 0.14 million for each of the 37 counties, i.e., only about 7% of the average Y 2 million required per county.
It is difficult to assess accurately the feasibiilty of the proposed investment plan for two reasons. -First, because data on.projected growth of the consolidated provincial health budget are not available. Second, because a complete estimate of the cost of.the investment plan is not available.
Consolidated provincial etpenditures on capital construction plus equipment were Y 46.3 million in 1980 (of which Y 25.5 million for capital construction) and Y 50.2 million in 1981 (of which Y 25.9 million for capital -57-
construction). The minimum estimated annual expenditure requirement for capital construction an4 equipment under the proposed plan, Y 40 million, is broadly similar to these totals. Thus, if these allocations are sustained or increased in the future, and if total investment requirements are not much greater than Y 40 million, implementation of the plan should be more or less feasible.
However, it should be noted that there are some indications ,f infeasibility. The Provincial Health Bureau stated that they expected financial constraints to make it difficult to achieve the targets.. In addition, Yexian authorities reported financial difficulties with implementation of the project in the county. -58-
REFERENCES
The majority of information on which this report has been based was provided by staff members of the Ministry of Public Health of the People's Republic of China during the World Bank's Rural Health and Medical Education mission, September 23 to October 23, 1982, and especially during the field visit to Shandong Province, October 1 to 15, 1982.
Other information in the text is from the following documents:
The Administrative Divisions of the People's Republic of China. Cartographic - Publishing House, Beijing, 1980 (Shandong Province: pp. 54-58)
People's Republic of China, Administrative Atlas, U.S.. Government Printing Office, 1976 (Shandong: p. 41)
Atlas of Cancer Mortality in the People's Republic of China,.China Map Press, 1979
,A General Introduction of the Shandong Medical College, Jinan, China, March 1982 (unpublished)
An Introduction of the Pubtc Health Work in Yexian County. Printed docu- ment, Yexian Health Budeau, June 1982, 5 pp.
National Tuberculosis Epidemiology Survey Leading Group: A Summarized Report on the 1979 National Tuberculosis Epidemiology Sample Survey. Chinese Journal of Tuberculosis and Respiratory System Diseases, 1982, Vol.5, No.2 (in Chinese).
Primary Health Care - The Chinese Experience. Report of an Inter-regional Seminar, Yexian County, Shandong Province. WHO publication, Geneva, 1983, 105 pp.
Research Group for the Study of the Physique of Chinese Children--and-Youth: Research on physical shapes, functions and qualities of Chinese youth, Report on Science and Technique, Beijing 1982, 733 pp. (in Chinese)
Shandong Institute of Parasitic Diseases: Brief Notes on Bionomics and the Control of Anopheles sinensis in the Southern part of Shandong Province. Presentation to a WHO visiting group, Jining, October 29, 1979 (unpublished)
Shandong Institute of Parasitic Diseases, Deparment of Filariasis: Field Surveillance in Areas Where Filariasis Has Nearly Been Eradicated, Chinese Journal of Preventive Medicine, 1981, 15, 236 (in Chinese)
Chen-long, A Survey of the Medical Cost and Source of Income of Rural Medical and Health 'Care in Jia-ding County, Shanghai, and Yexian County, Shandong Province. Paper presented to the WHO/UNICEF Workshop on Project Cost and Financing Patterns of Primary Health Care at the Community Level, Geneva, December 1-5, 1980 - 59 -
Chen Zheng-ren, Wei Xi-hua and Zhu Zong-yao, BCG in China. Chinese Medical Journal, 1982, 95, 437-442
Clarke, C., China's Provinces, An Organizational and Statistical Guide. National Council for U.S. - China Trade, publ. 1982 (Shandong Province, pp. 315-332)
Cort, W.W., Grant J.B., and"Stoll, N.R., Distribution of Hookworm Infestation and Disease in China as Shown by the Literature and Answers to Questionnaires. In: Researches on Hookworn in China, The American Journal of Hygiene, 1926, Monographic series No.7, 56-113
Cort, W.W. and Stoll, N.R., Studies on Ascaris lumb,ricoides and Trichuris trichiura in China. The American Journal of HygIene, 1931, 14, 655-689
Geng Guanyi, Epidemiology of Hypertension. In: Progress of Epidemiology (Liuxinghingxue Jinzhan), Chapter 10, People's Health Press, Beijing, 1981 (In Chinese)
Grant, J.B, Cort, W.W. and Kwei, W.S., Signifiance of Hookworm Infestation in North China. In: Researches on Hookworm in China, The American Journal of Hygiene, 1926, Monographic series No.7, 115-124
Huang Senqi, The Present Status of Malaria Control in the People's Republic of China. Hubei Provincial Academy of Medical Sciences, Institute of Parasitic Diseases (unpublished report, 1980)
Kuo, C.W., Health Condition of Town District School Children in Tsingtao. National Medical Journal of China, 1947 (?), Vol. 35, 2, 83-87 (in Chinese)
Ma Gui-hou, Control of Filariasis in.Zhongxin People's Commune, Zhouxian County. Presentation to a WHO visiting group, Jining, October 30, 1979 (unpublished)
Marchisio, H., La vie dans les compagnes chinoises. Ed. du Centurion, Paris, 1982
Nugroho, G., Report on the Workshop on Primary Health Care, Yexian, ShandoNg Province, People's Republic of China, August 22 - September 5, 1980. WHO report (unpublished), WPRO Manila, No. WP/PRC/CHN/PTR/ 3.E, 1980
Piazza, A., Trends in Food and Nutrient Availability in China, 1950-1981. Bank Staff Working Paper No. 607, 1983, 125 pp.
Saint, E., Baddeley, H., Clunie, G., Kamien M., and Maxwell G., Report on a Feasibility Study Conducted at Shandong Medical College, Jinan, Shandong Province, People's Repubic-of China. Report to the Australian Government (unpublished), August 29, 1981 - 60 -
Scott, J.C., Health and Agriculture in China. Faber and Faber Ltd., publ. London, 1952, 279 pp.
Tao Zhenni, China's Primary Health Care, Inter-regional Seminar in Yexian. Beijing Review, 1982, 29, 18-19 and 28.
Wang Zhao-jun, Control of Insect-borne Parasitic Diseases in Shandong Province. Presentation to a WHO visiting group, Jining, October 29, 1979 (unpublished)
Wang Zhong-san, Yin Shun, and Shi Fa-mao. Filariasis Survey by Membrane Filtration Techniqie after Mass DEC Administration. Chinese Medical Journal, 1982, 95, 653-654
Winfield, G.F., On the Use of Ascaris lumbricoides as a Public Health Standard in the Study of Problems of Rural Sanitation. Transactions of the Ninth Congress of Far East Association of Tropical Medicine, Nanking, 1934, 2, 791-797.
Winfield, G.F., Studies on the Control of Fecal-borne Diseases in North China. II: The Distribution of Ascaris Lumbricoides Infestations in a Rural Population. Chinese Medical Journal, 1937a, 51, 502-518.
Winfield, G.F., Studies on the Control of Fecal-borne Diseases in North China. III: Family Environmental Factors Affecting the Spread of Ascaris Lumbricoides in a Rural Population. Chinese Medical Journal, 1937b, 51, 643-658
Winfield, G.F., and Chin Ta-hsiung, Studies on the Control of Fecal-borne Diseases in North China. VI: The Epidemiology of Ascaris Lumbricoides in an Urban Population. Chinese Medical Journal, 1938, 54, 233-254
Winfield, G.F., and Chin Ta-hsiung, Studies on the Control of Fecal-borne Diseases in North China. VII: The Epidemiology of the Parasitic Amoebae, Chinese Medical Journal, 1939, 56, 265-286
Wu Ying-Kai, Lu Chang-qing, Gao Run-Chuan, Yu Jiu-sheng and Liu Guo-chalg, Nationwide Hypertension Screening in China during 1979-198G, ,ChiAese Medical Journal, 1982, 95, 101-108
Ximen Lusha, Medical Care in a Shandong Village, China Reconstructs, 1981, 8, 26 - 27 (re Yexian)
Yang, M.C., A Chinese Village. Columbia University Press, New York, 1945
Zhong,-H.L., et al, Present Situation of Filariasis in China. Chinese Medical Journal, 1981, 94, 567
Zhou Zu-jie, The Malaria Situation in the People's Republic of China. Bulletin of the World Health Organization, 1981, 59, 931-936 -61-
Table 1
SHANDONG PROVINCE
HEALTH MANPOWER AND FACILITIES IN SHANDONG AS COMPARED t NATIONAL FI9URES IN CHINA 1981
% OF NATIONAL CHINA SHANDONG TOTAL Total Population 996,220,000 73,940,000 7.4 Number of Hospitalå 65,911 2,560 3.9 Number of Epidemic Prevention Stations 3,202 151 4.7 Number of MCH Stations 2.630 142 5.4 Number of Beds 2,017,088 117,970 5.8 Beds Per 1,000 Population 2.2 1.6
Population/Bed 494 627 Total Health Manpower 3,796,121 178,495 4.7 Number Senior Doctors 807,597 35,847 4.4
Population Per Doctor 1,233 2,063 Number Barefoot Doctors 1,396,452 144,788 11.1 Population Per Barefoot Doctor 714 478
Source: Ministry of Health, Beijing, and Provincial Health Bureau, Jinan. SHANDONG PROVINCE
HEALTH PERSONNEL AND FACILITIES IN 1981 DISTRIBUTION BY PREFECTURES AND MUNICIPALITIES
Ratio Number Number Number Administrative Ratio pSenior Senior Population of Population Health Assistant Other of Population Western Traditional Units Brigades 1981". Per Senior Doctors Health Units Beds Per Bed Doctors Doctors Doctor W & T Personnel
Total 86,143 73,948,324 76,324 117,970 627 31,717 4,130 2,063 32,635 110,013
Municipalities:
Jinan 2,265 3,295,517 2,208 9,850 334 5,167 Qingdao, 3,439 886 544 3,145 11,221 4,182,143 3,309 9,194 455 3,022 Zibo 1,601 265 1,272 3,311 11,620 2,192,417 1,529 7,204 304 1,879 Zaozhuang 2,932 228 1,041 2,170 5,914 2,684,093 2,420 5,318 505 1,185 99 2,090 1,322 4,645
Prefectures
Yentai 10,178 8,595,994 9,916 13,528 635 .'Weiffang 11,199 3,579 378 2,172 3,334 8,877,208 10,800 12,936 686 2,685 10,288 Huimin 7,806 282 2,992 3,191 10,010 5,291,950 6,008 9,806 540' Dezhou 9,510 5,478,502 2,208 213 2,186 2,249 7,026 7,674 714 1,558 7,353 Liaocheng 6,062 247 3,035 2,482 7,012 4,405,888 5,427 6,798 648 1,335 Talan 4,766 260 2,762 1,921 5,926 5,787,570 4,47A 8,099 - 715 Jining 2,502 376 2,011 2,521 5,699 5,543,177 4,999 8,308 667 8,910 Linyi 1 2,374 183 2,168 1,949 i 10,363,012 10,902 12,020 862 8,180, .'llee 8,2 7,250,853 2,517 270 3,718 2,709 7,302 7,235 1,002 1,706 10,366 443 3,374 2,331 8,568
Source: Provincial Health Bureau, Jinan. SHANDONG PROVINCE
UTILIZAT" OF SELECTED HOSPITAL FACILITIES
SHANDONG PROVINCE (Sample) /a QUFU COUNTY /d YEXIAN / Specializ!d County Commune County Commune Commune General Hospitals Hospitals Hospital Commune Wangzhuang Xiao Xua Hospital Touzhao Chenggan 1975 1981 1975 1981 1981 1979 1980 1981 1981 1981 1981 1981
Population SerVed - - - - 517,035 - - 44.990 40,047 833,863 32,722 32,071 Medical Staff - - - - 271 - - 17 24 - 21 18 Number of Out- Patient Visits - - - 168,862 26,675 28,664 26,679 37,949 200,885 83,253 175,614 Number of Beds 17,350 29,940 13,420 9,200 186 20 20 20 30 186 64 30 Number of Inpatlenta 540,115 958,753 62,028 49,524 5,826/b 836 1,245 965 1,324 4,904 1,598 479 Number of Patient-days - - - - 58,850 3,310 3,830 3,860 9,560 38,250 13,000 8,064 Average Duration of Stay (Days) 9.9 10.2 58.6 62.4 10.1 3.7 3.1 4.0 7.2 7.8 8.1 16.8 Occupancy Rate /c 84% 89% 74% 92% 87% 43% 52% 52% 87% 63% 62% 70%
Number of Deilver a - - - - 2,199 - - - - 480 317 577
a. Sample size: 153 hospitals in 1975; 233 in 1981. Source; Provincial Health Bireau, Jinan.4! lb Includes 2,199 deliveries. Other hospitals do not include deliveriei among inpatient.
/c Occupancy rates are calculated from inpatients only, eicluding deliveries and obstetric beds. /d Source: Data collected Our-ng the mission from county and commune health services.
00 64 -
SHANDONG PROV VCE 4> Pe
OU PUJT8 OF HEALTH SERVICE 5 >
Avera e/ Per Capita Income
S(Distributed \~ ,Total and Number Private) >Outpatients Visits Per (Yuans) Pop 1.ation Visits Ratio Inhabitant
Qu-Fu County,.>
County Hospital 517,000 168,862 0.33
Xiao-Xue Commune 178 40,047 37,949 0.95
Shu-Yuan Commune 241 38,587 25,843 0.67 Sglins' Brigade 268 1,960 7,050 3.60 4.6 Donglinxin 3ri. de 286 1,749 7,500 4.29 5.3
Wang-Zhuang Commu 96 44,99& 26,679 0.59 Yuan Brigade 2,074,246 9,200 4.44 5.4
Ye-Xian
County Hospital 833,863 200,885 0.24
Chengguan Commune 512 "32,097 175,614 5.48 Tongpiyu Brigade A78 '1,162 9,500 8.18 13 9
Zhuyo Commune 502 29,343 61,565 2.10 Zheng-Jia Brigade 516 1,127 8,181 7.26 9.6
Tou Zhao Commune 263 32,722, 83,253 2.54 Shi-Zuang Brigade 308 1,392 6,573 4.72 7.5
Xu-Jia Commune Xiao-Han- Brigade 568 41 11,644 7.10
1/ Assuming that the populatfi, in every brigade share an equal proportion' of visits delivered from commuhe and county hospitals on which they- depend.
Source: Data collected during £Teld visits from local health staff
SY,i 3. SHANDONG PROVINCE
WATER SUPPLY
% Meeting- Benefits to Urban Pop.a/ Benefits to Rural POp.a Number Safety Total Number Type Total Number Benefits to Total of Units Criteria in Millions Percént in Millions Percet Population % Rvnning Tap Water 96 b/ 100% 5.95 84.7 0 0 8.1 Simple Running Waterc/. 7,533 7% 0 0 6.36 9.6 8.6 Hand- Pumped Wells 3.1 million 50%' ? 17.30 25.8 23.3 6 Tinproved Old Piped Welis 300,000 30% - 30.11 45.0 40.6 Odd Sourcesd 11.00 16.4 14.8 Other ? 1.07 15.3 2.15 3.2 4.6
hese -/population numbers are based on the following .estimte: 1,024,300 (9.5%) of 66,915,700 in rural areas. the populatio b/ "Units" usig running tap -waterinclude'towns,-cities, factories or even Indigenous water systems Lidaller,institutions. including drinking and irrigation double usage systems. d/ "Odd sources" include old wells, reserved water, salted water. Source: Provincigl Epidemic Prevention .Station, Jinan. ID j
01 - 66 Table 6
SHANDONG VRØVINCE
COMMUNICABLE DISEASES: CASES REPORTED, MORTALITY, INCIDENCE PER 100,000 POPULATION
1977 1979 1981 No. Cases Incidence No. Cases Incidence No. Cases Incidence
ýMeningitis 5,843 8.2 6,591 9.1 4,574 6.2 Deaths 216 211 - 12
Pertussis 48,272 68.0 22,477 31 l 18,862 25.5 Deaths 23 3 4
Scarlet Fever 2,537 3.6 5,813 8.0 3,114 4.2 Deaths 4 5 2
Measles 81,214 114.5 52,060 72.0 32,514 44.0 Deaths 289 81 46
Influen:a 276,087 389.0 152,066 210.3 97,516 131.9 Deaths 0 0 1
Dysentery 244,377 344.3 216,912 300.0 219,682 297.1 Deaths 220 36 48 Typhoid/ Paratyphoid 6,498 9.2 3,277 4.5 5,345 7.2 Deaths 5 3 2
Hepatitis 28,066 39.5 37,512 51,9 34,650 46.9 Deaths 95 29 41
-Poliomyelitis 305 0.4 282 0.4 ~321 0.4 Deaths 2 5 13
Encephalitis B 1,451 2.0 1,334 1.8 1,078 1.5 Deaths 124 80 75
Hemmoragic Fever 235 0.3 266 0.4 1,793 2.4 Deaths 21 32 135
Målaria 78,114 110.1 74,107 102.5 69,846 94.5 Deaths 0 0 0
Reference Population: 70,975,00 72,300,000 73,940,000
Source: Provincial Epidemic Prevention Station and Provincial Health Bureau, Jinan. -67-
Table 7
SHANDONG PROVINCE
ACHIEVEMENTS IN CONTROL OF COMKUNICABLE DISEASES IN YEXIAN
Morbidity per 100,000 Population Disease Maximum 1980 1981 Recorded
Diphteria 169.0 (1960) - No Case Since 1974-
Polioniyelitis 7.8 (1966) - No Case Since 1976-
Measles 1,221.4 (£950) 1.7 23.4 519.8 (1964)
Pertussis 270.6 (1959) 3.5 1.8
Meningitis 987.0 (1967) 16.4 17.4
Typhoid 45.9 (1959) 2.3 10.3
Encephalitis B 85.2 (1966) 0.8 0.2
Malaria 399.0 (1970) 5.2 1.7
Kala-Azar 350.0 (1950) -No case since l963-
Source: Yexian, County Health Bureau. - 68 -
Table 8
PREVALENCEe AND INTENSITY OF ASCARIASIS IN SELECTED AREAS F SANDONG PROVINCE
Mean Number of Number Prevalence Eggs per Gram, Area ,Date Age of People of in Feces of Groups Examined Ascariasis Positive Cases
YANTAI Prefecture 1923-24 Total 890 81.4
3 villages less than 0 - 9 146 93.0 29,306 20 miles from the city 10 - 19 256 95.0 23,300 (Source: Cort et al.)
JINAN Municipality 1937 Total 1,190 81.0 16,900
13'villages around 0 - 9 366 78.0 25,500 Lungshan 10 - 19 288 94.0 16,900 23 miles east of Jinan (Source: Winfield)
JINAN city 1938 Total 2,751 35.4 10,600
(Source: Winfield & Ta) 0 - 9 721 42.0 12,300 10 - 19 1,177 38.3 9,800 JINAN Municipality 1973-74
School sample in 0 - 9 140 91.4 37,300 Zhangqiu county 10 - 19 137 89.1 9,500 (Unpublished)
-Note: Detailed figures do not show any significant difference between males and females. IMMUNIZATION SCHEDULE IN RURAL AREAS OF CHINA
Diphtheria Age Poliomyelitis Pertusis (Years) (per. os.) Measles Encephalitis B Tetanus (DPT) Diphtheria BCG
6 months Initial initial
7-12 months Initial Whole Course
1 Initial
2 Repeat Repeat Repeat Reinforce
3 0% Repeat Repeat
4 Repeat
5 Reinforce
7 Repeat Repeat Repeat Repeat 10 Repeat Repeat 11 Reinforce
12 (Repeat
14 Repeat
Source: Ministry of Health, Beijing. -70- Table 10
RELATIVE FREQUENCY OF CANCER BY SITE COMPARISON OF SHANDONG WITH CHINA (Pee2lOO Cancer Deaths)
SHANDONG CHINA Males Females Males Females
Cervix Uteri - 26.8 - 18.4 Stomach 27.7 17.9 Esophagus 26.1 18.7 25.8 14.9 24.6 Liver 18.2 16.7 8.6 18.1 Lungs 10.3 10.8 7.8 8.5 5.9 Colon and Rectum 4.4 4.3 5.1 5.6 Leukemia 3.4 3.6 3.5 4.1 Breast - 5.4 - Nasopharynx 4.8 1.6 1.5 3.1 Other 2.3 9.6 9.2 11.0 11.7
100.0 100.0 100.0 100.0
Source: Atlas of Cancer Mortality, 1979
Table 11
AGE-ADJUSTED CANCER MORTALITY RATES PER 100,000 POPULATION COMPARISON OF SHANDONG WITH CHINA (Based on 1964 Census)
SHANTDONG CHINA Males Females Males Females
Cervix Uteri - 13.2 - Stomach 10.0 19.1 8.8 20.9 Esophagus 10.2 17.8 7.4 19.7 Liver 9.9 11.6 4.2 14.5 Lungs 5.6 7.4 3.8 6.8 3.2 Breast - 2.7 - Colon and 2.6 Rectum 3.1 2.1 4.1 Leukemia 3.0 2.3 1.8, 2.8 Nasopharynx 2.2 1.1 0.7 2.5 Brain 1.3 1.1. 0.9 1.4 1.1 Lymphoma 0.9 0.6 1.4 Other 1.0 4.7 3.0 6.1 4.2 All Cancer: 69.1 49.2 80.2 54.3
Source: Atlas of Cancer Mortality, 1979. 71 -
Table 12
SHANDONG PROVINCE
ANTHROPOMETRIC SURVEY IN QINGDAO MUNICIPALITY PRIMARY SCHOOLS, 1946
Age Groups Number in Sample Height (cm) Weight (kg) Males Females Males Females Males Females
7 - 8 950 613 119 121 22.0 21.5 8 - 9 1054 798 122 123 23.7 23.2
9 - 10 1049 810 130 129 27.7 29.5 10 - 11 1387 913 130 136 28.5 30.2 11 - 12 2098 1045 137' 140 29.9 32.1
12 - 13 1573 965 140 139 32.3 32.0
13 - 14 1456 891 149 142 37.0 37.1
14 - 15 829 964 .147 149 47.8 35.2 15 - 16 346 456 150 148 43.3 42.2
10,742 7,455
Source: C.W. Kuo, "Health Condition of Town District School Children in Tsingtao". SHANDONG PROVINCE
ANTHROPOMETRIC STATUS OF RURAL AND URBAN CHILDREN AND YOUTH, 1979
AGE MALES FEMALES RANGE (Years) Height (cm) Weight (kg) Height (cm) Weight (kg) Urban. Rural Urban Rural Urban Rural Urban Rural
7 - 8 121.8 +.35 117.8 + .36 21.7 + .17 20.5 + .15 120.5 + .36 115.9 + .34 20.7 + .16 19.5 +..15
8 - 9 127.0 + .35 121.8 + .34 24.2 + .1.9 21.9 + .16 125.4 + .37 119.2 + .38 22.7 + .20 20.7 + .16
9 - 10 131.3 + .39 125.2 + .36 26.2 + .22 23.6 + .17 130.6 + .38 123.7 + .36 25.2 + .20 22.8 + .17 10 - 11 136.0 +4.34 129.7 + .39 28.8 + .25 25.8 + .22 136.5 + .44 128.8 + .41 28.5 + .28 25.0 + .22 11 - 12 141.0 + .41 133.1 + .45 31.6 + .30 27.4 + .25 142.8 + .46 133.3 + .45 32.1 + .32 27.5 + .29 12 - 13 146.0 + .46 138.2 + .42 34.9 + .33 30.8 + .26 147.7 + .44 139.1 + .50 36.1 + .41 31.5 + .35 13 - 14 151.8 .54 143.4 + + .48 39.1 + .46 33.9 + .36 151.9 + .42 144.6 + .49 40.4 + .41 35.6 + .39
14 - 15 157.2 + .53 149.2 + .56 43.5 + .49 38.1 + .43 155,.3 + .36 149.0 + .42 44.2 + .39 39.6 + .39 15 - 16 163.4 + .50 155.6 + .62 49.0 + .48 43.1 + .49 156.6 + .37 153.2 + .40 47.5 + .44 44.6 + .39 16 - 17 167.5 + .43 160.5 + .45 53.9 + .47 47.8 + .43 158.3 + .33 155.0 + .34 48.5 + .38 47.0 + .36
17 - 18 169.3 + .39 164.0 + .47 55.5 + .41 51.6 + .44 158.8 + .39 156.4 + .31 50.3 + .38 49.0 + .34 18 - 25 171.7 + .43 N.A. 60.9 + .46 N.A. -160.2 + .38 N.A. 50.3 + .41 N.A. (D
Source: Data provided by Sandong Provincial Epidemic Prevention Station. Note: Entries In table are mean values + the standard error. Investigated: April - June, 1979 PHYSICAL GROWTH Table 14 NCHS PERCENTILES 23-
7 -4 5 7- ,8 9.-.-10 11 .12 13 -14 15- 16 -- 7 - 77-T - PI . 8- 77 76 76. s)
73 ANTHROP0METRIC STATUS OF 73 -- 185 7 7272 __ 72 71 -FEMALE CHILDREN AND YOUTH, SHANDONG PROVINCE, 1979 - /O1
69-175- - -T-5---70
68-6- ~ý {A68 67-170 17~6
66- ~~ r¯¯¯+ - - _-- -- 4 - 65 16516.5 64-~y † -- - -_64 61 -_,_-4__1_ 4,__ *160. -63 2- 61-155i- 6C - -c in 59-150
100 57-5 95-2
56 -RBAN 55-140 .200 54- 53-.135 ~--9 - y- -80- 18 5 170 49-1 -75-
48 - -r -160 47- .0 72!- 40 15 45115-
440
130
41- -- 120 40- - 39.10-- 50 110 38a- 95- -5100
36--
34-4-8 33-
31-- - - ~~-¯ ¯¯ . 0
30------6 - 29 - - - 5 in cm -
-- 40
30---- - lb EÄ -T-T 30 - 74 -
Table 15
SHANDONG PROVINCE
FOOD PRICES AND RATIONS IN YEXIAN CITY, OCTOBER 1982
Selling Price (Fen per Jin) Buying Price
Ration Shop:
Rice 11.5 None Glutinous Rice 16.8 19 Wheat (4 Types) 15.5 -,25.0 None Peanut Oil 79.5 115 Sesame Oil 94.5 128 Peanuts 48 48. Sesame Seeds 58 58 Soy Bean 14.2 34.5 Beans (Many Types) 15.5 - 30 20.5 - 35 State Store:
Green Beans 14 N.A Fresh-Cabbage 2.8 .Egg Plant 3 Taro Root 16 Hot Pepper 9 Seaweed 51 Bean Noodles 72 Soy Sauce 12 Vinegar 8 Salt (bulk) 12.5 Salt (packaged) 37 Sugar 88 Beer 71 - 110 Fen Per 1.28 Jin Bottle Cigarettes 16 - 88 Pen Per Pack of 20
Source: Data collected from stores in Yexian by mission members. NOTES:
1. In the Ration shop visited, individuals seemed to be acquiring rations for the entire month. So far as could be ascertained, the following were the only rationed items, (i) cooking oil, 1 jin per person per month; (ii) peanu^ i- per person per month; (iii) grain (mostly wheat) for laborers 56 jin per month, for officials 30 jin per month, for university student 35 jin/month, for senior middle school students,32 jin/month and for lower middle school student 30 jin/month. 2. The ration shop was buying some items at prices indicated; clearly since some buying prices were higher t1han selling prices, subsidy was involved. 3. 1 jin 500 grams. -75- Table 16
SHANDONG PROVINCE
BIRTH CONTROL SITUATION OF TWELVE COMMUNES IN QUFU COUNTY, 1981
UDmen of Number, of Number of Communes Child-bearing Birth Control Single-Child Number of Age Users Certificates Births Awarded
Shuyuan 5,471 4,303 1,158 750 Wang-zhuang 6,013 5,077 1,296 883 Dong-zhuang 5,770 4,970 950 682 Wucun 4,404 3,767 782 555 Yaocun 5,031 4,092 1,414 469 Shi-zhuang 6,497 5,332 1,714 859 Lingsheng 6,044 4,835 1,536 872 Xiao Xue 4,619 .4,112 1,015 741 Xizou 5,368 4,397 858 796 Nanyang 4,128 2,970 211 718 Nislian 1,735 1,438 282 243 Fongshan 5,064 4,136 964 744
TOTAL: 60,144 49,429 (82.2%) 12,180 (20.2%) 8,312
Source: County Bureau of Health, Qufu 0
C)
SHANDONG PROVINCE
AGRICULTURAL PRODUCTION SITUATION IN QUFU COUNTY, 1981
Surface Agriculture Income Labor Force Number Communes. Number Number of Arable (in 10,000 in of Yuans) of Production Land Total Of Which Population Agriculture Households Brigades Teams (mu) Side-Activities Income
Shuyuan 39,476 17,501 8,403 40 140 39,903 1,216.4 327.4 Ing-zhuang 44,990 21,327 10,096 40 228 72,422 1,266.8 440.1 Dong-zAuang 44,501 18,414 9,623 44 224 66,326 903.1 261,3 Wueun 37,168 18,090 8,562 37 167 66,228 718.0 145.4 Yaocun 42,288 19,939 9,440 52 194 72,423 1,145.5 365.3 Shi-zhuang 48,960 22,400 11,026 51 189 64,152 1,414.0 229.1 Lingsheng 50,390 21,698 11,421 51 242 82,741 1,471.1 146.4 Xiao xue 40,047 20,280 9,185 36 217 61,723 1,161.9 207.4 Xizou 43,662 20,347 9,704 33 184' 56,883 1,007.8 159.4 Nanyang 34,713 16,036 7,791 22 133 54,760 744.6 45.1 Nialian 13,238 . 4,390 3,035 19 63 11,116 106.2 4.4 Fongshan 39,302 17,345 8,474 -34 184 55,301 900.2 188.9
TOTAL: 478,735 211,767 106,760 459 2,165 703,978 12,055.1 2,520.2
Source: Qufu County Statistical Bureau
Note: Income figures represent collective brigade income only. All data presented in this Table exclude the city of Qufu.
/o -77- Table 18
SHANDONG PROVINCE
QUFU COUNTY HEALTH FACILITIES AND STAFF, 1957 - 1981
1957 1977 1981
Number of Hospitals n.d. 13 14
Hospital Beds 22 403 522
Total Staff 101 828 1,005
Of which Senior Level: 2 119 177
'Traditional Doctors 0 7 11 Western Doctors 2 104 4l5 Public Health Physicians 0 3 13 Senior Nurses 0 0 14 Others 0 5 24
Of which Middle Level: 63 273 346
Assistant Traditional Doctors 9 19 47 Assistant Western Doctors 18 108 106 Assistant Public Health 0 3 15 Nurses 29 88 98 Others 7 55 80
Of which Primary Level: 36 436 482
Part-Timé Personnel (Brigades)
Barefoot Doctors 0 1,153 1,123 /a Health Aides 0 1,284 614
Ratios
Population,per hospital - 37,000 Population pet bed 16,538 1,239 990 Population per senior physician 181,918 4,380 3,720 Population per barefoot doctor n.a. 43-3 460
/a Among which 703,(63%) have been retrainéd and upgraded to "rural doctors".
Sourcé: County Bureau of Health, Qufu SHANDONG PROVINCE.
QUFU COUNTY - AFFING AND UTILIZATION OF COMMUNE REALTH CENTERS,181
STAFF OUTPATIENT CLINIC HOSPITALIZATION
Average Of Which Number Number Average Number f Möves Communes Total Senior Junfor Others Number of Referred by of of Duration to Upper-1evel Technical Techni ca Patients Brigade Beds Inpatients of Stay Hospi;als la Per Day -Health Posts (days) e
Shuyuan 38 3 8 27 72.7 21 7 294 3.4 81 Vanä-zhuang 41 8 9 24 73.4 22 20 965 40 270
Dong-zhuang 45 6 15 24 85.0 47 35 1,334 7.1 290 00 Wucun 43 2 14 27 59.8 19 20 884 4.5 150
Yaocun 45 4 17 24 98.1 54 30 1,156 6.3 181 Shi-zhuan 45 4 12 29 72.1 21 10 714 4.1 170
Lingsheng 38 3 14 21. '87.5 41 15 1,074 4.3 285 Xiao xue 44 9 15 20 105.0 21 30 1,324 7,2 295 Xizou 46 4 10 32 75.1 41 11 749 5.5 201 Nanyang 55 8 25 22 103.0 83 z 42 1,784 7.4 410 NIslia 15 1 5 9 15.4 7 5 214 2.8 36
Fongshan 35 3 13 19 44.5 24 12 689 3.8 171
TOTALC 490 55 157 278 891.6 401 237 11,1816 5.1 2,540 la The number of patients referred to under "Upper-level Hospitals" may Iuäcudc transfers Of outpatients. Source: County Bureau of Health, Qufu
L_v $IHANDONG PROVINCE
QUFU COUNTY
INCIDENQE OF REPORTED dOMMUNICABLE DISEASES (Per 100,000 Population)
1971 1972 1973 1974 1975 1976 1977 978 1979 1980 1981
Dysentry 2,000 2,600 1,400 900 600 -406
Hepatitis 258 322 35 20 28 105 Mengt 42 32 25 24 30 40 Malaria 2 1,000 000 750 600 300 80 40 100 60 30 19.6 Typhid 1.5 10 34 12 9 8 Fertussis 60 14 15 6 8 6 Measles 200 150 130 5 0 70 50 2 Scarlet Fever I 8 38 6 2 1.5 Encephaltis B 4.3 4 0,9 2.8 1 0.5
Souree: 4hfu Epiaemic Prevention Station
0
•
twJ N ri) - 80 -
Table 21
SHANDQNG PROVINCE
QUFU COUNTY HOSPITAL
DISTRIBUTUION OF DIAGNOSIS TN 3,627 INPATIENTS ADMITTED DURING 1981
P-rcent of Total Pertent of Total Admissions Admissions
Digestive Ailments 21.2 Neurology 0.8 *Respiratory Diseases 17.3 Parasitic Diseases 0.7 Infectious Diseases 11.2 Muscular Ailments 0.6 Injuries 9.5 Dermatology 0.6 Cardio-vascular Diseases 8.9 Female genital system 0.5 Post-partum 6.2 Male genital system 0. 4 Neo-natal 5.0 Psychiatry 0.3 Cancer 4.7 Ear Diseases 0.2 Urology 3.8 Congential malformation 0.1 Intoxications 2.5 Others 1.1 Eye Diseases 1.6
Hematology 1.5
Endocrinology 1.2
Source: Qufu County Hospital & 81-
Table 22
SHANDONG PROVINCE
QUFU COUNTY HOSPITAL,
RANKING OF DEATH CAUSES IN 133 DEATHS DURING 1981
Number Percent of Total Deaths
Coronary Heart Diseases 5 24 18.0 Cerebro-vascular Diseases 21 15.3 Cancer , 16 12.3 Infectious (mainly post-surgical) 9 6.8 Cirrhosis 9 6.8 Intoxication 8 6.0- Neo-natal Death (< 1 month) 8 6.0 Intestinal Obstruction 6 4.5 Head Injury 6.0 Other 0 Injuries 3 Stomach Ulcer 2 Digestive Håmorrhagy 2 Other Causes 16 12.0
100.0
Squrce: Qufu County Hospital Table 23
SHANDO - PROVINCE
IMMUNIZATIONS DELIVERED IN QUFU COUNTY
Type of Vaccine . 1979 1980 1981
Smallpox /a .28,445 18,235 6,358 Polietyelitis per os 58,961 38,601 69,37§ (2 doses, 15 day intervals)
D.P.T. /b 24,087 i8,861. 18,689 Diphtheria 27,774 22,734 24,669 Encephalitis B 31,089 46,295 49,116 MbJI\ngitis A 60,385 26,78% 65,070 Measles 42,889 40,035 105,999
Influerza 7,904 27,287 Typhoid 37,093
TOTAL 281,534 238,836 376,373
/a Smallpox immunization was discontinued in November 1981. 7 Diphtheria/Pertussis/Tetanus: 3 shots at 15 day intervals.
Note: No data proided on BCG.
Source: Qufu County Epidemic Prevention Station a3- Table 24
SHAND0=G PROVINCE
CONSOLIDATED STATE EXPENDITURE ON HEALTH: 1975-1982
1975 1980 1981 1982 (est.)
RECURRENT
Total (Y'000s) 115,210 201,810 209,219 230,000 Per capita (Y-) - 2.77 2.83 -
Percent Share 76.7 76.7 75.4 - CAPITAL
ýTotal (Y'O0s) 14,800 25,450 25,880 15,700 1/ Per Capita (Y) - 0.34 0.35 -
Percent Share 9.9 9.7 9.3 GOVERNMENT°INSURANCE
Total (Y'000s) 20,200 35,750 42,400 -
Number Enrolled 691,303 884,797 1,051,153 -
Per Member (Y) 29.2 40.4 40.2 -
Percent Share 13.5 13.6 15.3
COMBINED
Total. (Y'000s) 150,210 263,010 277,49
Per Capita (Y) - 3.60 3.75 Percent Share 100.0 100.0 100.0 -
GROWTH RATE 1975/80 1973/81 1980/81 1981/82 (Annual Average, %)
Recurrent 11.2 9.9 3.7 9.9 Capital 10.9 9.3 1.7 -
Government Insurance 11.4 12.4 18.7 - Combined 11.2 10.2 5.5 -
/Province only'c 84-
Table 25
SHANDONG PROVINCE
DISTRIBUTION OF CONSOLIDATED STATE EXPENDITURE ON HEALTH PER CAPITA BY MUNICIPALITY AND PREFECTURE: 1981 (Muan)
Recurrent Govt. Insurance 'Papital Combined
TOTAL
Include provincial 2.83 0.57 0.35 3.75 Exclude provincial 2.39 0.54 0.20 3.13
Jinan 3.58 0.85 0,30 4.73 Qingdao 3.90 0.73 0.45 5.08 Zibo 3.41 0.67 0.25 4.33 Zaozhuang' 2.79 0.44 0429 3.52
PREFECTURE
Yantai 2.74 0.55 0.40 3.70 Ch(ngwei 2.24 0.43 0.19 2.86 Huimin 2.30 0.56 0.13 2.99 Dezhou 2.36 0.51 0.14 3.01 Liaocheng 2.68 0.74 0.13 3.55 Tai'an 1.89 0.54 0.19 2.61 Jining- 2.30 0.56 0.~15 3.00 Linyi 1.63 0.41 0.08 2.11 Heze 1.80 0.47 0.08 2.34 -85- Table 26
SHANDONG PROVINCE
FUNCTIONAL SHARES OF GOVERNMENT EXPENDITURE OF HEALTH
1975 1980 1981 1982 (est.)
TOTAL RECURENT EXPENDITURE: 110,210. 201,810 209,219 230,000 (Y'000s)
Percent Shares:
Hospitals 1/ 43.0 37.0 38.5 37.5 District hospitals and CHCs 2/ 20.0 25.5 26.5 24.2. Prevention 3/, 15.7 14.0 12.9 13.3 MCH 1.0 1.3 1.4 1. 6 Scientific research 4/ 0.7 2.7 1.8 2.0 Middle level training schools 4.8 4.6 5.1 4.3 Subsidy to rural coops. 5/ 1.5 1.0 0.5 3.9 Other / 13.3 13.9' 13.3 13.3
TOTAL CAPITAL EXPENDITURE .3/ 14,800 25,450 25,880 -
Percent Shares.:
General Hospitals 63.7 3.4 44.4 - Specialized Hospitals 11.8 15.3 13.1 - Middle Level Training Schools 6.8 10.3 8.3 - Other Health Units 17.7 31.0 16.2 - Medical: Colleges 8/ 0.0 0.0 18.1 -
1/ Includes general and specialized hospitals and sanatoria. 2/ Includes government and collective commune health centers - - - 3/ Includes epidemic prevention stations, immunisations and TB control. 4/ Includes a scientific and medical research unit plus subsidy Of the other medical research. 5/ Includes training and salary subsidy for barefoot doctors and provision of equipment for brigade health stations. 6/ Includes drug control, other medical' units and equipment for key counties. 7/ Includes transfer from central government. / Includes: Shandong Medical College, Weifang Prefectural Medical College, Qingdao Medical College and Shandong Traditional Medicine College. Prior. to 1981 these expenditures were financed from the Bureau of Education budget.
aa Table 27
SHANDONG PROVINCE.
STATE EXPENDITURE ON REALTH IN YEXIAN AND OUFU COUNTIES
YEXIAN - OUFU
1975 1980 1981 1981
Recirrent
Total (Y'OOOs) 595.1 1,180.0 1,309.1 770.0 Per capita (Y) 0.84 1.43 1.57 1.49 Percent of total 68.7 60.6 57.7 66.6
Government Insurance
Total (Y'OOOs) 180.9 267.2 361.6 385.7 Per capita (Y) 0.22 0.32 0.43 0.75 Percent of total 20.9 13.7 15.9 33.3
Capital
Total (Y'00Os) 90.0 500.0 600.0 0 Per capita (Y) 0.11 0.60 0.72 0 Percent of total 10.4 25.7 26.4 0
Total
Total (Y'OOOs) 866.0 1,947.2 2,270.7 1,155.7 Per capita (Y) 1.07 2.35 2.72 2.23 Percent of total 100.0 100.0 100.0 100.0
Note: Total recurrent expenditure oii health in Qufu was Y 453,700 in 1975 and Y 742,000 in 1980.
11 -87- Table 28
SHANDONG PROVINCE
SOURCES OF' FINANCE FOR GOVERNMENT EXPENDITURE ON HEALTH IN YEXIAN AND QINGDAO (% Shares)
YEXIAN QINGDAO
1975 1980 1981 1975 1980 1981
RECIRg NT
Central 100.0 0.0 0.0 100.0 0.0 0.0
Province 0.0 87.3 10.7 0.0 0.0 0.0
Prefecture 0.0 12.7 7.6 0.0 100.0 100.0 County 0.0 0.0 81.7 -
CAPITAL
Central 100.0 0.0 10.0 0.0 0.0 0.0 Province 0.0 60.0 25.0 23.6 - 39.9 47.8
Prefecture 0.0 40.0 25.0 76.4 60.1 52.2 County 0.0 0.0 50.0 - - -88- Table 29
SHANDONG PROVINCE
HEALTH INSURANCE EXPENDITURE IN SELECTED AREAS
YEXIAN - QTFU -
1975 1960 1981 1981
Government Insurance
Expenditure 180,847 267,200 361,600 385,645 Membership 7,304 9,202 9,445 10,795 Expenditure per member 24.76 29.03 38.28 35.72
Labor Insurance o
Expenditure - 732,000 200,374 Membership 9,302 18,797 18,545 5,835 Expenditure per member . - 39.47 34.34
County Collective Industry
Expenditure - 372,787 166,287 Membership 5,807 .11,915 12,944 5,311 Expenditure per member - 28.80 - 31.31
Commune Industry Insurance
Expenditure - - 230,952 143,000 Membership 12,113 18,736 19,246 7,150 Expenditure per member - - 12.00 20.00
Cooperative Insurance
Expenditure - 1,842,078 at-915,000 b/ Membership 785,300 480,875 Expenditure per member - 2.35 1.90
QINGDAO MUNICIPALITY
Government Insurance
Expenditure 1,230,000 3,198,000 3,057,000 Membership 36,600 78,000 82,400 Expenditure per Member 33.61 41.0 37.1
a/-Including Y 629,618 estimated income of baTefoot doctors; excluding -expenditure on reimbursed service fees for referred cases. b/ Including Y 307,000 expenditure on salaries and other payments to barefoot doctors. -89 - 89 Table 3ý
SHANDONG PROVINCE
RURAL COOPERATIVE INSURANCE: BRIGADE LVEL DATA, 1981
QUFU YEXIAfN -Wangzhuang Shuyuan XXiao xue Zhuyó ® Chengguan Touzhao Yuan Gaojiacun Silinsi Donglinxing Dongfu ZhengjIa Togpiyu Shiuang,
Population 2,074 821 1,960 1,749 1,359 1,127 1,162 1,392 Barefoot Doctors 4 3 8 4 3 3 2 5 Income per Capita -246 435 268 280 135 - 278 308 Distributed 176 235 168 150 85 235 Private 228 158 7,0 200 100 130 50 - 50, 150 Income of Coop - - . - - - h/ 2,900 Brigade Prépaymen. t 4,148 1,700 - - 830 - 3,000 ld n.a. le Service Income - - -0
Expenditure of Coop 3,700 - - 5,500 - - - -2;100 Brigade Level 2,600 - -- - - Referrals - 1,800 1,100 ------300 Average BFD Salary 265 /a 420 360 233 Ib 380 Ie 480 360 300 Total Expenditure on on EFDs 1,060 1,260 2,880 932 1040 1,440 720 1,500 Benefit Entitlement
Relmburse"nt at brigade level'% 50/f 50 50 0 0 - Reimbursement for 70 100 referral, 2 50 50 0, 0 50 50 4
Includes salary subsidy Y 6-8 per month. b Includes salary subsIdy Y 3 per m6nth; excludes private litcome of Y 290 per year. c Includes salary subsidy Y 5 per month; excludes private income of Y 50 per yaar. d Approximately Y 2.5 per member paid into coop insurance fund for brigade level services and Y 0-50 per member paid to the Commune Health Center for free health maintenance services. Y 1.00 per member contributed by brigade welfare fund. Drugs only Costs greater than Y 100 eligible for subsidy from brigade or commune welfare fund. n No individual prepayment was required in the brigades at the time of. the mission. SHANDONG P¶Ov1NCE
COMPARISON OF REVENUES AND EXPENDITURES IN SEIÆCTED HOSPITALS
PERCENT OF OPERATING REVENUE /1 PERCENT- OF OPERATING EXPENDITURE
Drug Sales Fees Drug Sales Fees Total Revenue Excluding Including Subsidy Subsidy
Quingdao Municipality
Medical College Hospital 61 39 49 31 80 105
Yexian CCDty
County Hospital ... 85 108 Zhtyo CHC /2 70 25 73 26 104 120
Chengguan CHC 79 19
Touzhao CHC 73 22 58 17 79 96
/J, Excluding salary subsidLes /2 Commune Health Center
k_4 MD c $ - 9r-
Table 32
HANDONG PROVINCE
AVERAGE PATIENT CHARGES IN SELECTED HOSPITALS (Yuan)
Per Outpatient Per Inpatient /1
Quingdao Municipality
Medical College Hospital 2.98 119.63
Yexian Conty
County Hospital 16.09 46.43
Zhuyo'CHC /2 2.22 34.53 Chengguan CHC 1.46 27.39 Touzhao CHC 1.65 26.99
/1 Including obstetrics 7-? Commune Health Center
0 . (r
0 .. , -. r - 92 - Table 33
SHANDONG PROVINCE
THE ONE-THIRD COUNTY PROGRAM (37 COUNTIES)
Prefecture Counties to be Upgraded Counties to Upgrade e (or Municipality) Between 1979 and 1983 During 1984-1990
Jinan Municipality Licheng
Qingdao Municipality Jimo
Zibo County Zichuan District
Zaozhuang County Shueicheng District
Dezhou Prefecture Shanghe Ningjin Jiyang Qihe
Huimin Prefecture Huantai Lijin Boxing Zhanhua
Changwei Prefecture Pingdu Changyi Zhucheng Lingu
Yantai Prefecture Yexian Rongcheng Huangxian Rushan Haiyang
Linyi Prefecture Mengyin Juxian Rizhao Cangshan
Tailan Prefecture Laiwu Dongping Feicheng
Jining Prefecture Zouxian Qufu Jinxiang
Heze Prefecture Shanxian Heze Yuncheng
Liaocheng Prefecture Chiping Yanggu Guanxian