CHINA the Health Sector

A WORLD BANK COUNTRY STUD' PUB-4664

CHINA Public Disclosure Authorized The Health Sector Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized

I) I1 :!

A WORLD BANK COUNTRY STUDY

CHINA The Health Sector

Dean T. Jamison John R. Evans Timothy King Ian Porter Nicholas Prescott Andre Prost

The World Bank Washington, D.C., U.S.A. Copyright CC)1984 The International Bank for Reconstruction and Development/THE WORLD BANK 1818 H Street, N.W. Washington, D.C.20433, U.S.A.

World Bank Country Studies are reports originally prepared for internal use as part of the continuing analysis by the Bank of the economic and related conditions of its developing member countries and of its dialogues with the govemments. Some of the reports are published informally with the least possible delay for the use of governments and the academic, business and financial, and development communities. Thus, the typescript has not been prepared in accordance with the procedures appropriate to formal printed texts, and the World Bank accepts no responsibility for errors. The publication is supplied at a token charge to defray part of the cost of manufacture and distribution. The designations employed, the presentation of material, and any maps used in this document are solely for the convenience of the reader and do not imply the expression of any opinion whatsoever on the part of the World Bank or is affiliates concerning the legal status of any country, territory, city, area, or of its authorities, or concerning the delimitation of its boundaries or national affiliation. The full range of World Bank publications is described in the Catalog of World Bank Publications; the continuing research program of the Bank is outlined in IAkrld Bank ResearchProgram: Abstracts of Current Studies. Both booklets are updated annually;the most recent edition of each is available without charge from World Bank Publications in either Washington or Paris (see the back cover for addresses).

Eleven supplementary papers are available separately from this report. A list of the titles and authors of these papers follows the Table of Contents.

Library of Congress Cataloging in Publication Data

Main entry under title:

China, the health sector.

(A World Bank country study) Report written by Dean T. Jamison and others. Includes bibliographical references. 1. Public health--China. 2. Medical care--China. I. Jamison, Dean. II. World Bank. III. Series. RA527.C536 1984 362.1'0951 84-13150 ISBN 0-8213-0384-8 Preface

This report is based on the findings of a World Bank rural health and medical education mission that visited China for four weeks during September and October of 1982. The mission consisted of Mr. Dean T. Jamison (mission chief and economist), Mr. Timothy King (population specialist), Dr. Stanley Music (epidemiologist), Mr. Nicholas Prescott (economist), Dr. Andre Prost (public health specialist) and Ms. Khanh Lac Truong (mission secretary). The mission was joined in the field for part or all of its stay by the following Bank staff members and consultants: Dr. John R. Evans (then Director, Population, Health and Nutrition Department), Mr. Ian Porter (economist, China Division), Mr. Jacques van der Gaag (economist, Development Research Department) and Dr. Mary Young (child health specialist, consultant). Ms. Catherine Fogle provided research assistance. The World Health Organization (WHO) made two staff members available as resource persons for part of the mission; these were Dr. Eric Goon (WHO representative to China) and Dr. John Krister (WHO regional office for the Western Pacific, Manila). In addition, WHO (Geneva) hosted a seminar -- chaired by its Director-General, Dr. Halfdan Mahler -- to review the mission's findings concerning medical education; the seminar provided valuable information and perspectives for preparation of the report. A draft of the mission's report was submitted to the Chinese government in September, 1983, and discussed with the government in February, 1984; this version of the report has been revised in light of government comments.

The mission worked closely with numerous officials of the Ministry of Public Health and of the Health Bureaus of Shandong and Sichuan Provinces. Their tireless help, their patience and, above all, their valuable insights were essential to preparation of this report.

- iii - CURRENCY EQUIVALENTS

The Chinese currency is called Renminbi (RMB). It is denominated in yuan (Y). Each yuan is subdivided:

1 yuan = 10 jiao = 100 fen

Exchange rates used in this report are as follows:

1979 $1.00 = Y 1.55 1980 $1.00 = Y 1.50 1981 $1.00 = Y 1.71 1982 $1.00 = Y 1.89 1983 $1.00 = Y 2.00

WEIGHTS AND MEASURES

Chinese statistics are usually in metric units; in addition, mu and jin are often used:

1 mu = 0.1647 acres = 0.0667 hectares (ha) 1 jin = 0.5 kg

FISCAL YEAR

January 1 - December 31

TRANSLITERATION

The Pinyin system is used in this report.

- iv - v

Contents

Page

Sunmnary...*--** - -.**-*-*.*-*.- -- -*-...... xi

Part I: The Main Report

Chapter 1. Introduction...... * ...... 1

Chapter 2. The Population,Health and Nutritional Status of the Chinese People: Trends and Current Situation...... 4

2.1 Trends in Population Size and FertilityLevels ...... 4

2.2 Achievementsin Reducing Mortality - Levels, Trends and Regional Differencesin Life Expectancy and Infant Mortality...... 7

- Trends in Life Expectancyand Infant Mortality - Regional Variation in Mortality

2.3 The Changing Disease Pattern and the Epidemiological l'ransition...... ,...... , ll......

- The Epidemiological Transition - Progress in Reducing Mortality - Progress in Reducing Morbidity - Other Causes of Morbidity

2.4 Improvementsin NutritionalStatus ...... 19

- Secular Improvementsin NutritionalStatus - MicronutrientDeficiency Disorders

2.5 Current Disease Problems.21

- Emerging Problems of Chronic Disease - Lingering Problems of InfectiousDisease - Malnutritionand Child Development - vi - Page

Chapter 3. The Health Sector and Its Financing .. 33

3.1 Health Policies...... 33

- General Policy Directions - Overview of Current Health Policy

3.2 Organization of Health Service Delivery...... 40

- Organization of Health Services - Health Campaigns and Epidemic Prevention Services - Traditional Medicine

3.3 Inputs to Medical Services...... 48

- Personnel: Categories, Training and Growth in Numbers - Facilities - Pharmaceuticals

3.4 The Impact of Health Resources...... 60

3.5 Health Sector Financing and Expenditures...... 62

- Health Sector Finance - Health Sector Expenditures - International Comparisons

Chapter 4. Beyond the Health Sector: Other Factors Influencing Population, Health and Nutritional Status...... 77

4.1 Food Availability and Food Policy ...... 77

4.2 Water Supply and Sanitation...... 81

4.3 Population Policies and Fertility Decline ...... 82

Chapter 5. Problems and Issues...... 91

5.1 Health Services for the Rural Poor: Completing the First Chinese Health Revolution...... 92

5.2 Addressing the Emerging Problems of Chronic Disease: Tasks for a Second Chinese Health Care Revolution...... 96

5.3 Issues in RuraL Health Care ...... 98

5.4 Issues in Medical Education...... 102 - vii -

Part II: Statistical Annexes

Page

List of Annex Tables ...... 106

Annex A: Demographic and Economic Indicators ...... 112

Annex B: Health Status Indicators ...... 119 - Mortality - Morbidity - Provincial Data

Annex C: Health Facility and Manpower Availability Indicators ...... 142 - Data for Recent Years - Historical Figures - Provincial Data

Annex D: Food Availability and Nutritional Status Indicators ...... 162 - Food and Nutrient Availability and Prices - Estimates of Nutrient Requirements - Anthropometric Data

Annex E: Economic and Financial Indicators ...... 179 - General Data - Provincial Data

Charts and Maps

Charts (at end of report)

Chart 1. Organization Plan of the Ministry of Public Health

Chart 2. Institutes of the Medical Academies

Chart 3. Organization and Function of the State Pharmaceutical Administration

Maps (at end of report)

Map 1. Crude Birth and Death Rates by Province, 1981 (IBRD 18207)

Map 2. Life Expectancy and Cross Per Capita Output Value of Industry and Agriculture by Province (IBRD 18206)

Map 3. Tuberculosis Prevalence by Province, 1979 (IBRD 17129Rl)

Map 4. Hypertension Morbidity by Province, 1979-1980 (IBRD 17042R1)

Map 5. Health Facilities and Personnel, 1979 (IBRD 18208)

Map 6. Nutrient Production Data, 1980 (IBRD 18210) - viii -

Figures and Tables Page

Figures in Text

2.1 The Total FertilityRate in China, 1950-81...... 6

2.2 Expectationof Life at Birth, 1950-82...... 9

3.1 Organizationof Health and Birth Planning Services...... 36

3.2 Total Number of Doctors of Western and Chinese Traditional Medicine (per 1000population) ...... 53

3.3 Recurrent Expenditureon Health, 1981: Sources of Finance, Resource Inputs and Delivery Systems ...... 63

3.4 Distributionof Population by Insurance Status...... 65

3.5 Urban-RuralDifferentials in Recurrent Health Expenditure,1981 ...... 65

4.1 Infant Mortality Rates and Total Daily Per Capita Food Energy Availability, 1950-82...... 79

5.1 Projected PopulationOver 50 Years of Age, 1980-2030...... 95

Tables in Text

1.1 Selected Development Indicators,China and Other Countries..O...... 3

2.1 Summary Measures of Estimated Fertilityand Mortality for Five Year Periods, 1940-1980...... 5

2.2 Official Estimates of Life Expectancy and Infant Mortality, 1949 and 1982...... 7

2.3 Percentage Distributionof Deaths by Cause, China and Model High- and Low-IncomeCountries ...... 13

2.4 Principal Causes of Death, Rural and Urban Areas, 1980...... 22

2.5 Percentageof 7-Year Old Boys Malnourished, Selected Provinces, 1979 .. 32

3.1 Selected Health Care Workers - Educationand Role . . 51

3.2 Availabilityof Health Care Personnel - China and Other Developing Countries.54

3.3 Medical School, University and SecondaryEnrollments - China and Other Countries ...... 55

3.4 Medical School Graduates and Increases in Senior Medical Manpower, 1977-81 ...... 56 - ix, -

Page

3.5 Increases in Numbers of Hospital Beds, 1979-81...... 57

3.6 Ministry of Public Health Expenditure, 1977-81 ...... 66

3.7 Estimated Distribution of Recurrent Expenditure by Input ... 74

3.8 International Comparisons of Health Expenditure ...... 76

4.1 Total Daily Per Capita Food Energy and Protein Availability and Requirements, Selected Years ...... 78

5.1 Rural-Urban Differences Related to Health ...... 93

5.2 Hypertension Prevalence in China, 1980-2010 ...... 97 x -

List of Supplementary Papers Population

1. China: An Evaluation of Demographic Trends -- 1950-82 (PHN Technical Note DEM 4) by Kenneth Hill

2. Population Policy in China Since 1950 and its Demographic and Economic Implications (PHN Technical Note GEN 11) by Timothy King

3. Income and Other Factors Influencing Fertility in China (PHN Technical Note GEN 12) by Nancy Birdsall and Dean T. Jamison

Health

4. Determinants and Consequences of Health Resource Availability in China (PHN Technical Note GEN 13) by Nicholas Prescott, Dean T. Jamison and Nancy Birdsall

5. Health Sector Finance and Expenditures in China (PHN Technical Note GEN 14) by Nicholas Prescott and Dean T. Jamison

6. Medical Education in China (PHN Technical Note GEN 15) by John R. Evans

Nutrition

7. Trends in Food and Nutrient Availability in China, 1950-81 (PHN Technical Note GEN 16) by Alan Piazza

8. The Nutritional Status of Children in China: A Review of the Anthropometric Evidence (PHN Technical Note GEN 17) by Dean T. Jamison and F.L. Trowbridge

Case Study on Shandong Province

9. HeaLth Sector Issues in Shandong Province (PHN Technical Note GEN 18) by Andre Prost, Jacques van der Gaag, John Krister, Nicholas Prescott and Mary Young

10. The Barefoot Doctor: Training, Role and Future (PHN Technica! Note GEN 19) by Mary Young

11. Commune Health Care in Rural China (PHN Technical Note GEN 20) by Jacques van der Caag

1/ These papers are available in the Population, Health and Nutrition Department Technical Notes Series; the number of the paper in the series appears in parentheses folLowing its titLe. Papers may be obtained from the Population, Health and Nutrition Deparcment Library. - xi -

Summary

1. Before 1949, China's population suffered a crippling burden of disease and premature death; perhaps the most striking success of China's subsequent anti-poverty struggle has been a dramatic increase in life expectancy, with a concomitant reduction in the burden of illness. Public health measures -- combined with reductions in malnutrition, improved water supplies and close attention to hygiene and sanitation-- have increased life expectancy from about 32 years in 1950 to 69 years in 1982, which is only about six years less than in the industrialized market economies. Nonetheless, progress in improving health conditions has been far from uniform, and major rural-urbandifferences (and differencesamong rural areas) exist.

2. The multi-sectoral influences responsible for improving health conditions in China -- as well as the emphasis within the health sector on prevention, on community mobilization and finance, and on barefoot doctors -- have strongly influenced the thinking of health care professionalsthroughout the developing world. Indeed the 1978 Alma-Ata declaration,on 'health for all by the year 2000' through a strategy of primary health care, was much influenced by the Chinese model. But because China's system has matured and the problems it must address have changed, health conditions and health care deliveyv in China should now be re-evaluated in light of the substantialnew informationavailable.

3. To assist Bank staff working on health projects in China, as well as health care professionals in general, this review of the health sector begins by noting China's achievements in population control, health status and nutrition. A section specifically on health then looks at the policies, sources of financing and resource use that have contributed to China's successes. The report then discusses the evolution of several influenceson health from outside the sector -- nutritional improvements,greater access to clean water and sanitary waste disposal, and fertility reduction. A discussion follows of the problems that remain as the two major challenges to the health sector through the rest of the century. The major findings of the review are highlighted in this summary.

Achievements

4. Population. China's census of June 30, 1982, recorded a population of 1008 million; this exceeds by 73 percent the total recorded in the PRC's first census, conducted in 1953. The population growth rate in the intervening 29 years was thus 1.9 percent per annum. Trends in total fertilityand mortality during this period have been far from steady, however, and demographic conditions still vary markedly among regions in China. Birth rates were around 45 per 1000 in the mid-1950s, implying a fertility rate of about 6.5 births per woman. Death rates fell from about 30 per 1000 at the beginning of the 1950s to about 23 in 1957, equivalent to a life expectancyof about 38 years. Successes prior to the Creat Leap Forward of 1958 were, however, followed by a period of catastrophe: mortality rose sharply around - xii -

1960 and the birth rate plunged, resulting in a population loss of more than 1 percent. Following the 1959-62 famine, the birth rate surpassed the 1950s level and then declined slowly until the end of the decade. The drop in fertility since 1970 has been remarkable, with the total fertility rate declining to about 2.5 over 1975-80; however, the total fertility rate rose to 2.8 in 1981. The population growth rate rose to about 1.3 percent per annum in 1981 from its low in the late 1970s of just over 1 percent per annum.

5. Fertility declines have been much more rapid in urban than in rural areas. The rural birth rate, indirectlyderived from the 1982 census data, is almost double the urban rate (22.5 per thousand versus 12.4), and the rate is about 7.2 higher in autonomous regions. These findings are roughly consistent with estimates by the State Family Planning Commission, which suggest a 1982 total fertility rate of 2.9 in rural areas and 1.5 in urban areas.

6. Health status. The World Bank has constructeda set of estimates of post-1940 trends in life expectancy and infant mortality, and two points concerning the results bear particular comment. First, the Bank's estimates generally agree with official estimates on the dramatic improvementsin life expectancy and reductions in infant mortality. Continuing a pattern of improvements that had begun five or ten years earlier, life expectancy rose from less than 35 years in the immediate post-1949 period to almost 70 years in the early 1980s; the estimated infant mortality rate declined from 250 in 1950 to less than 50 in 1981. Second, while the Bank's estimates agree with official figures on the general pattern of improvement, Bank estimates of infant mortality are substantially higher than those of the government. Under-reporting of infant births and deaths could well account for this difference and, if so, this indicates that the problems of antenatal and early postnatal care in China deserve more attention than the official data suggest.

7. Estimates have been made of life expectancy by municipality,province and autonomous region, based on data from a major 1973-75 cancer mortality survey. These estimates range from 59 years in Cuizhou to 72 in Shanghai, denoting very substantial inter-provincialdifferences. Some (but far from all) of these differences can be accounted for by differences in income. Statistical analysis of the cancer survey concluded that life expectancy in urban areas is, on average, 12 years higher than in typical rural areas; life expectancy in low-income rural areas (defined as having a distributed per capita income of less than 50 yuan in 1979) is 5 years less than in typical ones. Analysis of data on death rates from the 1982 census reached similar conclusions. This rural-urban difference exceeds that found in most other developing countries, strongly reinforcingthe importanceof stated government policies to improve conditions in rural areas.

8. Periodic epidemics, together with a high level of infectious disease morbidity and malnutrition, earned pre-1949 China its reputation as the "sick man of Asia" and led to the low levels of life expectancy just indicated. China's substantial success against infectious disease has resulted not only in increased life expectancy, but also in the emergence of new leading causes of morbidity and mortality. In urban areas and much of rural China, parasitic and infectiousdiseases have been substantiallyreplaced as causes of death by - xiii -

heart disease, cancer, stroke, accidents and chronic respiratory diseases. For example, the mortality rate of heart diseases increased from 71 per 100,000 in 1958 to 141 per 100,000 in 1979 in four urban Beijing districts. Infants, children and young women have been supplanted by the middle-agedand elderly as the population groups with highest mortality, and older age groups are consuming an increasing proportion of medical care.

9. This transformation,which has already occurred in the industrialized countries, is now referred to as the 'epidemiologictransition'. Although urban Chinese disease patterns are increasingly similar to those in high income countries, the transition is still progressing in rural China. Some communicable diseases -- such as dysentery, tuberculosis and hepatitis -- remain important national problems. In poorer parts of China, health conditions probably lag 20 years behind those attained in more developed areas. Further, in vulnerable geographic or climatic areas, infectious and parasitic diseases such as leprosy, malaria and schistosomiasisremain major problems.

10. Nutritional status. Available data suggest steady improvements in the nutritional status of school-age children in China, at least in urban areas. Data on changes in nutritional status are often reported in growth rate per decade. Rates of increase in average height in China for two recent decades were 1.55 cm per decade in rural Shanghai, 2.49 for Guangzhou city, 1.48 for rural Guangdong, and 3.8 for urban Beijing (for 9-year-olds). These data are difficult to interpretwithout comparative data from earlier periods in China, or from other developing countries. These rates are, however, as high, or higher, than those in 20th century Europe, which suggests important successes. If the European experience is any guide, these increases can be expected to continue well into the next century.

11. In urban areas, malnutrition has been substantiallyreduced and can no longer be considered an important problem. Many children in rural areas, by contrast, continue to suffer moderate-to-seriousmalnutrition. A 1979 survey of 16 provinces and municipalities provides a basis for assessing urban-rural and inter-provincialdifferences in child malnutrition. A clear pattern of moderate rural malnutrition can be seen, with an estimated 12.7 percent of seven-year-oldrural boys having stunted growth in the 16 provinces surveyed; for Sichuan, the figure was 37 percent. In urban areas, only 2.6 percent of children are stunted. Reasons for the better situation in urban areas include lower prevalence of disease and more food of better quality (urban food subsidies were an estimated 96 yuan per urban dweller in 1981 and accounted for over 4 percent of GDP). The persistence of substantial undernutrition in rural China provides further evidence that the epidemiologicaltransition is far from complete and that continued attention needs to be paid to disease problems typical of low-income countries.

The Health Sector

12. Health policy. Relative to most other countries, China has emphasizedpublic preventive over curative health services,without neglecting the importance of curative measures both for the well-being of the population - xiv -

and for the task of controlling communicable disease. Major campaigns were mounted shortly after 1949 to improve environmental sanitation; to eliminate the "four pests" -- rats, flies, mosquitoes, and bedbugs; to vaccinate against and cure infectious diseases; and to control the vectors of major endemic disorders such as malaria and schistosomiasis. Mass mobilization played a key role in the success of these campaigns. The allocation of health resources to preventive activities (and to whatever curative services were provided in urban areas) generated a demand for at least minimal curative services and pharmaceutical availability in the rural areas, and health policies of the Great Leap Forward and Cultural Revolution periods responded to that concern. These vigorous preventive efforts have undoubtedly been enormously successful in reducing morbidity and mortality. Curative care is now receiving increased emphasis, however, and the preventive approach to disease control so far seems to be playing only a marginal role in dealing with today's problems of chronic disease.

13. China's concern with prevention has also led to pursuit of a health strategy that reaches well beyond the health system per se. In particular, improved nutrition, provision of safe water supplies and sanitary and convenient means of waste disposal, fertility reduction and widespread educational improvements have been major policy objectives. The administrative capacity and political will of the Chinese Government have, despite occasional setbacks, been essential to the success of such a multifaceted strategy.

14. Impact of health resource availability. Accompanying the implementation of health policy has been a rapid growth in availability of hospital facilities and health personnel. Nonetheless, China's successes in the health sector have generally been attributed to the manner in which resources were deployed more than to the availability of doctors and hospitals. Analysis of the factors influencing morbidity and mortality tends to support this view. Further, as the disease profile moves more toward chronic and away from communicable disease, increases in income are unlikely to continue to lead to improved life expectancy; rather, available data suggest that income increases are now leading to life style changes that put individuals more at risk of chronic diseases. This suggests the priority for seeking affordable public policies for postponing the onset and managing the consequences of chronic disease, with the required qualitative change in the education and functions of health personnel. To avoid inevitable tendencies simply to increase the numbers of doctors and other personnel available, careful health manpower development planning will be required; essential to that planning will be concern for how to provide service in rural areas, how to train physicians appropriately when major investments in equipment are not feasible, and how to ensure appropriate concern for community and preventive medicine.

15. Health sector financing and expenditures. Total health expenditure in 1981 is estimated at approximately Y15.0 per capita, of which Y14.3 is for recurrent expenditure and YO.6 for capital construction. This represents 3.3 percent of GDP per capita in 1981. The allocation of expenditure can be anaLyzed according to sources of finance, delivery systems and expenditure on - xv -

resource inputs. Financing comes in about equal amounts from three main sources -- private outlays (32 percent), labor insurance (31 percent) and state budget expenditures (30 percent). Production brigades finance the residual seven percent. Likewise, the structure of health services delivery is essentially tripartite. The rural collective system, principally brigade and commune health facilities, delivers the largest share of health services, valued at approximately 40 percent of the total; the government system delivers about 32 percent; and the enterprise system, which serves enterprise employees and dependents exclusively, delivers 25 percent of total services. Private medical practice has recently been authorized but is as yet of little significance. Pharmaceuticals are by far the most important resource input into the health sector, accounting for 58 percent of total expenditure; Western drugs alone consume 49 percent of total health expenditure. Personnel costs (at wages prevailing in China) account for less than a quarter of total expenses. (However, this figure excludes the cost of unpaid labor, either voluntarily or otherwise mobilized, for which virtually no relevant data exist, but whose contribution to the success of many preventive efforts, particularly those associated with environmental sanitation, must have been substantial.)

16. A high proportion of total expenditure is mediated through insurance schemes. This reflects the high degree of health insurance coverage, one of the major achievements of the Chinese health system. Only about 30 percent of the population are completely uninsured, virtually all of them residing in rural areas.

17. Considerable urban-rural differentials in health expenditure exist in China. Urban expenditure is estimated at Y33 per capita, more than triple the estimated rural expenditure of Y9 per capita. State subsidies for health care for urban dwellers are at almost ten times those for rural dwellers -- approximately Y26 per capita compared to less than Y3 per capita. Private expenditures per capita amount to less than Y3 in urban areas but over Y5 in rural areas.

18. Given the emphasis in China on preventive medicine, it is surprising that less than 5 percent of total health care resources are directed to prevention and over 95 percent to provision of curative services. Traditional medical practice receives about 14 percent of the total allocation.

Problems and Challenges

19. China's efforts to reduce the incidence of communicable disease and the prevalence of malnutrition, thereby greatly reducing mortality rates, have led to a dramatic increase in life expectancy. This success might well be labelled the first Chinese health care revolution. But this revolution has left in its wake two distinct problem areas. First, success to date has been uneven: health conditions in cities are very good indeed, and many rural areas lag the cities by only 5 or 10 years in life expectancy. But the health conditions of perhaps 100-200 million rural Chinese remain similar to those prevailing in typical developing countries. These people live in poor and remote parts of China; economic and administrative infrastructure is lacking; - xvi -

education levels are probably low. There are no easy or inexpensiveways to improve health conditions in these areas. Second, the emerging prevalence of chronic disease is becoming a major concern. The current pattern of causes of death in China is very much like that of the industrializedworld -- heart disease, cancer and stroke head the list. Treatments for these diseases used in the West tend to be extremely costly and only moderately effective. But patients' demands for treatment and efforts by physicians to effect a cure often involve significantexpenditures with relativelylittle health impact.

20. In light of these problems, two priority challenges now face the health sector in China:

(a) The first challenge is that of completing the first Chinese health care revolutionby extending the methods that have been successfulin most of China to areas where mortality rates and deaths due to infectious diseases remain high; and

(b) The other challenge is that of forging a second Chinese health care revolution, which would develop and implement approaches to management of chronic disease that combine prevention, low-cost treatment, rehabilitation and humane care. The problems to be overcome in forging this second revolution are massive, but even partial success would be of immense value not only to China, but also to the internationalcommunity.

21. Completingthe first revolution. Major disparitiescontinue to exist among and within provinces and between rural and urban areas in availability of health services and in health status. Effective health care delivery has been consolidated in urban areas. The next priority, which is recognized by the Ministry of Public Health, is to consolidate gains made in some rural areas and extend a similar level of service to poorer areas. An important next step is the development of detailed plans for reducing mortality rates and morbidity due to specific diseases in poor counties; those plans must include epidemiologicalconsiderations, financial analysis, and assessment of manpower needs, training and deployment. Civen the poverty of most locales where the first health revolution needs to be completed, it will inevitably require outside finance (from the provincial or central government) to implement effective policies for closing the gap in health conditions. While the amounts involved are not large compared to current levels of state subsidy for urban dwellers, the problem of generating the requisite resources is nonetheless real.

22. A particularly important development for rural health care in China is the decline of rural cooperative health insurance systems after the introduction of production responsibility systems. In 1975, 85 percent of productionbrigades had cooperativeinsurance, but this figure had declined to 58 percent by 1981. In consequence,nearly half of the rural population must pay the full price for medical services; this proportion will very likely continue to increase. This trend has two highly undesirable consequences. First, the major gains in welfare that can be achieved by risk sharing are lost without health insurance schemes. While the rural cooperative systems -xvii -

had many defects, including incapacity to share risks over large numbers of individuals, they nonetheless provided an important basic service. Second, fee-for-service approaches to provision of health care inevitably neglect public preventive measures, though these have played a vital role in China's success. Moreover, those preventive activities that involve mobilization of labor on an unpaid basis may particularly suffer from the responsibility system and lead to a resurgence of parasitic and infectious diseases, unless alternativefinancing mechanismsare in place.

23. Tasks for a second Chinese health care revolution. Success in the control of communicabledisease has transferred the burden of China's health problems to the older age groups, who are particularlyvulnerable to chronic disorders. Prevention is relatively difficult for most chronic diseases, and development of effective, yet low-cost, strategies for dealing with these disorders is a priority. The major pitfall is the temptationto emulate high- cost curative approaches that have proved relatively inefficaciousand that, even in high-income countries, have resulted in a massive drain on national economic resources. Neither preventive nor curative measures to deal with chronic diseases can be expected to have the same dramatic impact on life expectancyas the control of communicableand infectiousdiseases. The latter raised life expectancy principally by reducing mortality among infants and children; tragic as these early deaths may be, the emotional and economic cost, to family and society, of premature death of productive adults is far greater. Programs to deal with chronic disease will thus result in welfare gains that are more than proportionate to their limited effect on life expectancy.

24. Some measures for prevention of chronic diseases can be taken right now, particularlycontrol of salt intake and tobacco consumption. Levels of salt consumption in China exceed those in most other countries and, in consequence, China has a high (and rising) incidence of hypertension (high blood pressure). Excess salt consumption leads to preventable heart disease and stroke, which are a major public health problem in China today. Tobacco consumption in China has been exceptionallyhigh for a country at its income level, but despite a policy to discourage smoking begun two years ago, tobacco consumption has increased dramatically. (Indeed, the Sixth Five-Year Plan calls for an 81 percent increase in tobacco production between 1980 and 1985.) The resulting increases in lung cancer and chronic respiratory diseases will entail much human suffering, lost productivityand unnecessary medical expenses. Other preventivemeasures may be less obvious: Prevention of chronic disease is inherently more difficult than prevention of communicabledisease. Thus it is essential to recognize this and to commit substantial resources to develop strategies for prevention of chronic diseases.

25. Also important is the development and widespread implementationof strategies for dealing with patients that have chronic diseases. These strategies must include capacity to provide treatment that may be successful and that is affordable; rehabilitation of individuals partially or wholly incapacitatedby non-communicabledisease; and humane care for the terminally - xviii -

ill (an area where major and quite affordable advances have been made in Western medical practice). Essential to the success of these strategies will be appropriately trained manpower including physicians who can provide real care without relying on imported methods that use highly expensive equipment and procedures.

26. A final factor in achieving the second health care revolution will be the designing of an insurance and financing structure that encourages prevention and discourages the current tendency to overuse facilities. The insurance structure should provide strong disincentives for introduction of high-cost procedures that could be afforded only by a few. By using high deductibles and only partial contributions to subsequent costs the insurance structure should also create incentives for both patient and doctor to utilize health resources prudently.

Strategy Issues

27. The problems just discussed challenge the Chinese health care system to major innovation. Innovation is essential both because the resources available for health care in China are small compared to those available in the West, and because China has far more ambitious plans than most low-income countries for meeting the health needs of its population. Even with the most rapid conceivable growth in spending on health -- which would come at the cost of much-needed investment in other sectors -- China could provide the highly capital-intensive curative medicine of the West for only a few. Resource constraints thus necessitate hard choices: imported approaches to care for a tiny elite and little or no improvement for the vast majority, or careful analysis and innovation to extend the reach of limited resources. Faced with these constraints, China's past strategy with its emphasis on labor-intensive practices still makes economic sense. Moreover, an innovative approach, though it entails higher risks, is required precisely because no comprehensive strategy exists for extending the first health care revolution and forging the second. Development of the essence of such a strategy - with its financial, political and manpower implications - is a high priority.

28. Central to the implementation of strategies for addressing China's health problems is the development of institutions capable of innovation, experimentation and analysis of public health problems. Upgrading the medical colleges, particularly the 13 core medical colleges, can play a key role here, provided their professors develop research and teaching interests that go beyond technical developments in biological science and clinical medicine. The MOPH's initiative in establishing a National Center for Preventive Medicine and a Research Center for Health Planning and Statistics should improve China's capacity to develop economically viable solutions to major health problems. Likewise the MOPH's emphasis on improving resource allocation and management skills -- throughout the health system and at individual institutions -- should improve efficiency. Beyond these general efforts to develop institutional capacity for innovation and efficiency, a number of specific issues (discussed in Chapter 5 of the report) should be considered. A few of the key points are raised below. - xix -

29. Financing health care in poor areas. While the state shoulders the burden of financing health care in urban areas, a policy of 'self-reliance' (i.e. local and individual finance) is implemented in rural areas. This has been satisfactory for well-off rural areas; in poor parts of rural China, however, even minimal services are often unavailable. An important policy question for the government is whether to postpone efforts to improve health care in poor areas until further gains have been made in cities and well-off rural areas. Actively assisting poor areas would require central government finance, but the impact of health investments in these areas would likely exceed those elsewhere; thus concern for efficiency would reinforce equity considerations in favor of such a policy.

30. Major commune clinics. The Government's policy is to encourage creation of major commune clinics, with better equipment and well qualified medical personnel, so that they can meet many demands that might otherwise be placed on county hospitals. Creation of these clinics -- which might be small (50 to 150 bed) hospitals with 3 to 8 doctors -- is perhaps the highest priority for improving access to curative care in rural areas, many of which are remote from county hospitals. Further, they would relieve the mounting pressures the referral system is placing on county hospitals. Securing appropriately qualified personnel for these major clinics will be a delicate task, particularly in light of the Cultural Revolution experience with forced rustication of doctors, and will require adequate incentives for staff, including satisfactory equipment and working conditions.

31. Scientific evaluation capability and health systems research. The evaluation of the effectiveness of new and traditional techniques of diagnosis, treatment and prevention is assuming much greater importance because of the high cost of modern medical technology. Key medical colleges are often pioneers in introducing new medical techniques and should develop the capability for such evaluation. Epidemiological principles need to be applied not only to non-infectious diseases, but also to the evaluation of disease control measures, and the quality of care and resource allocation in the health system, i.e. health systems research. This is as important in clinical medicine, both Western and traditional, as it is in public health.

32. Prevention of chronic disease. Despite the importance attached to 'putting prevention first', relatively little attention has been paid to prevention of ailments such as cardiovascular disease, cancer and chronic respiratory disease. Even in many rural areas, these disorders account for most deaths. A clear priority is to establish (or designate) institutions with responsibility for surveillance and prevention of chronic disease. Resumen

1. Con anterioridada 1949, la poblaci6n de China sufria una carga debi- litante de enfermedades y muertes prematuras; tal vez el 6xito mas notable del pais en su lucha posterior contra la pobreza ha sido el aumento espectacularde la esperanza de vida, con una disminuci6nconcomitante de las enfermedades. Las medidas de salud publica, combinadas con la reducci6n de la malnutrici6n, el mejor abastecimientode agua y la mayor atenci6n a la higiene y el saneamiento, han aumentado la esperanza de vida desde cerca de 32 aniosen 1950 a 69 aniosen 1982, lo que es s6lo alrededor de seis aiiosmenos que en los paises industrializados con economia de mercado. Sin embargo, el progreso en el mejoramiento de las condiciones de salud esta lejos de ser uniforme, y existen grandes diferencias entre las zonas rurales y urbanas (y tambien entre las rurales).

2. Las influencias multisectorialesresponsables del mejoramiento de las condiciones de salud en China, y tambi6n la importancia dada en el sector a la prevenci6n de enfermedades, la movilizaci6n de la comunidad, el financiamiento, y la labor de los m6dicos descalzos, han influido poderosamente en el pensa- miento de los profesionales de la salud en todo el mundo en desarrollo. En efecto, el modelo chino ejerci6 fuerte influencia en la declaraci6n de Alma-Ata en 1978 de "salud para todos en el anio 2000" mediante una estrategia de aten- ci6n primaria de la salud. Pero debido a que el sistema ha madurado y a que han cambiado los problemas que debe enfrentar, las condiciones de salud y la presta- ci6n de cuidados de la salud en China deben ahora reevaluarsea la luz del con- siderablevolumen de nuevas informacionesde que se dispone.

3. A fin de ayudar al personal del Banco que trabaja en proyectos de salud en China, y tambien a los profesionalesde la salud en general, este exa- men del sector comienza seiialandolos logros del pais en materia de control de la poblaci6n, estado de salud y nutrici6n. A continuaci6nen una secci6n espe- cifica se examinan las politicas, las fuentes de financiamientoy la utilizaci6n de recursos que han contribuido a los exitos de China. Enseguida se analiza la evoluci6n de varias influencias externas: mejoramientos nutricionales, mayor acceso al agua potable y a la eliminaci6n de desechos mediante metodos sanitarios, y reducci6n de la fecundidad. Posteriormentese presenta un analisis de los problemas que subsisten y que plantean los dos principales desafios al sector hasta el fin del siglo. En este resumen se destacan las principales conclusionesdel estudio.

Logros

4. Poblaci6n. El censo de China realizadoel 30 de junio de 1982 arroj6 una poblaci6n de 1008 millones de habitantes, lo que excede en 73% el total registrado en el primer censo de la Republica Popular de China efectuado en 1953. Por lo tanto, la tasa de crecimiento de la poblaci6n en los 29 aiios intermedios fue de 1,9% al afio. Sin embargo, las tendencias en la fecundidad total y la mortalidad durante este periodo han estado lejos de ser uniformes, y las condicionesdemograficas aun varian marcadamenteentre las distintas regiones del pais. Las tasas de natalidad eran de alrededor de 45 por 1.000 a mediados del decenio de 1950, lo que significa una tasa de fecundidad de cerca de 6,5 nacimientos por cada mujer. Las tasas de mortalidad descendieron desde

- xx - - xxi -

cerca de 30 por 1.000 a comienzos de los aiios cincuenta a alrededor de 23 en 1957, lo que equivale a una esperanza de vida de aproximadamente38 anios. Sin embargo, los exitos anteriores al "gran salto hacia adelante" de 1958 fueron seguidos por un periodo de catastrofe: la mortalidad se elev6 bruscamente alrededor de 1960 y la tasa de natalidad descendi6 vertiginosamente,dando por resultado una perdida de poblaci6n de mas del 1%. Tras la hambruna de 1959-62, la tasa de natalidad excedi6 el nivel de los anioscincuenta y enseguida dismi- nuy6 lentamente hasta el final de la d6cada. El descenso de la fecundidad desde 1970 ha sido extraordinario,al disminuir la tasa total a cerca de 2,5 en el periodo de 1975-80; sin embargo, se elev6 a 2,8 en 1981. La tasa de crecimiento de la poblaci6n aument6 alrededor de 1,3% al anioen 1981 de su punto bajo registrado a fines del decenio de 1970 de apenas sobre el 1% anual.

5. Las disminucionesde la fecundidad han sido mucho mas rapidas en las zonas urbanas que en las rurales. La tasa de natalidad en estas ultimas, deri- vada indirectamentede los datos del censo de 1982, es casi el doble de la tasa en las zonas urbanas (22,5 par 1.000, frente a 12,4) y es alrededor de 7,2 mas alta en las regiones aut6nomas. Estos resultados equivalen aproximadamente a las estimaciones de la Comisi6n Estatal de Planificaci6n de la Familia, que senialauna tasa de fecundidad total en 1982 de 2,9 en las zonas rurales y de 1,5 en las urbanas.

6. Situaci6n en materia de salud. El Banco Mundial ha elaborado un con- junto de estimacionesde las tendencias de la esperanza de vida y la mortalidad infantil posteriores a 1940; al respecto, dos puntos acerca de los resultados merecen comentario especial. En primer lugar, las estimaciones del Banco con- cuerdan en general con las estimacionesoficiales acerca de los impresionantes mejoramientos de la esperanza de vida y las disminuciones de la mortalidad infantil. Continuando con el esquema de mejoramiento que habia comenzado cinco o diez anios antes, la esperanza de vida se elev6 de menos de 35 anios en el periodo inmediatamenteposterior a 1949 a casi 70 aniosa principios de los anios ochenta; la tasa estimada de mortalidad infantil disminuy6 de 250 en 1950 a menos de 50 en 1981. En segundo termino, si bien las estimaciones del Banco respecto al esquema general de mejoramiento coinciden con las cifras oficiales, las relativas a la mortalidad infantil son apreciablementemas altas que las del Gobierno. La notificaci6n incompleta de los nacimientos y muertes de ninios menores de un aniobien podria explicar esta diferenciay, de ser asi, indica que los problemas relacionadoscon los cuidados prenatales e inmediatamenteposnata- les en China merecen mas atenci6n de lo que sugieren los datos oficiales.

7. Se han efectuado estimacionesde la esperanza de vida por municipali- dad, provincia y regi6n aut6noma, en base a datos derivados de un importante estudio sobre la mortalidad debida al cancer realizado en 1973-75. Dichas estimaciones varian desde 59 aniosen Guizhou a 72 en Shanghai, lo que denota diferencias interprovincialesmuy considerables. Algunas de estas discrepancias (pero no todas) pueden explicarse por diferencias de ingresos. El anAlisis estadistico del estudio sobre la mortalidad debida al cancer lleg6 a la conclu- si6n de que la esperanzade vida en las zonas urbanas es, como promedio, 12 aiios mas alta que en las rurales tipicas; la esperanza de vida en las zonas rurales de bajos ingresos (que se definen como las que tenian un ingreso per capita - xxii -

distribuido de menos de 50 yuan en 1979) es de 5 aniosmenos que en las tipicas. El analisis de los datos sobre las tasas de mortalidad que se han derivado del censo de 1982 lleg6 a conclusionessimilares. Esta diferencia entre zonas rurales y urbanas excede la que se observa en la mayoria de los demas paises en desarrollo, y refuerza vigorosamente la importancia de las politicas declaradas del Gobierno de mejorar las condicionesen las zonas rurales.

8. Las epidemias peri6dicas, junto con un elevado nivel de morbilidad debido a enfermedades infecciosas y malnutrici6n, le dieron a China antes de 1949 la reputaci6n del "enfermo de Asia" y llevaron a los lajos niveles de esperanza de vida que se acaban de senialar. El 6xito considerabledel pais en su lucha contra las enfermedades infecciosas ha dado por resultado no s6lo una mayor esperanza de vida sino tambien el surgimientode nuevas causas principales de morbilidad y mortalidad. En las zonas urbanas y en gran parte de las rurales, las enfermedades parasitarias e infecciosas han sido en gran medida reemplazadascomo causas de muerte por las enfermedadesdel coraz6n, el cancer, los accidentes cerebrovasculares,las enfermedadesrespiratorias cr6nicas y los accidentes en general. Por ejemplo, la tasa de mortalidad a causa de enfermedades del coraz6n aument6 de 71 por 100.000 en 1958 a 141 por 100.000 en 1979 en cuatro distritos urbanos de Pekin. Los niniosmenores de un aino, los ninios pequenos y las mujeres j6venes han sido reemplazados por las personas de edad mediana y los ancianos como los grupos de poblaci6n con la mAs alta mortalidad. Ademas, los grupos de edad avanzada consumen una creciente proporci6n de los serviciosm6dicos.

9. Esta transformaci6n,que ya ha ocurrido en los paises industrializados, se conoce actualmente como la "transici6n epidemiol6gica". Si bien las caracteristicasde la morbilidad en las zonas urbanas de China son cada vez mas similares a las de los paises de ingresos altos, la transici6n aun esta en marcha en las zonas rurales del pais. Algunas enfermedadestransmisibles, como la disenteria, la tuberculosisy la hepatitis, siguen siendo importantesproble- mas nacionales. En las regiones mas pobres, las condiciones de salud probablemente van 20 aniosa la zaga de las logradas en otras zonas mas avanzadas. Ade- mAs, en zonas geograficaso climaticas vulnerables, las enfermedades infecciosas y parasitarias como la lepra, el paludismo y la esquistosomiasissiguen siendo problemasgraves.

10. Estado nutricional. Los datos disponibles indican mejoramientos cons- tantes en el estado nutricional de los nianosen edad escolar en China, al menos en las zonas urbanas. Los datos sobre variaciones en la situaci6n nutricional a menudo se indican en tasas de crecimiento por decenio. Las tasas de aumento de la estatura media de China correspondientesa dos decenios recientes fueron de 1,55 cm por decenio en la regi6n rural de Shanghai, 2,49 cm en la ciudad de Guangzhou, 1,48 cm en la zona rural de Guangdong y 3,8 cm en la zona urbana de Pekin (en niniosde 9 anios). Estos datos son dificiles de interpretarsin otros comparativosde periodos anteriores en el pais o de otros paises en desarrollo. Sin embargo, las tasas son tanto o mas altas que las de Europa del siglo XX, lo que sugiere importantes6xitos en esta materia. Si la experiencia europea sirve de alguna orientacion, puede preverse que estos aumentos continuaran hasta entrado el pr6ximo siglo. - xxiii -

11. En las zonas urbanas, la malnutrici6nse ha reducido considerablemente y ya no puede considerarseun problema importante. Por contraste, muchos ninios en las zonas rurales continuiansufriendo una malnutrici6n entre moderada a seria. Una encuesta de 16 provincias y municipalidadesrealizada en 1979 proporciona la base para evaluar las diferencias urbano-ruralese interprovinciales en la malnutrici6n infantil. Pueden observarse caracteristicas evidentes de malnutrici6nmoderada en las zonas rurales, con un porcentaje estimado de 12,7% de niniosvarones de 7 aiiosde edad en zonas rurales que tienen crecimientoatro- fiado en las 16 provincias encuestadas;en Sichuan, la cifra asciende a 37%. En las urbanas, s6lo el 2,6% de los niniosestan mal desarrollados. Las razones para la mejor situaci6n en las zonas urbanas incluyen la menor frecuencia de enfermedades y mas alimentos de mejor calidad (los subsidios urbanos para alimentos se estimaron en 96 yuan por habitante urbano en 1981 y representaronmAs del 4% del PIB). La persistenciade un nivel apreciable de subnutrici6nen las zonas rurales de China ofrece pruebas adicionalesde que la transici6n epidemio- l6gica esta lejos de terminar y que es necesario continuar prestandoatenci6n a los problemas de las enfermedadestipicas de los paises de ingresos bajos.

El sector de salud

12. Las politicas de salud. En comparaci6n con la mayoria de los demas paises, China ha hecho hincapie en los servicios preventivos de salud mas bien que en los curativos, sin descuidar la importancia de las medidas curativas tanto para el bienestar de la poblaci6n como para la labor de controlar las enfermedades transmisibles. Poco despu6s de 1949 se organizaron importantes campafiaspara mejorar el saneamiento ambiental, eliminar las "cuatro plagas": ratas, moscas, mosquitos y chinches, efectuar vacunaciones contra las enfermedades infecciosasy curar 6stas, y controlar los vectores de los principales trastornos endemicos como el paludismo y la esquistosomiasis. La movilizaci6n de las masas desempen16una funci6n clave en el exito de estas campanas. La asigna- ci6n de recursos de salud destinados a las actividades preventivas (y a cual- quier servicio curativo que se proporcionaba en las zonas urbanas) gener6 una demanda de servicios curativos por lo menos minimos y la disponibilidadde pro- ductos farmac6uticosen las zonas rurales; las politicas de salud en las epocas del "gran salto hacia adelante" y la Revoluci6n Cultural respondieron a esa inquietud. Estos vigorosos esfuerzos preventivos indudablemente han tenido enorme 6xito en reducir la morbilidad y la mortalidad. Sin embargo, actualmente se presta mas atenci6n a los servicios curativos,y el metodo preventivo de control de las enfermedadeshasta ahora parece estar desempeniandos6lo una funci6n marginal en el tratamiento de los problemas actuales de las enfermedades cr6nicas.

13. La preocupaci6nde China respecto a la salud y prevenci6n de enfermedades tambien ha llevado a la adopci6n de una estrategia de salud que va mas alla del sistema de salud per se. En especial, la mejor nutrici6n, el suministro de agua potable, los metodos apropiadosy sanitarios de eliminaci6nde desechos, la disminuci6n de la fecundidad y los mejoramientos generalizadosen edu- caci6n han sido objetivos importantesde politica. La capacidad administrativa y la voluntad politica del Gobierno chino, no obstante algunos reveses ocasiona- les, han sido factores fundamentalespara el exito de esta estrategia multiface- tica. - xxiv -

14. Las repercusiones de la disponibilidad de recursos destinados a la salud. Junto con la aplicaci6n de politicas de salud se ha registrado un rapido aumento en la disponibilidadde servicios hospitalariosy de personal de salud. Sin embargo, los 6xitos del pais en este sector en general se han atribuido a la manera como se han utilizado los recursos mas bien que a la disponibilidadde medicos y hospitales. El anAlisis de los factores que influyen en la morbilidad y la mortalidad tiende a corroborar esta opini6n. Ademis, a medida que los tipos de enfermedadesse acercan mAs a las enfermedadescronicas y se alejan de las transmisibles,no es probable que los aumentos de ingresos sigan conduciendo a una mejor esperanza de vida; mas bien, los datos disponibles sugieren que los aumentos de ingresos actualmente se traducen en cambios de modo de vida que hacen a las personas mAs propensas a contraer enfermedades cr6nicas. Esto sugiere la prioridad en formular politicas puiblicasecon6micamente viables orientadas a postergar el comienzo y a administrar las consecuencias de las enfermedades cr6nicas, con el cambio cualitativo requeridoen la educaci6n y las funciones del personal de salud. A fin de evitar la tendencia inevitable a aumentar simplemente el numero de medicos y de otro tipo de personal disponibles, serA necesario planificar cuidadosamente la formaci6n de los recursos humanos del sector; es fundamental en esta planificaci6nproporcionar servicios en las zonas rurales, formar medicos en forma adecuada cuando no es posible efectuar inversiones importantes en equipos, y asegurar que se preste la importanciadebida a la medicina comunitariay preventiva.

15. El financiamientoy los gastos del sector de salud. Los gastos totales del sector de salud en 1981 se estiman en aproximadamenteY 15,0 per capita, de los cuales Y 14,3 se destinan a gastos de operaci6n y Y 0,6 a gastos de capital. Esto representa el 3,3% del PIB per capita en 1981. La asignacion de gastos puede analizarse de acuerdo con las fuentes de financiamiento,los sistemas de prestaci6n de servicios y los gastos por insumos de recursos. El financiamiento proviene en montos casi iguales de tres fuentes principales: desem- bolsos privados (32%), seguros de los trabajadores (31%) y gastos presupuesta- rios estatales (30%). Las brigadas de producci6n financian el 7% restante. De la misma manera, la estructura de la prestaci6n de servicios de salud es basica- mente tripartita. El sistema colectivo rural, en especial los servicios de salud de las brigadas y comunas, proporciona la parte mayor de los servicios de salud, que se valoran en aproximadamenteel 40% del total; el sistema guberna- mental suministra alrededor del 32%, y el sistema de las empresas estatales, que atiende exclusivamentea los empleados de las empresas y a sus cargas familia- res, entrega el 25% de los servicios totales. Recientementese ha autorizado la prActica medica privada, pero hasta la fecha tiene poca importancia. Los pro- ductos farmaceuticos son con mucho el insumo mas importante en el sector de salud, puesto que representa el 58% de los gastos totales; s6lo los farmacos de tipo occidental consumen el 49% de los gastos totales en salud. Los costos de personal (a los salarios prevalecientes en China) representan menos de una cuarta parte de los gastos totales. (Sin embargo, esta cifra excluye el costo de la mano de obra no remunerada,ya sea voluntaria o movilizada de otra manera, respecto de la cual prActicamenteno existen datos pertinentes,pero cuya con- tribuci6n al exito de muchos esfuerzos preventivos, en especial los asociados con el saneamientoambiental, debe haber sido considerable.) - xxv -

16. Una elevada proporci6n de los gastos totales se produce a traves de los planes de seguros. Esto refleja el alto grado de cobertura de los seguros de salud, que es uno de los grandes logros del sistema de salud en China. S61o cerca del 30% de la poblaci6n no tiene ningun seguro y practicamente todo este grupo vive en las zonas rurales.

17. Existen considerables diferencias urbano-rurales en los gastos de salud. Los gastos en las zonas urbanas se estiman en Y 33 per capita, lo que es mais de tres veces los de las zonas rurales, que se estiman en Y 9 per capita. Los subsidios estatales destinados a la atenci6n de la salud de los habitantes urbanos son casi diez veces superiores a los que reciben los rurales, --aproximadamente Y 26 per capita en comparaci6n con menos de Y 3 per capita. Los gastos privados per capita ascienden a menos de Y 3 en las zonas urbanas, pero a mas de Y 5 en las rurales.

18. Debido a la importancia de la medicina preventiva en China, es sor- prendente que menos del 5% de los recursos totales de la atenci6n de la salud se destine a cuidados preventivos y mas del 95% al suministro de servicios curativos. La prActica de la medicina tradicionalrecibe aproximadamenteel 14% de la asignaci6n total.

Problemas y desafios

19. Los esfuerzos de China por reducir la incidencia de las enfermedades transmisiblesy la frecuencia de la malnutrici6n-- disminuyendoasi considerablemente las tasas de mortalidad--han llevado a un aumento notable de la esperanza de vida. Este exito bien podria denominarse la primera revoluci6n china de atenci6n de la salud. Pero esta revoluci6n ha dejado como secuela dos esfe- ras distintas de problemas: la primera es que el 6xito hasta la fecha ha sido desigual: las condicionesde salud en las ciudades son efectivamentemuy satis- factorias, y la esperanza de vida en muchas zonas rurales va a la zaga de las ciudades en s6lo cinco o diez aiios. Sin embargo, las condiciones de salud de tal vez 100 a 200 millones de habitantes rurales siguen siendo similares a las que predominan en los paises en desarrollo tipicos. Estas personas viven en regiones pobres y remotas del pais; carecen de infraestructuraecon6mica y administrativa,y los niveles educacionalesson probablementebajos. No hay maneras faciles o de bajo costo de mejorar las condiciones de salud en estas regiones. En segundo lugar, la nueva frecuencia de las enfermedadescr6nicas ha pasado a ser una preocupaci6nimportante. El esquema actual de las causas de mortalidad en China es muy similar al de los paises industrializados: las enfermedadesdel coraz6n, el cAncer y los accidentes cerebrovascularesencabezan la lista. Los tratamientosde estas enfermedadesque se utilizan en el Occidente tienden a ser extremadamente costosos y s6lo medianamente eficaces. Pero las demandas de tratamiento de los pacientes y los esfuerzos de los m6dicos para lograr su curaci6n a menudo comprenden gastos considerables con relativamente pocos efectos en la salud.

20. Habida cuenta de estos problemas, el sector de salud en China enfrenta actualmentedos desafios prioritarios: - xxv i -

a) El primero consiste en finalizar la primera revoluci6n china de aten- ci6n de la salud, ampliando los metodos que han tenido exito en la mayor parte del pais a las zonas donde las tasas de mortalidad y las muertes debido a enfermedades infecciosas siguen siendo elevadas, y

b) El segundo es forjar una segunda revoluci6n china de atenci6n de la salud, en que se elaborarian y aplicarian metodos para controlar las enfermedades cr6nicas combinando los servicios preventivos, el tratamiento de bajo costo, la rehabilitaci6n y los cuidados humanitarios. Los problemas que es preciso superar para forjar esta segunda revolu- ci6n son enormes, pero incluso el 6xito parcial seria de inmenso valor no s6lo para China sino tambi6n para la comunidad internacional.

21. C6mo finalizar la primera revoluci6n. Continuan existiendo grandes disparidades entre y dentro de las provincias y entre las zonas urbanas y las rurales en cuanto a la disponibilidad de servicios de salud y la situaci6n sani- taria. El suministro eficaz de atenci6n de la salud se ha consolidado en las zonas urbanas. La siguiente prioridad, que es reconocida por el Ministerio de Salud Publica, consiste en consolidar los avances hechos en algunas zonas rurales y extender un nivel similar de servicios a las zonas mas pobres. Un pr6ximo paso importante esta en la preparaci6n de planes detallados para reducir las tasas de mortalidad y morbilidad debido a enfermedades especificas en los distritos pobres; esos planes deben incluir consideraciones epidemiol6gicas, analisis financiero y evaluaci6n de las necesidades de recursos humanos, capacitaci6n y utilizaci6n. Dada la pobreza de la mayoria de las localidades donde se requiere finalizar la primera revoluci6n en materia de salud, inevitablemente se necesitara financiamiento externo (del gobierno provincial o central) para aplicar medidas eficaces que reduzcan la diferencia en las condiciones de salud. Si bien las sumas que entran en juego no son cuantiosas en comparacion con los niveles actuales de subsidios estatales a los habitantes urbanos, el problema de generar los recursos necesarios es, sin embargo, real.

22. Una evoluci6n especialmente importante para la atenci6n de la salud en las zonas rurales de China es la disminuci6n de los sistemas de seguros cooperativos de salud en estas zonas despues de la introducci6n de los sistemas de responsabilidad de la producci6n. En 1975, el 85% de las brigadas de producci6n tenia seguros cooperativos, pero esta cifra habia disminuido a 58% en 1981. En consecuencia, casi la mitad de la poblaci6n rural debe pagar el precio total de los servicios m6dicos y es muy probable que la proporci6n continue aumentando. Esta tendencia tiene dos consecuencias sumamente inconvenientes. La primera es que, sin planes de seguros de salud, se pierden los principales beneficios en bienestar que pueden lograrse mediante la participaci6n en los riesgos. Aunque los sistemas cooperativos tenian muchos defectos, incluida la incapacidad para compartir los riesgos con respecto a un gran nuimero de personas, proporcionaban sin embargo un servicio basico importante. En segundo lugar, los m6todos de honorarios por servicios en el suministro de atenci6n de la salud inevitablemente descuidan las medidas preventivas publicas, no obstante que han desempe- nado una funci6n vital en el exito logrado en esta esfera. AdemAs, las actividades preventivas que comprenden la movilizaci6n de la mano de obra sobre una base no remunerada pueden resultar especialmente afectadas por el sistema de responsabilidad y llevar al resurgimiento de enfermedades parasitarias e infecciosas, a menos que se establezcan otros mecanismos de financiamiento. - xxvii -

23. Tareas para una segunda revoluci6n en materia de atenci6n de la salud en China. El 6xito en el control de las enfermedades transmisiblesha traspa- sado la carga de los problemas de salud del pais a los grupos de edad avanzada, que son especialmente vulnerables a los trastornos cr6nicos. La prevenci6n es relativamentedificil en la mayoria de las enfermedades cronicas, y la prepara- ci6n de estrategias eficaces aunque de bajo costo para tratar estos trastornos constituye una prioridad. El escollo principal esta en la tentaci6n de emular metodos curativos de alto costo que han demostrado ser relativamenteineficaces y que incluso en paises de ingresos altos han dado por resultado una enorme dis- minuci6n de los recursos econ6micos nacionales. No cabe esperar que ni las medidas preventivas ni las curativas para tratar los trastornos cr6nicos tengan el mismo efecto espectacular en la esperanza de vida que el control de las enfermedadestransmisibles e infecciosas,que tuvo el efecto de elevar la esperanza de vida sobre todo al reducir la mortalidad entre niiiosde menos de un anio y niniospequenios; con todo lo tragico que pueden ser estas muertes prematuras, el costo afectivo y econ6mico, para la familia y la sociedad, de la muerte pre- matura de adultos productivos es mucho mayor. Por consiguiente, los programas para tratar las enfermedadescr6nicas daran por resultado beneficios en bienestar que son mAs que proporcionalesa su efecto limitado en la esperanzade vida.

24. Pueden adoptarse de inmediatoalgunas medidas para prevenir las enfermedades cronicas, en especial el control del consumo de sal y de tabaco. Los niveles de consumo de sal en China exceden los de la mayoria de los demas paises y, en consecuencia, China tiene una alta (y creciente) incidencia de hiperten- si6n (elevadapresi6n sanguinea). El exceso de consumo de sal conduce a enfermedades del coraz6n y a accidentes cerebrovascularesevitables, que actualmente constituyen un importante problema de salud pulblicaen China. El consumo de tabaco ha sido excepcionalmentealto para un pais de su nivel de ingresos, pero a pesar de la politica para desalentar el hAbito de fumar que se inici6 hace dos anios,el consumo de tabaco ha aumentado en forma impresionante. (En efecto, el Sexto Plan Quinquenal preve un aumento del 81% en la producci6n de tabaco entre 1980 y 1985.) Los consiguientes aumentos en cancer del pulm6n y enfermedades respiratoriascr6nicas conllevan mucho sufrimiento humano, p6rdidas de producti- vidad y gastos medicos innecesarios. Otras medidas preventivas pueden ser menos evidentes: la prevenci6n de las enfermedades cr6nicas es inherentemente mas dificil que la de las transmisibles. En consecuencia,es fundamental reconocer este hecho y comprometer recursos apreciables a la elaboraci6n de estrategias tendientesa prevenir las enfermedadescr6nicas.

25. Tambi6n reviste importancia la preparaci6n y aplicaci6n generalizada de estrategias para tratar pacientes que tienen enfermedades cr6nicas. Dichas estrategias deben incluir la capacidad para proporcionar tratamiento eficaz y financieramenteaccesible; la rehabilitaci6nde personas parcial o totalmente incapacitadaspor enfermedades no transmisibles y los cuidados humanitarios de las que padecen enfermedades terminales (esfera en que se han logrado avances importantes y posibles de financiar en la practica medica de Occidente). De importancia fundamental para el 6xito de estas estrategias son los recursos humanos apropiadamentecapacitados, incluidos los medicos que pueden proporcionar atenci6n eficaz sin depender de m6todos importados que utilizan equipo y procedimientossumamente costosos. - xxviii -

26. Un ultimo factor para lograr la segunda revoluci6n en materia de aten- ci6n de la salud sera el diseiiode una estructura de seguros y financiamiento que fomente la prevenci6n de enfermedades y desaliente la actual tendencia a emplear excesivamentelos servicios. La estructura de seguros debe proporcionar fuertes desincentivos a la introducci6n de procedimientosde elevado costo que esten unicamente al alcance de unos pocos. Al utilizar sumas deducibles elevadas y s6lo aportaciones parciales a los costos posteriores, la estructura de seguros tambien debe crear incentivos para que tanto el paciente como el medico utilicen prudentementelos recursos del sector.

Problemas de estrategia

27. Los problemas que se acaban de analizar plantean un desafio al sistema de atenci6n de la salud en China frente a innovaciones importantes. Las innovaciones son fundamentalestanto porque los recursos para la atenci6n de la salud en el pais son pocos en comparaci6n con los disponibles en el Occidente como porque China tiene planes mucho mas ambiciosos que la mayoria de los paises de ingresosbajos en cuanto a satisfacer las necesidades de salud de su poblaci6n. Incluso con el aumento mas rapido que fuera posible de los gastos en salud, que se harian a costa de inversiones muy necesarias en otros sectores, China podria proporcionars6lo a unos pocos la medicina curativa de Occidente que tiene uso sumamente intensivo de capital. Por lo tanto, las restricciones de recursos exigen decisiones dificiles: m6todos importados para atender a una minoria selecta y poco o ninguinmejoramiento para la vasta mayoria, o analisis cuidado- sos e innovacionespara ampliar el alcance de los recursos limitados. Enfren- tada a estas restricciones,la anterior estrategia de China con su 6nfasis en las practicas con gran intensidad de mano de obra aum tiene sentido desde el punto de vista econ6mico. Adernis,un metodo innovador, si bien conlleva riesgos mas elevados, se requiere precisamente porque no existe una estrategia general para ampliar la primera revoluci6n de atenci6n de la salud y forjar la segunda. La elaboraci6nde la base de esta estrategia,con sus repercusionesfinancieras, politicasy de recursos humanos, tiene una elevada prioridad.

28. Un factor fundamental en la aplicaci6n de estrategias para tratar los problemas de salud de China es el establecimientode instituciones capaces de innovaciones,experimentos y analisis de los problemas de salud puiblica. El mejoramientode las escuelas de medicina, en especial de las 13 escuelas principales, puede desempeniaruna funci6n clave en este Ambito, siempre que los profe- sores tengan intereses de investigaci6ny de docencia que trasciendan los ade- lantos tecnicosen las ciencias biol6gicas y la medicina clinica. La iniciativa del Ministerio de Salud Piublicade establecer un Centro Nacional de Medicina Preventivay un Centro de Investigaci6nsobre Planificaci6n de la Salud y Esta- disticas debe contribuir a mejorar la capacidad del pais para encontrar solucio- nes econ6micamente viables a los principales problemas de salud. De igual manera, la importancia que el Ministerio de Salud Piublicaotorga al mejoramiento de la asignaci6n de recursos y las capacidades administrativas-- en todo el sistema de salud y en las instituciones--debe ayudar a mejorar la eficiencia. Ademas de estos esfuerzos generales orientados a crear la capacidad institucio- nal de innovaci6ny eficiencia, deben considerarsevarios problemas especificos (que se analizan en el Capitulo 5 del Informe). A continuaci6n se presentan algunos de los puntos principales. - xxix -

29. El financiamientode la atenci6n de la salud en las zonas pobres. Mientras el Estado tiene la responsabilidadde financiar la atenci6n de la salud en las zonas urbanas, en las rurales se aplica la politica de autosuficiencia (es decir, financiamientolocal e individual). Esto ha resultado satisfactorio para las zonas rurales acomodadas; sin embargo, en las regiones pobres de China rural, a menudo no se dispone siquiera de servicios minimos. Una cuesti6n importantede politica que debe resolver el Gobierno es si postergar los esfuerzos por mejorar la atenci6n de la salud en las zonas pobres hasta que se hayan hecho mas avances en las ciudades y en las zonas rurales pr6speras. La asisten- cia activa a las zonas pobres requeririael financiamientodel gobierno central, pero el efecto de las inversiones en salud en estas zonas probablemente excede- ria las repercusionesde las inversionesen regiones mis pr6speras del pais; por consiguiente,la preocupaci6nen cuanto a la eficiencia reforzaria las consideraciones de equidad en favor de una politica de esta naturaleza.

30. Clinicas comunitarias importantes. La politica del Gobierno consiste en fomentar el establecimientode importantes clinicas comunitarias,mejor equi- padas y con personal m6dico bien calificado para que puedan satisfacer muchas demandas que de lo contrario podria haber en los hospitales de distritos. La creaci6n de estas clinicas, que podrian ser pequenioshospitales (50 a 150 camas) con tres a ocho medicos, es tal vez la prioridad mayor para mejorar el acceso a los servicios curativos en las zonas rurales, muchas de las cuales estan muy alejadas de los hospitales distritales. Por aniadidura,aliviarian las presiones en estos hospitales debido al sistema de envio de pacientes. La obtenci6n de personal adecuadamentecalificado para estas importantes clinicas serA una tarea delicada, sobre todo en vista de la experiencia de la Revoluci6n Cultural que oblig6 a los m6dicos a ejercer su profesi6n en las zonas rurales, y requerira incentivos apropiados para el personal, que incluyen equipo y condiciones de trabajo satisfactorios.

31. La capacidad de evaluaci6n cientifica y la investigaci6nsobre sistemas de salud. La evaluaci6n de la eficacia de las t6cnicas nuevas y tradiciona- les de diagn6stico,tratamiento y prevenci6n asume mucha mas importancia debido al elevado costo de la tecnologia medica moderna. Los principales colegios m6dicos a menudo son los pioneros en introducir nuevas tecnicas medicas y deben formar la capacidad para efectuar esta evaluaci6n. Es necesario aplicar principios epidemiol6gicosno s6lo a las enfermedadesno infecciosas sino tambien a la evaluaci6n de las medidas de control de enfermedadesy a la calidad de los cuidados y la asignaci6n de recursos en el sistema de salud, es decir, a la inves- tigaci6n sobre los sistemas de salud. Esto reviste tanta importancia en la medicina clinica, occidentaly tradicional,como en la salud puiblica.

32. La prevenci6n de enfermedades cr6nicas. A pesar de la importancia dada a "situar a la prevenci6n en primer lugar", se ha prestado relativamente poca atenci6n a la prevenci6n de trastornos como los de tipo cardiovascular,el cancer y las enfermedades respiratorias cr6nicas. Incluso en muchas zonas rurales, la mayoria de las muertes se deben a estos trastornos. Una prioridad evidente consiste en establecer (o designar) instituciones responsables de observar continuamentey prevenir las enfermedadescr6nicas. Resume

1. Avant 1949, les maladies et les deces pr6matur6s prelevaient un tribut 6crasant sur la population chinoise; l'augmentation spectaculaire de l'esp6rance de vie et la reduction des maladies qui l'a accompagn6e sont peut-etre les marques les plus frappantes du succes que la Chine a remporte dans sa lutte contre la pauvrete. Les mesures de sante publique - associees a la reduction de la malnutrition, a l'amelioration de l'alimentation en eau et a l'interet porte a l'hygiene et a 1'assainissement - ont fait passer l'esperance de vie de 32 ans en 1950 a 69 ans en 1982, c'est-a-dire qu'elle n'est plus que de six ans inferieure a celle des pays industrialises a economie de marche. Mais les progres r6alises dans le domaine sanitaire sont loin d'etre uniformes et de grandes diff6rences subsistent encore entre les regions rurales et les r6gions urbaines, de meme entre les regions rurales elles-memes.

2. Le fait que des interventions plurisectorielles aient permis d'am6liorer la situation sanitaire en Chine et qu'une priorite ait 6t6 accordee a la m6decine pr6ventive, a la mobilisation des collectivites avec leur participation financiere ainsi qu'a l'utilisation de medecins aux pieds nus, a profondement marqu6 la maniere de penser des specialistes de la sant6 de tous les pays en d6veloppement. En fait, la declaration d'Alma-Ata de 1978, sur "la sant6 pour tous en l'an 2000", reposant sur les strat6gies de "soins de sante primaires", s'est largement inspiree du modele chinois. Mais le systeme chinois a mari et les problemes qu'il lui faut r6soudre aujourd'hui ont change; il faut donc reevaluer la situation sanitaire en Chine et les soins de sant6 sur la base des nombreux renseignements dont on dispose actuellement.

3. Pour aider le personnel de la Banque qui travaille sur des pro- jets de sante en Chine et plus generalement les specialistes de la sante, la presente etude expose d'abord les resultats obtenus dans les domaines du controle de la croissance demographique et dans ceux de la sante et de la nutrition. Une section speciale est consacree a la sante, a l'action men6e au niveau politique, aux sources de financement et a l'utilisation des ressources qui ont contribu6 aux succes de la Chine. Le rapport analyse ensuite l'influence que divers facteurs exterieurs ont exercee sur la sant6 tels : am6lioration de la nutrition, meilleur acces a l'eau potable, elimination hygienique des d6chets, r6duction de la fecondite. Enfin ce rapport examine les grands defis qui vont se poser a la Chine d'ici A la fin du siecle. Ce sont les principales conclusions de cette etude qui sont reprises dans ce resume.

Realisations

4. Population. Lors du recensement du 30 juin 1982, la Chine comptait 1.008 millions d'habitants, c'est-a-dire 73 % de plus que lors du premier recensement de 1953. Pendant 29 ans, le taux de croissance demographique a donc ete de 1,9 % par an, mais I'evolution de la fecondite et

- xxx - - xxxi - de la mortalite est loin d'avoir ete r6guliere au cours de cette p6riode et la situation demographique est encore tres diff6rente selon les e6gions. Vers le milieu des ann6es 50, le taux de natalite 6tait d'environ 45 pour 1.000, c'est-a-dire que le taux de fecondite 6tait a peu pres de 6,5 naissances par femme. Le taux de mortalit6, qui etait de quelque 30 pour 1.000 au debut des annees 50, est tomb6 a environ 23 pour 1.000 en 1957, ce qui correspond a une esp6rance de vie d'environ 38 ans. Les succes qui avaient pr6c6d6 le Grand Bond en avant de 1958 ont 6te sui- vis par une p6riode catastrophique : la mortalite a brutalement remonte aux environs de 1960 et le taux de natalite a accuse une chute verticale, ce qui a cause une perte de plus de 1 % de la population. Apres la famine des annees 1959-62, le taux de natalit6 a depass6 son niveau des ann6es 50 puis a diminu6 lentement jusqu't la fin de la decennie. Depuis 1970, la chute de la fecondit6 a 6te tres notable, l'indice synth6tique de fecon- dit6 tombant a environ 2,5 au cours de la periode 1975-80; en 1981 il est cependant remonte a 2,8. Le taux de croissance demographique, qui etait tomb6 a un peu plus de I % par an a la fin des annees 70, est lui aussi remonte et a atteint un peu plus de 1,3 % en 1981.

5. La baisse de la f6condit6 a 6te beaucoup plus rapide dans les villes que dans les campagnes. Calcul6 a partir des chiffres du recensement de 1982, le taux de natalit6 dans les r6gions rurales atteint presque le double de celui des regions urbaines (22,5 pour 1.000, contre 12,4) et celui des regions autonomes est environ 7,2 fois plus 6leve. Ces chiffres concordent a peu pres avec ceux de la Commission d'Etat au planning fami- lial qui estime que l'indice synthetique de fecondite, en 1982, etait de 2,9 dans les regions rurales et de 1,5 dans les r6gions urbaines.

6. Situation sanitaire. La Banque mondiale s'est livr6e a une s6rie d'estimations sur 1'6volution de 1'esp6rance de vie et de la morta- lit6 infantile apres 1940 et les r6sultats qu'elle a obtenus appellent deux commentaires. En premier lieu, ses chiffres concordent a peu pres avec les estimations officielles sur l'amelioration spectaculaire de 1'esperance de vie et sur la reduction de la mortalit6 infantile. L'esperance de vie, qui avait commence a progresser cinq a dix ans auparavant, est passee de moins de 35 ans au d6but des annees 50 a pres de 70 ans au debut des ann6es 80 et le taux estimatif de mortalit6 infantile est tombe de 250 en 1950 a moins de 50 en 1981. Deuxiemement, si les estimations de la Banque relatives a cette tendance gen6rale a l'amelioration concordent avec les chiffres officiels, elles leur sont par contre tres nettement sup6rieures en ce qui concerne la mortalit6 infantile. Cette difference peut fort bien s'expliquer par le fait que les naissances et les deces d'enfants ne sont pas tous declar6s; dans ce cas, la conclusion qui s'impose est qu'il faut accorder plus d'attention aux soins pr6nataux et postnataux que ne semblent l'indiquer les documents officiels.

7. Partant des donnees recueillies au cours d'une enquete approfon- die sur la mortalite par cancer en 1973-1975, on a calcule 1'esp6rance de vie par municipalit6, par province et par region autonome. Ces calculs font apparaitre d'importantes differences entre les provinces : 59 ans a - xxxii -

Guizhou et 72 ans a Shanghai. Certaines (mais non pas toutes, loin de la) peuvent s'expliquerpar des differencesde revenu. L'analyse statistique des resultats de l'enquete sur le cancer a montre que l'esperancede vie dans les r6gions urbaines etait en moyenne de 12 ans superieurea celle des r6gions rurales types; dans les r6gions rurales a faible revenu (cWest-a-direcelles oiile revenu par habitant etait inf6rieura 50 yuan en 1979), elle 6tait de cinq ans inferieurea celle des r6gions types. L'analyse des taux de mortalite tir6s du recensementde 1982 a donne des r6sultatsanalogues. Ces differencesentre les villes et les campagnes sont plus marquees que dans la plupart des autres pays en developpement, ce qui confirme l'importancedes mesures prises par le Gouvernementpour ameliorer la situation dans les campagnes.

8. Des 6pidemies periodiques,ainsi qu'une importantemorbidite due aux maladies infectieuseset a la malnutritionqui 6taient responsables d'une breve esperance de vie, avaient valu a la Chine d'avant 1949 d'etre appelee "l'homme malade de l'Asie". Les succes remportes dans la lutte contre les maladies infectieusesn'ont pas seulement contribu6 a augmenter 1'esp6rancede vie mais ont aussi fait apparaitre de nouvelles causes de morbidite et de mortalite. Dans les zones urbaines et dans une grande partie des campagnes, les parasitoseset les maladies infectieusesont 6t6 remplac6esdans des proportionsimportantes, en tant que causes de deces, par les maladies cardiaques,le cancer, les congestionscerebrales, les accidents et les affections respiratoireschroniques. Le taux de mortalite par maladies cardiaques,par exemple, est passe dans les quatre districts urbains de Beijing de 71 a 141 pour 100.000 entre 1958 et 1979. Ce n'est plus chez les nouveau-n6s,les enfants et les jeunes femmes que la mortalite est la plus elevee mais chez les individus d'age moyen et les personnes ag6es, et ce sont les groupes d'age plus vieux qui sont proportion- nellement les plus grands consommateursde soins m6dicaux.

9. Les pays industrialisesont deja franchi le stade que l'on d6signe aujourd'hui sous le nom de "transitionepid6miologique". Mais cette transition est toujours en cours en Chine rurale, alors que la phy- sionomie de la pathologieurbaine ressemble de plus en plus a celle que l'on trouve dans les pays a haut revenu. Certaines maladies transmissibles - dysenterie, tuberculoseet hepatite - sont toujours des problemes nationaux importants. Sur le plan sanitaire, les regions pauvres de Chine ont probablementvingt ans de retard sur les plus developpees. De plus, dans les zones climatiquesou geographiquesvulnerables, les maladies infectieuseset les parasitoses (lepre, paludisme et schistosomiase) continuentde poser de tres serieux problemes.

10. Etat nutritionnel. Les chiffres dont on dispose semblent indiquer une am6liorationr6guliere de 1'etat nutritionneldes enfants chinois d'age scolaire, du moins dans les villes. Les donn6es relatives aux modifications de l'etat nutritionnels'expriment souvent en taux de croissance de l'enfant par decennie. Au cours des deux dernieres decennies, la taille moyenne des enfants a augmente de 1,55 cm par decennie dans la r6gion rurale de Shanghai, de 2,49 cm a Guangzhou, de 1,48 cm dans la zone rurale de Guangdong, et de 3,8 cm dans les zones urbaines de Beijing - xxxiii -

(pour les enfants de 9 ans). Il est difficiled'interpreter ces chiffres sans les comparer a ceux qui portent sur des p6riodes ant6rieuresou qui concernentd'autres pays en developpement. Ces taux de croissance sont cependantaussi 6leves, voire plus eleves, que ceux qui ont ete enregis- tr6s en Europe au XXe siecle, ce qui temoigne des grands progres r6a- lises par la Chine et si l'on en juge par ce qui s'est pass6 en Europe, on peut s'attendre a ce que ces augmentationsse poursuiventpendant une bonne partie du XXIe siecle.

11. Dans les regions urbaines, la malnutritiona beaucoup regresse et l'on ne peut plus la consid6rer comme un probleme majeur. Dans les regions rurales, en revanche, beaucoup d'enfants continuent a en souffrir plus ou moins severement. Une enquete menee en 1979 dans 16 provinces et municipalitespermet de mesurer les differencesde malnutritionenfantine existant entre les villes et les campagnes et entre les provinces. L'image qui s'en d6gage est celle d'une malnutritionrurale moder6e : dans les 16 provinces etudiees, environ 12,7 % des garcons de sept ans souf- fraient d'un ralentissementde croissance;dans la province de Sichuan, le chiffre atteignait 37 % alors qu'il n'etait que de 2,6 % dans les zones urbaines. Si la situation est meilleure dans les villes, cela tient a la moindre pr6valence de la maladie et a une alimentationplus abondante et de meilleure qualit6 (on estimait les subventionsaux produits alimentaires dans les villes a 96 yuan par habitant en 1981, c'est-a-direa plus de 4 % du PIB). La persistanced'une s6vere sous-nutritiondans les regions rurales montre que la transitionepimediologique est loin d'etre termin6e et que les autorites doivent continuer de s'attaquer aux maladies qui sont caract6ristiquespour des pays a faible revenu.

Le secteur de la sante

12. Politique sanitaire. Si l'on compare la Chine a la plupart des autres pays, on constate qu'elle a mis davantage l'accent sur les services pr6ventifs sans negliger pour autant les mesures curatives qui permettent d'am6liorer le bien-etre de la populationet de lutter contre les maladies transmissibles. De grandes campagnesont 6te lancees peu apres 1949 pour ameliorer la salubritede l'environnement,pour 6liminer les "quatre pestes" (rats, mouches, moustiques,punaises des lits), pour vacciner la population contre les maladies infectieuseset les gu6rir et pour maitriser les vecteurs des grandes maladies endemiques comme le paludisme et la schistosomiase. La mobilisationdes masses populaires a joue un role d6cisif dans le succes de ces campagnes. L'affectationde ressourcesaux actions preventives (et aux services curatifs qui pouvaient exister en zone urbaine) a eu pour effet d'amener les populationsrurales a demander un minimum de services curatifs et de produits pharmaceutiques,demande que la politique sanitaire durant la periode du Grand Bond en avant et de la Revolution culturellea permis de satisfaire. Ces efforts vigoureux dans le domaine de la m6decine preventiveont sans aucun doute permis a la Chine de remporter d'enormes succes dans la lutte contre la morbidit6 et la mortalite; aujourd'hui cependant,elle met davantage l'accent sur les soins curatifs et la pr6ventionne semble jouer qu'un role marginal dans la lutte contre les maladies chroniques. - xxxiv -

13. En accordant une large place a la pr6vention, la Chine a 6t6 amen6e a appliquer egalement dans le domaine de la sante une strat6gie qui a largement deborde le cadre sanitaire proprement dit. Elle s'est assigne en particulier pour objectifs d'am6liorer la nutrition, de construire des r6seaux d'adduction d'eau potable, de mettre en place des systemes hygie- niques d'6vacuation des d6chets, de r6duire la f6condit6 et d'am6liorer largement l'education. Malgre quelques revers subis ici et la, la capacite administrative et la volont6 politique des autorit6s chinoises ont 6te essentielles au succes de cette strat6gie tous azimuts.

14. Disponibilite des ressources sanitaires. L'application de la politique sanitaire s'est accompagn6e d'une augmentation rapide des moyens hospitaliers et du personnel de sante, mais on attribue g6n6ralement les succes de la Chine dans le secteur de la sante davantage a la maniere dont ses ressources ont 6t6 deployees qu'a l'existence de medecins ou d'h6pitaux - opinion que tend a corroborer l'analyse des facteurs qui influent sur la morbidit6 et la mortalit6. Compte tenu par ailleurs de l'6volution du profil de la pathologie - les maladies chroniques tendant a remplacer les maladies transmissibles -, il est peu probable que l'augmentation des revenus continuera de se traduire par un allongement de 1'esp6- rance de vie; en fait, les chiffres sembleraient meme indiquer que l'augmentation des revenus conduit au contraire a des modifications du mode de vie qui accroissent la vuln6rabilite de l'individu aux maladies chroniques. I1 semble donc necessaire d'accorder une priorite a la recherche de mesures qui, tout en etant financierement realisables, per- mettraient de retarder l'apparition des maladies chroniques, d'en maitriser les consequences, et de les accompagner par des modifications qualitatives dans la formation et l'attribution des fonctions du personnel de sant6. Pour ne pas c6der a l'in6vitable tentation d'accroitre simplement les effectifs du personnel medical et sanitaire, il faudra en planifier soigneusement la valorisation; pour cela, il sera notamment indispensable d'6tudier les moyens de desservir les populations rurales, de donner aux m6decins la formation voulue, la oui d'importants investissements en mat6- riel sont financierement exclus, et de r6pondre aux besoins de la m6decine communautaire et preventive.

15. Financement et depenses du secteur de la sante. On estime qu'en 1981, les depenses de sante se sont elev6es a environ 15 yuan par habitant, dont 14,3 yuan pour les depenses ordinaires et 0,6 yuan pour les investissements, ce qui representait 3,3 % du PIB par habitant en 1981. On peut analyser l'affectation de ces depenses selon les sources de financement, les systemes de prestations de service et les d6penses consacrees aux intrants en ressources. Le financement vient en parties a peu pres 6gales de trois sources principales : fonds prives (32 %), assurance travail (31 %) et budget de l'Etat (30 7'), les brigades de production finan- qant les 7 % restants. La structure des prestations des services de sante est essentiellement tripartite : le reseau collectif rural (installations de sant6 des brigades et des communes) assure la plus grande partie des services de sante, soit environ 40 % du total, celui de l'Etat environ 32 % et celui des entreprises, r6serv6 uniquement aux employes et aux personnes a leur charge, 25 %. L'exercice de la medecine privee a et6 r6tabli recemment mais il n'est pas encore tres d6veloppe. Les produits - xxxv - pharmaceutiques repr6sentent l'intrant de loin le plus important du secteur sant6 et entrent pour 58 % dans les d6penses totales; a eux seuls, les m6dicaments occidentaux absorbent 49 % du total des depenses du secteur. Les coats salariaux (vu les salaires pay6s en Chine) representent moins du quart du total des d6penses. (N'est toutefois pas inclus dans ce montant le coat de la main-d'oeuvre non salari6e, volontaire ou non, pour laquelle il n'existe pratiquement aucune donn6e, mais qui a du largement contribuer au succes de nombreuses campagnes de prevention, en particulier dans le domaine de l'assainissement de l'environnement.)

16. Une forte proportion des depenses est couverte par des systemes d'assurance; ceci montre l'importance de la couverture de I'assurance maladie, qui est l'une des grandes reussites du systeme de sant6 chinois. Environ 30 % seulement de la population ne sont couverts par aucune assurance; il s'agit presque uniquement de personnes vivant en zone rurale.

17. Les d6penses de sant6 varient consid6rablement entre la ville et la campagne. Dans les villes, elles sont evalu6es a 33 yuan par habitant, soit plus de trois fois plus que dans les campagnes (9 yuan par habitant). Les subventions accordees par l'Etat aux citadins pour les soins de sante sont pres de dix fois plus elevees que celles qu'il accorde aux ruraux - environ 26 yuan contre moins de 3 yuan par habitant. Dans les zones urbaines, les depenses prises en charge par l'habitant lui-meme sont infe- rieures a 3 yuan alors qu'elles d6passent 5 yuan dans les zones rurales.

18. Etant donne l'importance accord6e a la medecine pr6ventive, il est surprenant de constater que moins de 5 % du total des ressources con- sacr6es a la sante vont a la prevention et plus de 95 % aux soins curatifs. La m6decine traditionnelle recoit environ 14 % du credit total.

Problemes et d6fis

19. Les efforts faits par la Chine pour r6duire l'incidence des maladies transmissibles et la prevalence de la malnutrition (qui ont permis une forte baisse des taux de mortalite) se sont traduits par une augmentation spectaculaire de l'esp6rance de vie. On pourrait appeler cette r6ussite la premiere revolution sanitaire, mais cette revolution a laisse subsister dans son sillage deux s6ries de problemes. D'abord, la r6ussite n'a pas 6te 6gale partout : les conditions de sant6 dans les villes sont tres bonnes et beaucoup de r6gions rurales n'ont que cinq a dix ans de retard sur les villes pour ce qui est de 1'esperance de vie. Mais entre 100 et 200 millions de ruraux se trouvent sur le plan sanitaire dans la meme situation qu'un pays en developpement classique. Habitant des regions pauvres et isol6es, ils ne disposent d'aucune infrastructure 6conomique et administrative et leur niveau d'education est probablement bas. I1 n'existe aucun moyen facile ou financierement peu cociteux pour ameliorer 1'etat sanitaire de ces r6gions. Ensuite, l'apparition d'une pr6valence importante des maladies chroniques devient une source - xxxvi - d'inqui6tudemajeure. Les causes de deces en Chine sont actuellementles memes que dans les pays industrialis6s: cardiopathies,cancer et congestionscerebrales viennent en tate de liste. Les traitements appliqu6s dans les pays occidentauxsont extr&mementcoateux et moder6ment efficaces. Mais les traitementsexig6s par les malades et les efforts m6dicaux pour les guerir represententsouvent des depenses considerables dont l'effet sur la sante est relativementfaible.

20. Le secteur de la sante se trouve donc plac6 aujourd'huidevant deux d6fis :

a) premierement,mener a bien la premiere r6volutionsanitaire en 6tendant aux r6gions ouile taux de mortalit6 et le nombre des deces par maladies infectieusesrestent eleves les m6thodes qui se sont r6velees efficaces dans le reste du pays; et

b) deuxiemement,pr6parer la deuxieme revolution sanitaire qui mettra au point et appliquera des methodes de lutte contre les maladies chroniques qui combinerontla pr6vention,les traitements a faible coat, des techniques de rehabilitationet de soins "humains". Les problemes a resoudre sont considerables mais toute reussite dans ce domaine, fat-elle incomplete,sera d'une immensevaleur non seulementpour la Chine mais pour la communaute internationaletout entiere.

21. Mener a son terme la premiere revolution. Des disparit6s tres importantessubsistent encore dans les services de sante et la situation sanitaire entre les provinces, a l'int6rieurdes provinces, et entre les campagnes et les villes. Les soins de sante ont ete amelior6s dans les zones urbaines et la prochaine tache prioritaireconsiste maintenant, comme le reconnait le Ministere de la sant6 publique,a consolider les progres r6alises dans certaines regions rurales et a assurer la meme qualite de prestationsaux r6gions plus pauvres. Il va donc falloir elaborer des plans d6tailles pour abaisser les taux de mortalit6 et de morbidite causes par certainesmaladies particulieresdans les regions pauvres, en tenant compte des facteurs epidemiologiques,des conditions financiereset des besoins en personnel, de leur formation et de leur distribution. Etant donne la pauvret6 de la plupart des regions ouila premiere revolution des soins de sant6 doit etre menee a son terme, un financementexterieur (du Gouvernementprovincial ou central) sera indispensablepour prendre les- mesures qui permettrontde faire disparaltreles disparites entre les diff6rentessituations sanitaires. Meme s'il ne s'agit pas de sommes consid6rablesau regard des subventionsque l'Etat accorde actuellement aux citadins,elles n'en seront pas moins difficiles a trouver.

22. L'un des phenomenes qui ont une importance particulieresur l'evolutiondes soins de sante dans la Chine rurale est le d6clin des systemes d'assurancemaladie des cooperativesrurales apres l'introduction des systemes dans le cadre desquels le paysan conserve une partie de sa production. En 1975, 85 % des brigades de production 6taient couvertes - xxxvii - par des assurancescoop6ratives, mais ce chiffre etait tomb6 a 58 % en 1981. Pres de 50 % de la populationrurale doit donc prendre integrale- ment a sa charge les frais medicaux et ce pourcentageva tres probablement augmenter encore. Cette 6volution a deux consequencesdefavorables : en premier lieu, les grands progres que le partage des risques permet d'ac- complir dans l'inter8tdu bien-etre de la population se trouvent perdus en raison de l'absenced'une assurance maladie. Meme si les systemes de coop6rativesrurales avaient de nombreux defauts et etaient notamment dans l'impossibilitede repartir les risques sur un grand nombre de personnes, ils offraient neanmoins un important service de base. Deuxiemement, le fait de concevoir les soins de sante comme un service qu'il faut payer a pour r6sultat que les mesures publiques de prevention se trouvent in6vita- blement neglig6es,bien qu'elles aient joue un role capital dans le succes de la Chine. De plus, les activites de pr6vention qui impliquent la mobilisation d'une main-d'oeuvreben6vole risquent particulierementde souffrir du systeme du "lopin individuel"et d'aboutir a la r6apparitionde parasitoseset de maladies infectieusessi d'autres mecanismes de financement ne sont pas mis en place.

23. Objectifs de la deuxieme r6volutionsanitaire. Les succes remportes dans la lutte contre les maladies transmissiblesont deplace les problmes de sante et les ont transferes sur les groupes plus ages parti- culi&rementvuln6rables aux maladies chroniques,dont la plupart se pretent assez difficilementa des mesures de prevention. I1 faut donc en priorit6 mettre au point des strategiesefficaces mais en meme temps peu couateusespour les combattre. Le grand danger serait de ceder a la tentation de s'inspirer des techniques tres on6reuses qui se sont r6v6lees relativementinefficaces et qui, meme dans les pays a revenu eleve, ont mis tres lourdementa contributionleurs ressources6conomiques. Aucune mesure, qu'elle soit preventive ou curative, contre les maladies chroniques n'aura jamais un effet aussi spectaculairesur l'esp6rancede vie que la lutte contre les maladies transmissibleset infectieuses. Celle-ci a permis en effet d'augmenter l'esperancede vie en r6duisant la mortalite infantile et juvenile;mais pour tragique que soit la mort d'un enfant, le d6c6s pr6matur6d'un adulte actif est moralement et 6conomiquementbeau- coup plus couiteuxpour la famille et la societe. Les programmes de lutte contre les maladies chroniquesauront donc sur le bien-etre des effets benefiques qui seront plus que proportionnelsa l'effet limite qu'ils auront sur l'esp6rancede vie.

24. Certainesmesures de prevention des maladies chroniques peuvent etre prises des a pr6sent, en particulieren ce qui concerne la consommation de sel et de tabac. La consommationde sel est beaucoup plus 6lev6e en Chine que dans la plupart des autres pays et l'incidencede l'hypertension y est par consequent6levee (et en augmentation). Une consommation excessive de sel est une cause de cardiopathieset de congestionscerebrales qu'il serait possible d'eviter et qui sont l'un des problemes majeurs de sante publique dans la Chine d'aujourd'hui. La consommationde tabac est exceptionnellementelevee pour un pays du niveau de revenu de la - xxxviii -

Chine mais, malgre une campagne antitabac lancee il y a deux ans, la consommation a augmente de facon spectaculaire. (En fait, le Sixieme Plan quinquennal prevoit une augmentation de 81 % de la production de tabac entre 1980 et 1985.) Les cancers du poumon et les affections chroniques des voies respiratoires qui en r6sultent coateront cher en souffrances humaines, en perte de productivit6 et en frais medicaux inutiles. Les autres mesures preventives sont peut-ttre moins evidentes : les maladies chroniques sont en effet par leur nature meme plus difficiles a pr6venir que les maladies transmissibles. Il est donc indispensable de reconnaitre cette difficulte et de consacrer des ressources importantes a l'6labora- tion de strategies destinees a prevenir les maladies chroniques.

25. I1 importe egalement de mettre au point et d'appliquer sur une grande 6chelle des strat6gies concernant les soins a donner aux personnes atteintes de maladies chroniques. Ces strategies devront prevoir des traitements efficaces et peu coateux, des techniques de rehabilitation des personnes totalement ou partiellement handicap6es par une maladie non transmissible, et des soins "humains" pour les mourants (domaine dans lequel la m6decine occidentale a fait de grands progres moyennant des d6penses parfaitement supportables). Pour que ces strategies r6ussissent, il faudra que le personnel m6dical, y compris les medecins, recoive une formation qui lui permette de soigner les malades sans recourir a des methodes importees de l'etranger qui necessitent des traitements et un equipement tres couteux.

26. Pour que se r6alise cette deuxieme revolution sanitaire, il faudra enfin concevoir un r6gime d'assurance et des modalites de financement qui encouragent la pr6vention et d6couragent la tendance actuelle a la surutilisation des installations sanitaires. Le regime d'assurance devra comporter de puissants moyens de freiner l'introduction de soins couteux que quelques-uns seulement auraient les moyens de s'offrir. En appliquant des "tickets moderateurs" elev6s et en ne remboursant qu'en partie les frais m6dicaux, on inciterait aussi bien les malades que les medecins a utiliser avec mesure les ressources des services de sante.

Problemes de strat6gie

27. Pour r6soudre les problemes mentionnes ci-dessus, la Chine va devoir innover. I1 lui faudra absolument le faire a la fois parce que les ressources dont elle dispose pour les soins de sante sont faibles par rapport a celles des pays occidentaux et parce que les objectifs qu'elle s'est fixes pour repondre aux besoins de sa population dans le domaine de la sante sont beaucoup plus ambitieux que ceux de la plupart des pays a faible revenu. A supposer mame que les d6penses de sante augmentent aussi rapidement qu'on peut l'imaginer - et elles ne pourraient le faire qu'aux d6pens d'investissements qui sont indispensables dans d'autres secteurs - la Chine ne pourrait encore assurer qu'a tune faible fraction de sa population les soins tres coateux qut'implique la m6decine curative des pays occidentaux. Ses ressources limit6es la placent donc devant un choix dif- - xxxix - ficile : soit appliquer des techniques import6es de l'6tranger pour soigner une toute petite elite sans aucun espoir ou presque d'ameliorer le sort de l'immense majorit6 de sa population, soit etudier soigneusement les moyens nouveaux qui s'offrent a elle de faire b6neficier une plus large fraction de la population des ressources limit6es dont elle dispose. La strategie anterieure de la Chine, qui mettait l'accent sur les techniques a forte intensit6 de main-d'oeuvre, est toujours economiquement valable. En outre, l'approche innovatrice, bien qu'elle comporte des risques plus grands, s'impose pr6cis6ment parce qu'il n'existe aucune strat6gie d'ensemble pour continuer la premiere revolution sanitaire et preparer la seconde. Elaborer une telle strategie - avec les consequences financieres, politiques et humaines qu'elle entraine - est une tache hau- tement prioritaire.

28. L'application de strat6gies qui permettent de s'attaquer aux problemes de sant6 du pays exige avant tout la creation d'institutions capables d'analyser les problemes de la sante publique, d'experimenter et d'innover. L'amelioration des ecoles de medecine et en particulier de 13 ecoles principales peut jouer A cet 6gard un r6le d6cisif a condition que leurs professeurs s'int6ressent a des recherches et a un enseignement qui transcendent les progres techniques de la biologie et de la m6decine clinique. La creation par le Ministere de la sant6 publique d'un Centre national de m6decine pr6ventive et d'un Centre de recherche pour la plani- fication et les statistiques de la sant6 devrait permettre a la Chine d'etre mieux A meme de trouver des solutions economiquement viables A ses principaux problemes de sant6. De meme, l'importance que le Ministere de la sant6 publique accorde a une meilleure affectation des ressources et des techniques de gestion a l'int6rieur de tout le systeme sanitaire et de chaque institution devrait 6galement en ameliorer l'efficacite. Au-dela de ces efforts qui visent d'une maniere generale a accroltre la capacit6 institutionnelle d'innover et de mieux utiliser les ressources, il faut examiner un certain nombre de questions specifiques (etudi6es au Cha- pitre 5 du rapport) dont quelques-unes sont mentionn6es ci-apres.

29. Financement des soins de sant6 dans les r6gions pauvres. Alors que l'Etat prend a sa charge les soins de sante dans les zones urbaines, il applique dans les zones rurales la politique de l'autosuffisance (c'est-a-dire celle du financement par les collectivites locales et par les habitants eux-memes). Cette politique a donne de bons resultats dans les regions rurales aisees, mais dans les plus pauvres, les services les plus rudimentaires sont souvent inexistants. La question de principe importante qui se pose a l'Etat est de savoir s'il doit attendre, pour ameliorer les soins de sant6 dans ces regions pauvres, que de nouveaux progres aient 6te r6alises dans les villes et dans les regions rurales ais6es. Une assistance energique aux r6gions pauvres exigerait des fonds du Gouvernement central mais l'effet des investissements dans le domaine de la sante y serait probablement plus important qu'ailleurs; le souci d'efficacit6 rejoindrait donc celui de l'equite. - xl -

30. Grandes cliniques communales. La politique du Gouvernementcon- siste a encourager la cr6ation de grandes cliniques communales,bien 6qui- p6es et dotees d'un personnel sanitaire qualifi6, capables de repondre aux besoins auxquels, sans elles, les h6pitaux de r6gion devraient faire face. La cr6ation de ces cliniques - qui pourraient etre de petits h6pi- taux de 50 a 150 lits avec trois a huit medecins - est peut etre la mesure qui s'impose le plus pour am6liorer l'acces aux soins curatifs dans les zones rurales, dont beaucoup sont eloigneesdes hopitaux de r6gion. Elles permettronten outre d'all6ger la pression croissante qu'impose aux h6pi- taux de region le fait d'avoir a diriger les malades vers les centres de traitement. I1 sera probablementdifficile de trouver le personnel quali- fi6 pour ces cliniques, la r6volution culturelleayant en particulier oblig6 les medecins au "retour a la terre", et il faudra pr6voir des inci- tations suffisantespour le personnel,notamment en matiere d'6quipement et de conditions de travail.

31. Capacit6 d'evaluationscientifigue et recherche sur les systemes de sant6. Les techniquesmedicales modernes etant tres coateuses, l'evaluation de l'efficacitedes techniques (nouvelleset traditionnelles)de diagnostie,de traitement et de pr6ventionprend actuellementbeaucoup plus d'importance. Les grandes 6coles de medecine font souvent oeuvre de pionniers lorsqu'ellesintroduisent de nouvelles techniquesmedicales et elles devront se doter des moyens qu'exige cette 6valuation. Les prin- cipes d'6pid6miologiene devront pas s'appliquerseulement aux maladies non infectieusesmais aussi a l'evaluationdes mesures de lutte contre la maladie, a la qualite des soins et a l'affectationdes ressources au sys- tcme de sant6, autrement dit a la recherchesur les systemes de sant6. Ceci est important en ce qui concerne aussi bien la medecine clinique - occidentale et traditionnelle- que la sant6 publique.

32. Pr6vention des maladies chroniques. Malgre l'importancequi s'attachea "prevenir d'abord", on n'a prete que peu d'attentiona la pr6- vention des maladies comme les maladies cardiovasculaires,le cancer et les affections respiratoireschroniques. Meme dans de nombreuses regions rurales, ces maladies sont responsablesde la plupart des d6ces. La creation (ou la designation)des institutionsqui seront chargees de la surveillance et de la pr6vention de ces maladies est donc une mesure de toute 6vidence prioritaire. 1. INTRODUCTION

1.01 Chinese development efforts from 1949 to about 1979 emphasized two main objectives -- developmentOf a heavy industrial base and eliminationof the worst aspects of poverty. l The population of China in 1949 suffered a crippling burden of disease and premature death; perhaps the most striking success of China's subsequent anti-poverty struggle has been to increase dramaticallythe level of life expectancy with a concomitant reduction in the burden of illness in the society. Public health measures -- combined with reductions in malnutrition, improved water supplies and close attention to hygiene and sanitation -- have reduced the infant mortality rate ffom perhaps 250 deaths per 1,000 live births in 1950 to fewer than 50 now; 2 they have virtually rid the country of previously hyperendemic diseases such as smallpox, cholera and venereal disease; and they have greatly reduced the burden of illness and lost labor productivity associated with parasitic infections such as malaria and schistosomiasis. The best single indicator of the health status of a developing country's population is life expectancy from birth, and by this measure China's success has been dramatic: between 1950 and 1982 life expectancy increased from 32 to 69 years, a level that is now only about six years lower than that found in the industrialized market economies. Progress in elimination of the adverse consequences of poverty has, then, been rapid -- at least insofar as high levels of morbidity and mortality figure prominently among poverty's consequences. Nonetheless, it is important to bear in mind from the outset that progress in improving health conditions has been far from uniform, and that major rural-urban differences (and differences among rural areas) exist. Maps 1 and 2 illustrate very clearly the inter-provincialvariations that r ain in death rate, birth rate, life expectancyand per capita output levels. -t

1/ For an overview of the Chinese economic system and its recent performance, see China: Socialist Economic Development (Washington,D.C.: The World Bank, 1983).

2/ The figures used in this report for infant mortality rates, population totals, life expectancy, total fertility rates and other demographic indicators result from a demographic analysis prepared by the World Bank to model officially available data. This analysis appears in Supplementary Paper No. 1 to this report. (Titles and authors of supplementarypapers are listed after the table of contents.) Principal results of the demographic model appear in Annex Table A.2; official demographicdata appear in Annex Table A.1.

3/ Maps vividly communicate the regional variations that tend to be obscured in reports, such as this one, that deal principally with general trends and issues. To help maintain the perspective of major inter-provincial variation, this report includes a variety of maps, which appear at the end of the volume. - 2 -

1.02 Although China's overall living standards have substantially improved during the period since 1949 -- indeed, they have improved somewhat more rapidly than have living standards in developing countries generally -- it is important to emphasize that general improvements in living standards alone can account for only a fraction of China's achievements in health. Table 1.1 presents selected development indicators for China and a number of other countries and groups of countries. Columns (1) and (5) indicate that, although per capita GNP is low in China, life expectancy is nonetheless high by comparison even with countries having substantially higher income levels. Income growth in China has been moderately rapid, but columns (1), (2) and (6) of Table 1.1 suggest that neither the level nor growth rate of income explain China's improvement in life expectancy: the 27-year increase in life expectancy between 1960 and 1980 exceeds that of other countries sufficiently to indicate the importance of other factors. Potential other factors, beyond the activities of public health agencies, are education levels (column (8) of Table 1.1), reductions in population growth rate (columns (3) and (4)), availability of food (column (7)), distribution of available food and improvements in water supply and sanitation. China's achievements in each of these areas, relative to its income level, has undoubtedly complemented the efforts of public health authorities in effecting the mortality and morbidity reductions of the past 30 years. Symmetrically, investment in improving health conditions has very likely been an important contributor to income growth, fertility reduction and improved nutritional status. Although these linkages remain to be established for China, evidence from other countries -- reviewed in the World Bank's World Development Report, 1980 -- suggests the probable impact on these areas of health improvements.

1.03 This report begins by reviewing China's achievements to date in improving health and its related achievements in reducing fertility and malnutrition. It further describes the structure, operations and finance of the health care system and attempts to delineate (albeit qualitatively) the role of these and other factors underlying China's success. The report then attempts to delineate the key problems now facing the health care system in China and, in light of these problems, to raise two sets of issues -- those in rural health care and in medical education. This report's treatment of issues is selective in emphasizing only these two aspects of the health care system. These are obviously important areas, though, and ones that the Chinese Government has requested World Bank assistance in developing. In addition to dealing with only a selection of issues, this report should be viewed as preliminary, as an initial effort of the World Bank to understand better a system whose complexity (and past successes) certainly defy easy understanding or description. The report should be read with that caveat very much in mind. Table 1.1 SELECTED DEVELOPMENT INDICATORS, CHINA AND OTHER COUNTRIES

Per Capita Growth Rate of Population Total Life Expectancy (Years) Daily Per GNP, 1980 Per Capita GNP, Growth Rate Fertility Gain between Capita Energy Adult Literacy (1980 U.S.$) 1960-80 (1 p.a.) 1960-80 (% p.a.) Rate, 1980 1980 1960 and 1980 Supply, 1977 (kcal) Rate, 1977 (2) (1) (2) (3) (4) (5) (6) (7) (8)

Low-income economies (excluding India and China) 230 1.0 2.5 6.1 57 15 2,113 34 India 240 1.4 2.2 4.9 52 9 2,021 36 Sri Lanka 270 2.4 2.0 3.6 66 4 2,126 85 China 290 3.6 a/ 1.8 2.5 67 27 b/ 2,237 66 Pakistan 300 2.8 3.0 6.1 50 7 2,281 24 Indonesia 430 4.0 2.2 4.5 53 12 2.272 62 Thailand 670 4.7 2.7 4.0 63 11 1,929 84 Middle-income economies 1,400 3.8 2.4 4.8 60 9 2,561 65 Hong Kong 4,240 6.8 2.5 2.2 74 7 2,883 90 Non-market industrial economies 4,640 4.2 0.9 2.3 71 3 3,489 100 Industrial market economies 10,320 3.6 0.9 1.9 74 4 3,377 99

Sources: For countries other than China and for country groupings, WDR82-World Development Report 1982 (Washington, D.C.: The World Bank, 1982). For China, WDR82 and this report. WDR82 defines 'low-income economies' as those having a per capita income of $410 or less in 1980; 33 such economies are included in WDR82 tables. The 'middle-income economies' are those of developing countries that have per capita incomes between $410 and $4510; this group includes 62 countries. The non-market industrial economies have incomes ranging from $3,900 to $7,180 and the industrial market economies have incomes ranging from $4,880 to $16,440. a/ This figure for China is the growth rate of gross domestic product (GDP) minus the population growth rate. For the period 1960-80, GNP and GDP in China grew at approximately the same rate. b/ 1960 and the adjacent years were periods of acute famine and turnmoil in China, which resulted in substantially elevated mortality rates. The 27-year gain in life expectancy reported here is, therefore, based on an imputed 1960 life expectancy that is the average of the 1957 and 1963 life expectancies. - 4 -

2. THE POPULATION, HEALTH AND NUTRITIONAL STATUS OF THE CHINESE PEOPLE: TRENDS AND CURRENT SITUATION

2.01 Since 1949, China has achieved an important reduction in mortality and concomitant increase in life expectancy,which result from a major overall improvement in health status. About 15 years ago fertility rates began to decline, and they have now reached levels that are among the lowest in the developing world. Incidence and prevalence of infectious diseases and malnutritionthat were principally responsiblefor high levels of mortality in 1949 have been strikingly reduced, although progress has not been uniformly successful,and these diseases continue to impose a heavy burden, particularly in urban areas, on an important fraction of the rural population. Chronic diseases, meanwhile, have become an increasing burden, particularly in urban areas, as the age profile of the population changes to include higher proportionsof middle-aged and older persons. This chapter reviews trends in fertility and mortality in the Chinese populationand accompanyingchanges in patterns of morbidity and malnutrition; it concludes with a section summarizingthe current situation.

2.1 Trends in Population Size and Fertility Levels

2.02 The census of June 30, 1982, recorded a population of 1008 million Chinese. This exceeds by 73 percent the total recorded in the PRC's first census, which was conducted in 1953; the population growth rate in the intervening 29 years was 1.9 percent per annum. Trends in fertiiity and mortality during this period have been far from steady, however, and even at present demographic conditions vary markedly from one part of China to another. Map 1 illustrates this variation by depicting provincial levels of crude death and birth rates for 1981 (obtained from the 1982 census). The discussion of general trends in this chapter should be read with this underlyingvariation in experiencevery much in mind.

2.03 For many years data concerningpopulation was only sparsely available to foreigners. In recent years, however, a great deal more information on China's demographic experience since 1949 has become available. In particular, in late March, 1983, the State Statistical Bureau released a substantial amount of new data from which a demographic model of China in the post-1949 period could be constructed. These data included single-year age and sex distributions of the population from the 1953 and 1964 censuses (only 5-year groupings had previously been available) as well as single-year age distributions from the 1982 census for three populous and typical provinces. 1, These data have allowed constructionof a much improved account of population growth in China, of trends in mortality and fertility, and of the underlying assumptions required for population projections. Not all of the available data are consistent with one single interpretation, however, and it is therefore possible to reconstruct China's recent demographic history in a

1/ See "Major Figures of the Third Chinese Population Census", (Beijing: PopulationCensus Office of the State Council, 1983). - 5 -

number of different ways. Supplementary Paper No. 1 presents one such reconstruction, the principal results of which are summarized in Table 2.1 and, in more detail, in Annex Table A.2. I/

Table 2.1: SUMMARY MEASURES OF ESTIMATED FERTILITYAND MORTALITY FOR FIVE YEAR PERIODS, 1940-1980

Crude Crude Rate of Expectation Birth Death Natural Total Infant of Life Period Rate Rate Increase Fertility Mortality at Birth -- per thousand per year - Rate Rate (years)

1940-1945 38.0 38.6 -0.6 5.3 290 27.7

1945-1950 41.7 35.7 6.0 5.9 265 30.5

1950-1955 44.7 30.9 13.8 6.5 236 34.1

1955-1960 39.8 27.3 12.5 5.8 229 34.8

1960-1965 38.3 21.9 18.4 5.9 208 37.7

1965-1970 38.2 13.3 24.9 5.5 137 49.0

1970-1975 28.6 9.5 19.1 4.1 96 57.3

1975-1980 19.5 8.5 11.0 2.7 65 64.2

Source: World Bank estimates developed in SupplementaryPaper No. 1.

2.04 Table 2.1 shows substantiallyhigher fertility and mortality rates in the 1950s than the official series (Annex Table A.1) of birth and death rates (which are themselves inconsistent with the official series of end-year population totals). Birth rates were around 45 per 1000 in the mid-1950s, implying a total fertility rate of about 6.5. Death rates fell from about 30 per 1000 at the beginning of the 1950s to about 23 in 1957, suggesting a life expectancy of about 38 years. These gains prior to the Great Leap Forward of 1958 were, however, followed by a period of famine and disorder; mortality rose sharply around 1960, and the birth rate plunged. Following the 1959-62 famine, the birth rate rose to at least the level of the 1950s and then declined slowly until the end of the decade. The drop in fertility since 1970 has been very remarkable indeed. Figure 2.1 graphs the estimated total

I/ SupplementaryPaper No. 1 is being revised in light of additional data and analysis; the revision should be available early in 1985. The further analysis estimates infant mortality rates to be closer to officially reported figures than are the estimates in Table 2.1 and elsewhere in this report. - 6 -

Figure 2.4 TheTotal FertilityRate in China, 1950-81

7.5

6.5 -

5.5-

TFR

4.5-

3.5-

2.5

1950 1955 1960 1965 1970 1975 1981

Year

WorldBank-25322 -7 -

fertility rate for China from 1950 to 1981; it shows very clearly the early variations, the subsequent remarkable decline, and a recent increase. Policies responsible for this fertility decline are discussed in Chapter 4.

2.05 Fertility declines have been much more rapid in urban than in rural areas, and, as Map 1 illustrated, levels vary substantially from one part of the country to another. It is possible, using census data at the provincial level, to construct in drect quantitative estimates of rural-urban and other fertility differences - ; the results suggest that rural crude birth rates (CBR) are almost twice as high as urban ones (22.5 per thousand versus 12.4) and that CBR is about 7.2 higher in Autonomous Regions than elsewhere. These findings are roughly consistent with estimates released by the State Family Planning Commission in late 1983 suggesting a 1982 total fertility rate in rural areas of 2.9 and in urban areas of 1.5.

2.2 Achievements in Reducing Mortality -- Levels, Trends and Regional Differences in Life Expectancy and Infant Mortality

2.06 Chinese statistics include several types of data that allow estimates to be made of life expectancy and other mortality indicators, such as the rate of infant mortality per thousand live births. In addition, the government from time-to-time provides its own estimate of life expectancy or infant mortality for the nation as a whole or for particular locales. 2/ The MOPH provided the World Bank, for example, with the estimates in Table 2.2. Other relevant statistics that have been made publicly available include end-of-year estimates from the vital registration system of total population, birth rates and death rates for most years since 1949, limited information from the

Table 2.2: OFFICIAL ESTIMATES OF LIFE EXPECTANCY AND INFANT MORTALITY, 1949 AND 1980

Mortality Indicator 1949 1980

Infant Mortality Rate (per thousand live births) (a) National 200 n.a. (b) Urban 120 13 (c) Rural n.a. 23.9 Life Expectancy (years) 35 69

Source: Data provided by MOPH to Rural Health and Medical Education mission. The 1980 figures were calculated using the definition of 'rural' that includes the population of county towns.

1/ Supplementary Paper No. 3 describes this analysis and its results.

2/ Most recently the China Daily (March 27, 1984) reported results from Chinese analysis of the 1982 census indicating a life expectancy in 1981 of 67.9 years and an infant mortality rate of 34.7. population censuses of 1953 and 1964, and preliminary information from the census of 1982. Annie Tables A-1, A-4 and A-5 provide compilationsof much of the availabledata. -

2.07 An additional important source of information was China's national cancer survey of 1973-75, which carefully collected data on all types of mortality and, in order to allow calculation of age-specific death rates, obtained an age distribution of the population as a whole from a sample survey. Chinese analysts used the cancer survey data to estimate a life expectancy in 1973-75 of 64.9 years; foreign analysts, attempting to correct for proy7ble under-reporting,provided a range of estimates from 61.7 to 64.4 years. - The World Bank's initial economic report on China 3- relied heavily on these latter estimates in its analysis. As indicated in section 2.1, however, far more data are now available upon which to base demographic analysis, and Supplementary Paper No. 1 utilizes these data in its construction of demographic trends and projections for China.

Trends in Life Expectancy and Infant Mortality

2.08 Table 2.1 presented the Bank's estimates of post-1940 trends in life expectancy and infant mortajity, and Figure 2.2 illustrates the results concerning life expectancy. - Three points concerning the results in Table 2.1 bear particular comment:

(i) The data it presents confirm the official estimates of dramatic improvements in life expectancy and reductions in infant mortality. Continuing improvements that had begun five or ten years earlier, life expectancy rose from less than 35 years in the immediate post-1949 period to almost 70 years in the early 1980s; the estimated infant mortality rate declined from 250 in 1950 to less than 50 in 1981.

1/ China's Pattern of Population Growth, by J. Banister, (Stanford University Press, forthcoming) provides an extensive review of official and other available data on mortality in China through about 1981. For more recent discussions of demographicdata from China, see SupplementaryPapers Nos. 1 and 2 to this report. 2/ See "Analysis of Life Expectancy in China, 1973-75," by Yung Shou-de, et al, Journal of Population and Economics (Beijing), 1981-1, Tables 3 and 4. Annex Table B-13 presents their estimates of life expectancy by province. For the results of foreign analysis, see "Mortality in China," by J. Banister and S. Preston, Population and DevelopmentReview, March 1981.

3/ See Annex H of China: Socialist Economic Development (Washington, D.C.: The World Bank, 1983).

4/ Estimates of life expectancy for individual years, as shown in Figure 2.2, may be somewhat unreliable; averages over 5-year periods and general trends, such as presented in Table 2.1, can be accepted with more confidence. Figure2.2 Expectationof Lifeat Birth.1950-1982

70-

60-

~40-

1950 1955 1960 iw6 1970 1975 1980 1985 Ylear

W000dBor*c- 25708 - 10 -

(ii) While the general pattern of improvement shown in Table 2.1 agrees with official figures, Bank estimat1 e of infant mortality are

substantially higher than official figures. -l Under-reporting of infant births and deaths coujd well account for the difference between official data and Bank estimates - and, to the extent that this is so, the problems of antenatal and early postnatal care in China deserve more attention than the official data suggest. Alternatively, recent reductions in the birth rate and advances in postnatal care may imply that 1982 life tables for China, if they were available, would show infant mortality to be lower, relative to mortality at older ages, than was the case in 1973-75 at the time of the cancer survey. Both explanations are probably in part correct. The registration data situation should improve in the near future, however, since one result of tight controls associated with the one child family policy (registration of pregnancies, etc.) will almost certainly be much-improved birth registration. It will also result in complete registration of infant deaths as parents will not wish to lose time in being recorded as eligible for a new pregnancy. In addition, China has requested collaboration from the International Statistical Institute for a World Fertility Survey type study in three provinces in the near future; this will provide sound estimates of mortality rates in infancy and early childhood.

(iii) The third obvious point about Table 2.1 is the dramatic decrease in life expectancy in the period 1958-61; this, combined with a similarly dramatic fertility decline, resulted in a loss of population of over I percent in 1960. This period was one of major agricultural failure that was in part caused by two successive years of bad weather and in part by economic mismanagement associated with the Great Leap Forward. Principally because of famine, but in part because of a breakdown in supply of other factors influencing health, there were perhaps 24 million excess deaths during this period.

1/ The World Bank demographic model constructed life tables for China using the 'West' model life table; in order to fit available data on age specific mortality rates, different 'West' mortality levels needed to be used for different age groups. This resulted in a higher infant mortality rate for given life expectancy than the most reasonable alternative model, an unmodified 'West' one. These life tables were chosen because they best fit data from the cancer survey, and a 1979 sample survey, which provide the only good age-specific death rate data available outside China.

2/ For example, when a highly reliable registration system was introduced in Shanghai County, estimates of infant mortality rose to 21.1 in 1977 from 11.4 in 1976, suggesting serious under-reporting in the routine system even in an economically advanced county with excellent health services. See "Vital Statistics" by Cu Xing-yuan and Chen Mai-ling, in Health Services in Shanghai County, supplement to American Journal of Public Health, September 1982. * 11 -

Regional Variation in Mortality

2.09 Map 1 illustrates inter-provincial variation in crude death rates and Map 2 illustrates estimates of life expectancy by municipality, province and autonomous region based on data from the 1973-75 cancer survey. Estimates range from 59 years in Guizhou to 72 in Shanghai, denoting very substantial inter-provincial differences. Some (but far from all) of these dif erences can be accounted for by differences in income, also shown in Map 2. U It is worth noting that variations in income among counties within a province (and among communes in a county) tends to be substantially higher than interprovincial variation. To the extent that this is true of mortality rates as well, and the evidence suggests that it is, even relatively well-off provinces probably contain many counties where life expectancy is less than 60 years.

2.10 Further statistical analysis of the cancer survey allowed estimates to be made of urban-rural differences in life expectancy and of differences between low-income and other rural areas (low income was defined as having, in 1979, a distributed per capita income of less than 50 yuan). This analysis concluded that life expectancy in urban areas is, on average, 12 years higher than in normal rural areas; life expectancy in low-income rural areas is 5 years less than in normal ones. 21 The rural-urban difference substantially exceeds that found in most other developing countries. These data strongly reinforce the importance of stated government policies to redress rural-urban differences in health service availability and government subsidies, which currently favor urban areas by a ratio of ten-to-one (Chapter 3).

2.3 The Changing Disease Pattern and the Epidemiologic Transition

The Epidemiological Transition

2.11 Throughout much of China's recorded history, periodic epidemics of plague, cholera, smallpox, etc. swept the land -- which, combined with frequent famine, sometimes decimated whole populations. These epidemics were superimposed on a high underlying level of morbidity and mortality that continued into 1949, and that earned pre-1949 China its reputation as the "sick man of Asia". China's success against infectious disease resulted in the emergence of new leading causes of morbidity and mortality, with chronic and degenerative ailments becoming major concerns. As life expectancy

1/ See Supplementary Paper No. 4 to this report for a statistical analysis of the impact of income and other variable's on life expectancy and CDR. That analysis suggested a 10 percent increase in income to be associated with about a 7 or 8 month increase in life expectancy.

2/ Further information on urban-rural differences in mortality comes from statistical analysis of data from the 1982 census concerning provincial crude death rates. That analysis suggests the CDR in rural areas to be about 7.1 per thousand; the estimated value for urban areas is about 4.8 (Supplementary Paper No. 4). - 12 -

increases, older age groups consume an increasing proportion of medical care, shifting the relative attention of health services from the younger groups. This transformation is now referred to as the "epidemiologic transition". That urban China has achieved this transition is certain, and many rural areas have progressed substantially through it. Few good national or population- based data exist for the 1950s, but broad patterns for those da0 are known and increasingly good data are available on subsequent change. - In urban China and much of rural China, parasitic and infectious diseases have been substantially replaced by heart disease, cancer, stroke, accidents, rheumatism and chronic respiratory diseases. For example, the mortality rate of heart diseases increased from 71 per 100,000 in 1958 to 141 per 100,000 in 1979 in four urban Beijing districts. Infants, children and young women have been supplanted by the middle-aged and elderly as the population groups with highest mortality. Although urban Chinese patterns are increasingly similar to those in high income countries (Table 2.3), the transition is still progressing.

2.12 The epidemioloF0cal transition began in the cities, especially Beijing and Shanghai. - Data obtainable today from a typical developing country and from an industrialized country are remarkably similar to what is shown to have happened in a particular district in Beijing over two short decades. The transition moved from urban centers and progressed through the

1/ Data from the early 1930s are available on death by cause for one district of Beijing and from Ting Hsien (county); the figures were collected by researchers from the (then) Peking Union Medical College and show an overall death rate in Beijing of almost 21 per 1000 and of tuberculosis of 3 to 4 per 1000. As expected, other infectious diseases are prominent among causes of death, although the absolute death rates from some non- communicable classes of disorders are also higher than at present. See "Selected Epidemiologic Aspects of Major Diseases and Causes of Death Among Chinese in the United States and Asia," by Haitung King, in A. Kleinman, et al (eds.), Medicine in Chinese Cultures (Washington, D.C.: U.S. Government Printing Office, 1975).

2/ Annex Table A-6 gives a view of the falling birth and death rates for urban and rural areas from 1954-79. Annex Table B-2 shows a fall in tuberculosis and other infectious diseases as principal causes of death for selected years over the same period, with a corresponding rise in chronic and degenerative diseases that attack the middle-aged and elderly. Annex Table B-4 compares age-specific mortality rates, 1957 vs. 1975, for urban and rural areas. The reported urban male and female infant mortality rates for 1975 dropped to 29 and 27 percent of the 1957 rates respectively, while the comparable rates for rural areas dropped to 27 and 26 percent of the 1957 rates. The same pattern holds for ages 1-2 and 3-6, with the improvements getting smaller thereafter. The two halves of Annex Table B-6 provide the data on cause of death in a representative district in Beijing in 1956-59 and 1974-78. - 13 -

Table 2.3 PERCENTAGEDISTRIBUTION OF DEATHS BY CAUSE, CHINA AND MODEL HIGH- AND LOW-INCOME COUNTRIES

Percentagedistribution of deaths China Model low- Model high- Cause 1973-75 income country income country

Infectious,parasitic and 25.5 43.7 10.8 respiratorydiseases

Cancer 10.3 3.7 15.2

Circulatorydiseases 25.5 14.8 32.2

Trauma and accidents 9.4 3.5 6.8

Other causes 29.3 34.3 35.0

Note: Causes of death were allocated into the four broad categories indicated in the table from quite different initial breakdowns; errors of classificationmay, therefore, exist. The percentage of deaths due to tuberculosisis the percentage of total deaths, not of the percentage of those in the "Infectious ... " category.

Sources: For China, 1973-75, see Annex Table B-3. For the model low- and high-income countries, see Health Sector Policy Paper, World Bank, 1980, p. 13. heartland of rural China to the frontiers of development -- the rugged periphery and far reaches of the southwest and west, where health conditions remain as they were perhaps 20 years ago in what are now more developed parts of China. The information system that documents these changes is itself, quite necessarily, a part of the development process. Thus it is not surprising that central and provincial health authorities appear to have little informationabout these areas that are just beginning the epidemiologic transitionand that encompass perhaps 15-20 percent of China's people. (This assumes that the population defined to be remaining in serious poverty by the World Bank's initial economic report remains much more at risk of pre- epidemiological transition diseases.) Even for relatively well off rural areas and for cities, data on age-specific death rates and on cause of death are limited and appear to over-representrelatively well off areas; thus, with the exception of the 1973-75 cancer survey data, available information on cause of death in China should be viewed with caution. - 14 -

Progress in Reducing Mortality

2.13 A short list of diseases almost certainly accounts for the majority of deaths in pre-1949 China. However, it must be borne in mind that specific infectious diseases are not the whole picture. Malnutrition and multiparity with youthful mothers and short birth intervals set the stage for much higher fatality rates than would be experienced by a well-nourished population practicing fertility control, even assuming the same infectious disease incidence. Before 1949, an estimated 10 percent of all newborns died from neonatal tetanus; malaria, diarrhea, and childhood penumonia were each responsible for the death of about 10 percent of all children before the age of 5. Only 50-60 percent of children born actually survived the first five years of life, with most deaths occurring early. Among adults tuberculosis was a major killer. The situation has now changed, as documented in three examples of childhood disease and a discussion of tuberculosis. Although diarrheal disease almost certainly was (and probably still remains) a major cause of childhood mortality and morbidity, almost no data are available on diarrheal disease prevalence in China.

2.14 Neonatal Tetanus. Neonatal tetanus is a fatal disease that is totally preventable at low cost with cord hygiene and maternal vaccination during pregnancy. This disease kills up to 10 percent of all infants born today in many developing countries, but is often unreported. A recent survey in rural Thailand indicates that tetanus kills 4.8 percent of newborn and accounts for 21 percent of infant mortality. A similar mortality rate in newborns is a reasonable assumption in pre-1949 China. Between 1949 and 1952, things began to change quickly. The national total of maternal and child health stations and centers went from 9 to 2379, thus giving China more than 90 percent of its 1981 total of MCH facilities in the first three yea ys. No other type of medical facility increased at anything like that rate - . MCH services in modern China monitor the greater proportion of deliveries (more than 90 percent in most provinces). They report that neonatal tetanus has become a rarity. As an example, the incidence of tetanus in Shandong province was only 2.5 cases per 10,000 births in 1981, and many counties have reported a zero incidence for several years in this province.

2.15 Malaria. Certainly one of the most important diseases in China in 1949, for adults as well as children, was mala7ia. The number of malaria patients was estimated at about 30 million 2 in 1950 when antimalaria campaign were launched, with an estimated 1 percent case fatality rate (300,000 deaths). Sample surveys in 1953 reported 70 percent infection rates among children in Guangdong; prevalence rates were as high as 48 percent in the general population of counties in Yunnan. Seventy percent of the counties of China were endemic for malaria in the early 1950's. MaLaria control was

1/ See Annex Table C-8.

2/ T.C. Hou, et al., Chinese Medical Journal, December, 1959. The same figure was given to the mission. - 15 -

carried out through mass treatment, mass chemoprophylaxis during the transmission period, extensive use of residual indoor insecticide spraying, control of larval breeding sites, and large scale environmentalmanagement.

2.16 The incidence of malaria declined steadily until 1978 and since then has remained relatively constant, with a reported mean of 2.96 million cases per year (Annex Table B-10). According to 1979 morbidity reports, about 285 million people lived in malaria free areas, and 342 million in areas with malaria incidence lower than 5 cases per 10,000 population - . Two hundred seventy million people lived in areas where satisfactory control was not achieved and where annual incidence was still between 5 and 100 cases per 10,000 population. Finally, 74 million people were at high malaria risk with an incidence above 100 per 10,000 population. In other words, one third of the population of China is now living in malaria free areas, another third in areas with minimum risk, and the remaining third in endemic areas.

2.17 Issues in malaria control are (a) the resistance of several vectors to currently used insecticides,(b) the resistance of the malaria parasite P. falciparum to chloroquine in Yunnan province and Hainan island, and (c) the difficulty of eliminating P. vivax infections, which can last for 5 years despite adequate treatment; it is noticeable that P. vivax is the only prevalent parasite north of latitute 25°N and accounts for 35 percent of malaria cases in South China. The situation can still be improved, and a reduction of incidence to 10 percent of its present level would be a reasonable goal, although the situationof malaria transmissionis unstable in Central China where outbreaks of the disease frequently result from floods. Mortality related to malaria will probably stay at a negligable level as P. vivax, unlike falciparum, is rarely fatal.

2.18 Childhood Pneumonias. Childhood pneumonias are the second to fourth leading cause of death in every developing country, depending on the efficacy of interventionsand on the coverage of the population with health services. China addressed the problem since the early 1960s when the control of acute respiratory diseases in children became an essential activity of MCH services. Data on incidence are not aggregated, even at provincial level. However, informations available in counties indicate an order of magnitude. For example, in Sui Hua County (Heilongjiangprovince), the 1981 incidenceof childhood pneumonia was 690 per 100,000 children under the age of 7. The case fatality rate is now very low and was probably cut to about one fifth of its former level.

2.19 Tuberculosis. Tuberculosiswas probably the leading cause of adult deaths in pre-1949 China, responsible for an estimated 200 to 230 annual deaths per 100,000 population. It was the major killer in big cities such as

1/ An incidence rate of 5 per 10,000 population is the criterion for considering endemic malaria eliminated from an area in China. It calls for the development of new strategies aiming at the detection of residual cases and radical treatment. - 16 -

Beijing, Tienjin, Shanghai and Cuangzhou in the early 1950's. After 1949, great concern was shown concerning tuberculosis. A BCG vaccination campaign started in 1950 (only 7,500 people had receive the immunizationbetween 1937 and 1949) with a locally produced vaccine. In 1979, the total number of vaccinations given since the beginning of the campaign was estimated at 500 million. The combined output of Chinese production laboratoriesis actually about 50 million doses per year.

2.20 As a result of this remarkable effort -- and also of the improvement of economic conditions, housing, nutritional status, and health care coverage -- tuberculosisprevalence has declined. By 1980, tuberculosishad dropped to the 9th rank among mortality causes. A national tuberculosismorbidity survey was carried out in 1979. The average prevalence of the disease in China was then 717 per 100,000 population. The highest figures were found in Xinjiang (Sinkiang), Tibet, Ningxia autonomous region and Heilongjiang province. In these areas, more than 1 percent of the population suffered from active pulmonary tuberculosis. The lowest rates were found in Shanghai, Inner Mongolia, Yunnan and Shaanxi with less than 0.08 percent of active cases. Map 3 shows current tuberculosisprevalence by province.

2.21 From tlkissurvey, the number of patients in China was estimated at about 7 million, 2 million of them being actively infectious by excreting bacillus. It was further estimated than only about 1/3 of the active cases had been identified. These data clearly indicate that, despite tremendous improvements, tuberculosis is still a major public health concern in modern China. A recent study indicates for example that in Heilongjiang pulmonary tuberculosiswas still responsiblefor 31 annual deaths per 100,000 population in the late 1970's, about half the mortality due to all cancers.

Progress in Reducing Morbidity

2.22 Annex Table B-10 discusses parasitic and non-parasitic disease categories that are representativeof t/much larger body of illness, against which great progress has been made. - The central themes of education, environmental sanitation, identificationand attempted destruction of vectors or reservoir hosts, etc., are seen in many variations as operational consequences of prevention-oriented strategies. Perhaps nowhere is this orientationmore visible than with the vaccine-preventablediseases.

2.23 Vaccine-PreventableDiseases. There is no doubt that China has made great strides in this class of preventablediseases. Smallpox,which may have had an incidence of 200 per 100,000 population before 1949, was eradicated in 1960 with the last cases in Tibet and Yunnan. Immunization is routinely performed against seven communicable diseases: poliomyelitis, measles, encephalitis, diphtheria, tetanus, pertussis, and tuberculosis. Rural

1/ Annex Table B-10 contains descriptive material concerning several infectious diseases in China. The reader is referred to that table for more detail than is appropriate to the text. - 17 -

immunization began later than urban immunization. Urban children were routinely immunized even before 1965 in most big cities, but the rural immunization rate at that time was about half that in the urban areas. Immunizationis free and is carried out largely by barefoot doctors who get a bonus for each innoculation given. Record-keeping is still rudimentary in much of China and no evaluation of the effective coverage of the target population is carried out. Much more sophisticated accounting is now beginning in some areas.

2.24 Poliomyelitisprovides a good illustrationof Chinese achievementsin control of vaccine-preventablediseases. Prior to 1955, epidemics were common, with local outbreaks occurring every year in various places, such as in the Nantong area and the city of Qingdao in 1955. In 1959 in Nanning, the incidence of polio was 151 per 100,000 while incomplete aggregate statistics from 17 provinces, municipalities and autonomous regions showed an overall incidence of 5 per 100,000. The chief interventionfor polio is a vaccine that was introduced in China as a live attenuated virus preparation in 1960. Despite problems, polio has gradually been brought under control. In 1978, 51.7 percent of the national total of 10,408 cases came from three provinces: Jiangxi, Fujian and Zhejiang. Shanghai reported 12 cases in 1978 and 27 cases in 1979. Of the 564 cases investigatedby Guangdong Province in 1979, 61.3 percent had never been immunized. Yunnan Province reported 318 cases from January-May 1980; none had ever been vaccinated. The 1971 incidence of polio for China was 2.12 per 100,000 and this has declined to a relativel stable incidence of somewhere between 0.5 and 0.75 in the years

1979-81. - In the past three years, no polio was reported in 768 prefectures and counties.

2.25 Similar achievements were made on control of other vaccine preventable diseases. In the past three years, no diphteria cases were reported in 1,040 cities, prefectures and counties, and 259 prefectures have basically controlled the incidence of measles. Annex Table B-9 documents the changes since 1974.

Other Causes of Morbidity

2.26 The incidence of many life-threateningdiseases, such as plague and cholera, has been greatly reduced since liberation. Kala Azar has been reduced to sporadic cases. A huge campaign has virtually eliminated venereal diseases. Filariasis is also progressively brought under control. Even endemic diseases difficult to control, such as leprosy and schistosomiasis, have been substantiallyreduced. Progress has also been made on the important water-borne diseases (dysentery, hepatitis, cholera, typhoid) although prevalences remain relatively high in some provinces (Annex Table B-19).

1/ This approximates the U.S. rate in 1961, which was subsequentlycut more than a hundredfold. - 18 -

2.27 As regards le yosy, the lowest published estimates of 1949 prevalence are of 600,000 cases - . However, international leprosy experts in the past have published estimates of up to three million cases, probably based on regional figures extrapolated to the whole of China. The Chinese official figure for 1951 of 1.2 million lepers is generally accepted as the best estimate for that period, indicating that the prevalence of the disease was about 225 per 100,000 population. Present figures indicate that the total number of leprosy patients is now between 100,000 and 200,000, which represents a decline in prevalence rate to less than 20 per 100,000 population. This decline is compatible with figures available in selected places, for example that of a reduced incidence in rural Shangai counties, from 3.5 new annual cases per 100,000 population during the period 1956-1960 to 0.11 cases between 1976 and 1980. A similar trend is documented in Shandong, Jiangxi, Fujian, and Guangdong provinces. China expects further progress to result in the elimination of leprosy during the next 20 years, although an increasing prevalence of secondary resistance to Dapsone may increase the cost of treatment (an 86 per 1,000 prevalence of resistance is documented in a recent survey conducted by Ji in Shanghai municipality).

2.28 Similarly, estimates of up to 32 million cases of schistosomiasis in 1949 have been publis/ ed. The figure, based on fragmentary surveys in 1948 of 6 million cases 2 is probably grossly underestimated. Emphasis on schistosomiasis control was part of the Patriotic Health Campaign. Large numbers of people were educated to control the vector population to complement large engineering programs in agriculture and water management. Populations in infected areas were screened for case finding and treatment of patients. As a result, 204 counties where schistosomiasis has been endemic (in Jiangsu, Fujian, Cuangdong provinces and Guangxi autonomous region) have substantially controlled their snail populations, and the number of patients to be treated is far fewer than it was. Control has still to be implemented in some mountain areas, marshland and lake regions; furthermore, there is some evidence that preventive measures are slackening and there is a resurgence of infestation. No figure is available, but the existing number of cases probably remains over two million.

I! Hu Chuan-Kuei et al, Chinese Medical Journal, 1982, 95, 109-112.

2/ Ma Shou-pai and Shao Bao-ruo, American Journal of Tropical Medicine and Hygiene, 1982, 31, 92-99. - 19 -

2.4 Improvements in Nutritional Status

2.29 This section summarizes the data concerning substantial improvements in children's nutritional status in China in the post-1949 period. The data show gains most clearly for urban children; data are less good for rural children and tend to be available principally for very well off rural areas (e.g. Shanghai County). Rural gains have probably been less impressive, and available data indicate substantial amounts of remaining rural malnutrition. The extent of the remaining problem and its effect on child development is discussed in section 2.5 below.

Secular Improvements in Nutritional Status

2.30 Ideally secular comparisons, i.e. comparisons over time, would be based on large representative samples of children measured in the same regions during the same season at regular time intervals, but data meeting all of these desirable criteria are not available for China. However, some sequential data are available for school-age children in urban Beijing, rural areas near Shanghai and for urban and rural areas in Guangdong Province, and these provide information concerning secular trends in growth in these areas. The extent to which these trends reflect overall patterns for Chinese children is unknown.

2.31 Another concern is whether the specific years for which data are available represent average years in terms of agricultural production and general food availability, since short-term food shortages or surpluses in the survey year could be reflected in the weights of children. However, it is far less likely that heights would be markedly affected by short-term food availability, so that height measurements may provide a particularly useful indication of longer term growth trends.

2.32 Overall, available data suggest a positive secular change in the growth of school-age children in China although data (particularly from rural areas) remain too limited for firm conclusions concerning the magnitude of this change or the representativeness of the change as a reflection of overall trends in growth among Chinese children. A supplementary paper presents data on improvements pver time in children's weights and heights using the

available data. - While the estimated growth rates of even 0.25 percent to 0.5 percent per annum cannot be sustained over a long period, they could persist through the end of this century.

2.33 Data on secular changes in anthropometric status are often reported in growth rate per decade, though such data tend to be available almost entirely from industrialized countries. Tanner reports, for example, that in nearly all European countries, "... from about 1900 to the present, children in average economic circumstances have increased in height at ages 5 to 7

1/ See Supplementary Paper Number 8 to this report, Tables 7-10. - 20 -

years by about 1-2 cm per decade." 1/ Rates of increase in height in China for two recent decades were 1.55 cm per decade in rural Shanghai, 2.49 for Guangzhou city, 1.48 for rural Guandong, and 3.8 for urban Beijing (for 9- year-olds). Rates were rather higher for C iinese 13-year-olds, but could be expected to be smaller for young adults. 2 Tanner observes that conditions that lead to secular increase in height have two effects - to increase the ultimately attained height, and to increase the rate of maturation. The increasedmaturation rate results in higher rates of secular change in height in youth (age 10-14) than in young adults. Tanner also refers to evidence that secular increases in height in the developed world, or at least among the privileged in the developed world, are drawing to an end.

2.34 In the absence of comparative data from earlier periods in China, or from other developing countries, it is difficult to set a context for interpreting the observed secular increases in height in urban China. That they are as high, or higher, than 20th century European experience, where incomes have been very high and rapidly growing, does, however, suggest important successes. If the European experience is any guide, these secular increases can be expected to continue well into the next century.

2.35 Since food energy availability per capita in China increased only slightly between 1957 and 1977, the explanation for secular improvements in anthropometricstatus must be sought elsewhere. One possibility, of course, is that there have been changes in the distribution of food - either toward more equality nationwide, or in favor of the relatively well off areas from which most of our data come. A second possibility is that improvements in health, principally through reduction in diarrheal infections, have facilitated growth. A third possibility is that nutrient requirements have declined because of changes in the age distribution or work habits of the population. The first and second of these explanations are to some degree plausible, but, at least so far as age distributionis concerned, per capita requirementsare likely to be increasing. It should also be noted that in the years since 1977 per capita food availabilityhas increased rapidly, and this can be expected to result in further improvementsin nutritional conditions.

MicronutrientDeficiency Diseases

2.36 In addition to information on anthropometric status, some data are available on prevalence of disorders due to deficiencies of a number of specific micronutrientsin the diet. Many of the data are available only for children. Generally speaking,micronutrient deficiencies appear to be less of an issue in China than in many low-income countries. However, mild anemia is

1/ See J.M. Tanner, Foetus into Man: Physical Growth from Conception to Maturity (London: Open Books, 1978), p. 150.

2/ See H.V. Meredith, "Findings from Asia, Europe, and North American on Secular Change in Mean Height of Children, Youths, and Young Adults," American Journal of Physical Anthropology,1976, v. 44, p. 322. - 21 -

widespread - in part because of inadequate iron intake in the diet, and in part because of iron losses due to hookworm infestation. (In southern China hookworm infection appears to be highly endemic, but the problem appears to receive little attention from health authorities.) Other deficiency diseases that remain important in China are rickets (vitamin D deficiency), goiter (iodine deficiency) and Keshan disease (selenium deficiency). There is relatively little vitamin A deficiency,which, in a number of other countries, is an important cause of impaired vision or blindness. Control of goiter has been the subject of extensive campaigns in recent years and, if these efforts succeed, goiter could cease to be an important problem in the near future. Keshan disease seems to be found exclusively in perhaps 15 provinces in China; it is virtually unknown elsewhere in the world. It frequentlyleads to death through heart failure among children or among women of childbearing age. Almost half of nutrition research in China is directed to understanding this disorder, which is now relatively unimportant as a public health problem. Selenium supplementVion of food in affected locales seems effective in reducing incidence.-

2.37 Even though substantial progress has been made in alleviating the problems resulting from micronutrient deficiencies, deficiency diseases do remain. The current national policy for upgrading rural health facilities is a natural vehicle for addressing these problems.

2.5 Current Disease Problems

2.38 Chronic diseases are of rising importancein all of China. For some time, these diseases have been the major causes of morbidity and mortality in urban areas, and they remain so. More recently, cardiovascular disease, cancers and other noncommunicable disorders that principally afflict the middle- and older-age groups have also become the principalhealth problems in most of rural China. Nonetheless, there remain important problems of infectious and parasitic disease, some of which (e.g. hepatitis, TB and dysentery) are prevalent in much of the country and some of which (e.g. leprosy, schistosomiasisand malaria) are important in only a relatively small number of provinces. Finally, the widespread implementationof the one-child family policy has led to increased concern -- by individual families, and by society as a whole -- for the optimal development of each child. Malnutrition remains an important impediment to child development in many rural areas.

Emerging Problems of Chronic Disease

2.39 Data in Table 2.3 showed that China's pattern of cause of death in 1973-75 was in between that of most of *the industrializedworld and the developing world. More detailed data in Table 2.4 show cause of death for selected urban and rural areas, and, particularly for urban areas, the similarity is very strong to that of high-incomecountries. Heart disease,

1/ Annex Table D-17 provides additional information on micronutrient deficiency diseases. Table 2.4 PRINCIPAL CAUSES OF DEATH, RURAL AND URBAN AREAS, 1980

17 Cities (urban) 38 Counties (rural) Diseases Death Rate % of Total Diseases Death Rate % of Total (1/100,000) Deaths a! (1/100,000) Deaths a/

Cerebrovascular Diseases 135.35 23.36 Heart Diseases 170.57 25.84

Heart Diseases 132.51 22.87 Cerebrovascular Diseases 113.06 17.13

Malignant Tumors 114.55 19.57 Malignant Tumors 96.89 14.68

Respiratory Disorders 51.97 8.97 Respiratory Disorders 79.14 11.99

Digestive Disorders 22.68 3.91 Digestive Disorders 34.82 5.28

Trauma 18.75 3.24 Pulmonary Tuberculosis 21.36 3.24

Pulmonary Tuberculosis 12.15 2.10 Trauma 18.40 2.79

Toxicosis 10.46 1.80 Infectious Diseases 18.24 2.76 (Excluding Pulmonary Tuberculosis) a/ Does not include all causes of death, hence total does not equal 100 percent.

Source: Annex Table B-1.

Note: Data were not provided on the representativeness of the 17 cities and 38 counties from which these data come. - 23 -

cancer, stroke and chronic obstructive lung disease are the first four leading causes of death. The table shows that this is true in rural as well as urban areas, although these f7ur categories account for a higher percentage of deaths in urban areas. I Despite considerable variation within China, this pattern seems to be the dominant one, and is supported by data provided from cities, from medical facilities and from other specialized sources. Together, diseases in these four categories, along with accidents, account for more than 70 percent of all deaths.

2.40 Heart Disease. The three leading categories of China's heart disease problems today are hypertension, cor pulmonale and rheumatic heart disease, in that order. The relative proportions vary considerably in the few places where studies have been done, and no national survey has yet been carried out. Coronary heart disease, a leading category of heart disease in industrialized countries, is the smallest of China's four major categories of heart disease. It is related (among other factors) to high calorie, high fat diets with cigarette smoking and sedentary life styles as additional major risk factors. Coronary heart disease prevalence is increasing in major Chinese cities, and this may reflect more cigarette smoking and a richer diet than previously. 2/ In four urban districts of Beijing, coronary heart disease is responsible for 141 deaths per 100,000 population (1979), representing 25 percent of all deaths, twice as much as in 1958 (71 per 100,000 i.e. 10.8 percent of all deaths).

2.41 Hypertension, or high blood pressure, can result in stroke, China's third leading cause of death, and in kidney failure (probably much under- recognized and under-reported). If the fatal hypertensive heart disease, stroke and hypertensive kidney disease cases were added together, hypertension would probably be the single largest disease risk factor for mortality in China today.

2.42 In 1979 China has conducted a National Hypertension Sample Survey. (Map 4 shows the survey's results concerning the prevalence of hypertension by province; Annex Table B-16 contains the detailed data from which the map was drawn.) A sample of more than four million people was tested and two categories of morbidity were defined: confirmed cases and marginal cases. Because of a younger age structure in China than in industrialized countries, the prevalence of hypertension should be standardized to allow international comparison. Projections of expected cases indicate that China may have more than 110 million cases of hypertension by the year 2010. This projection assumes that age-specific hypertension rates remain constant; it is reasonable

1/ Annex Table B-5 provides more detailed data on cause of death in rural areas for 1981.

2/ The ratio of saturated to unsaturated fats is particularLy high in China, and this may be an additional risk factor for arteriosclerotic heart disease. Unfortunately, public health policies seem not yet to exist concerning dietary risk factors for cardiovascular disease. - 24 -

to suppose, however, that increasingincome levels wilj result in increases in age-specificrates, further exacerbatingthe problem. -

2.43 The most important preventive step for hypertension involves dietary salt restriction,as excess salt consumption is a known etiologic factor. - The per capita salt consumption today in China ranges between 11 and 24 grams per day. This is an assumption of intake, based on excretion studies from a national sample of 3,000 persons from 11 locations in China. The estimated physiologicalrequirement is only 0.8 to one gram person per day. While it is not clear that this excess salt consumption contributes to illness in normal persons, it is well established that salt restriction in persons with hypertension reduces blood pressure, lowers the risk of hypertensive complications, and removes much of the hypertension-related premature mortality. Secondary prevention, using antihypertensivedrugs and patient education is going to be a costly therapeutic effort, because of the large number of cases projected for China in the next few decades.

2.44 The second most important category of heart disease is cor pulmonale, and that seems to be linked to the prevalence of chronic obstructivepulmonary disease (COPD), the fourth leading cause of death. COPD in China seems to have two major components, although a third component, cigarette smoking, seems to be rapidly rising. The first component, pneumoconiosis,results from the inhalation of mineral particles, as in silicosis and asbestosis or vegetable dusts (cotton). These are mainly occupational diseases of miners and agro-industrial workers; more than two million workers are at risk of pneumoconiosisin China. The second component is air pollution. China has a severe particulate air pollution problem due to a near total dependence on coal as an energy source, both in industry and for heating and cooking in the home (in many places). Indoor smoke from domestic furnaces is blamed for high prevalence of obstructive lung disease in cold or mountainous regions.

2.45 The third most important category of heart disease in China is post- rheumatic, resulting from repeated episodes of rheumatic fever, an infection with particular strains of streptococcus. The valves of the heart become insufficient (they do not close properly) or stenotic (they do not open

1/ These projections assume that the age-specificmorbidity rates (confirmed plus marginal) obtained in the National Hypertension Sample Survey, 1979- 1980, remain constant, and use population age distributions from projectionsprepared for World DevelopmentReport 1983. Analysis of data from the 1979 hypertension survey showed, however, a strong relationship between provincial income and the provincial hypertension rates. (See SupplementaryPaper No. 4 to this report.)

2/ This appears to have been understood long ago in China. The Huang Ti Nei Ching Su Wen observed, in about 1000 B.C., that "... if too much salt is used in food, the pulse hardens, tears make their appearance and the complexion changes." Cited in D. Denton, The Hunger for Salt, (Berlin and New York, Springer-Verlag,1982), p. 548. - 25 -

properly), making the heart a much less efficient pump with a risk of total failure. Between 1959 and 1980 the Tibet Research Institute of Medical Sciences conducted a 21 year study involving 2,627 patients of various ages and nationalities, all living between 2,500 and 4,500 meters above sea level. Rheumatic heart disease accounted for 19.03 percent of all the heart disease cases studied.

2.46 Stroke. Stroke is most often a complication of hypertension. It is a sudden rupture of a blood vessel within the brain. This resuLts in a serious debilitating illness with high mortality (up to 75 percent in rural counties) and, among survivors, long term debilitating consequences. Stroke was responsible for 152 deaths per 100,000 population in four urban Beijing districts in 1979 (27.3 percent of all deaths), as compared to 107 per 100,000 in 1958. Stroke is currently the third leading cause of death in China.

2.47 Cancer. Cancer has become the national health priority, being the first cause of death in China (about 25 percent of male deaths and 20 percent of female deaths). Between 1973 and 1975 China conducted a National Cancer 1' Mortality Survey - . Stomach cancer is the leading cause of cancer mortality, followed by cancer of the esophagus, liver, lung and colon/rectum. In each of these five sites the frequency is greater in men than women, but women also suffer from cervix and breast cancer. The overall cancer mortality rate for women (54 per 100,000 population per year) is, however, only about two-thirds that for men (80 per 100,000). Cancer mortality rates are somewhat higher in higher-income provinces than in low income ones, but the extent of the difference varies substantially for different types of cancer;2 1 ung cancer mortality, in particular, is much higher in higher income areas. -

2.48 The main feature in cancer epidemiology in China is the substantial variation in prevalence from region to region, with the existence of high risk areas for a single type of cancer in many parts of China. For example, nasopharyngeal cancer is a disease limited to Southern China with the highest incidence in Guangdong province from which it decreases in concentric bands. On the other hand, high prevalence of nasopharyngeal cancer persists in Cantonese emigrants to Hong Kong, Singapore, Hawaii and San Francisco, with evidence of decline only in the third generation Chinese in the U.S. Another example is cancer of the esophagus. Esophagal cancer mortality varies more

11 The late Premier Zhou Enlai himself convened a meeting of leading cancer scientists and stimulated the epidemiologic work by saying, "Cancer is your enemy. Where is your enemy?" Annex Table B-15 reports the survey's results concerning cancer mortality by province, and B-8 reports the national mortality rates for the seven most common types of cancer. Results of the survey itself appear in the 1979 Atlas of Cancer Mortality in the People's Republic of China.

2/ The relationship between mortality rates for different types of cancers and income levels and urbanization is examined in Supplementary Paper No. 4 to this report. - 26 -

than 600-fold across counties within China. There are six higher prevalence locations separated by long distances, the major one being a crescent-like focus located south of Beijing and encompassingparts of Hebei, Shanxi, Henan and Anhui provinces and the totality of Jiangsu. Another cancer, liver cancer, is concentratedin warm and humid coastal plains in the Southeast.

2.49 This specific geographicaldistribution has fostered the research on epidemiologicaldeterminants of selected cancers. Programs are carried out by 13 nationwide coordinating groups created to deal with the three major national problems, namely cancers of the liver, nasopharynx and esophagus. Following the fourth national cancer congress in 1977, further groups were created to deal with stomach, lung, cervix, leukemia, breast, and intestine cancers. A reference center was selected for each given cancer according to the incidence rate. A particular emphasis of epidemiologicanalysis has been on dietary habits and food hygiene, since 60% of all cancer deaths in China are due to cancer of the upper alimentary tract. I/

2.50 The main component of official policy is to prevent cancer through the identificationof causal factors rather than to invest money in heavily sophisticated equipment aimed at treating confirmed cases. The major difficulty is that a prevention policy is a long term enterprise, whereas social pressure calls for immediate improvement of treatment facilities. Moreover, China lacks the epidemiologists required to carry out extensive research programs, and modern oncology is not yet a part of the curriculum in all medical colleges. Only 50 physicians per year complete postgraduate training in oncology, which is insufficient to meet all provincial needs. Also any cancer is proved to result from multiple causes, and the group of determining factors may vary from region to region; it may take a long time, and much skilled epidemiological work, before a common denominator is identified or before integrated preventive measures result in a decreasing incidencerate.

2.51 The second component of Chinese cancer policy, namely early diagnosis and early treatment, requires improved diagnostic techniques in counties and rural facilities. For example, Sui Hua county authorities in Heilongjiang reported that treatment of the majority of cancers detected in the county was beyond their therapeutic resources, and that the diagnosis of cancer was usualLy missed in early stages. This poor capability is partially responsible 'forthe high case fatality rate (55.2 percent) that patients experience. On the other hand, early diagnosis and early treatment are not likely to change the mortality in stomach, liver, lung and pancreatic cancers.

2.52 Another important observation is a change in epidemiological trends. The incidence of stomach cancer is progressivelydecreasing in China, as it is in many other countries. In general, stomach cancer is more common among the poor and the decline is related to improved economic conditions.

-1/See "A Stratety Eor Cancer Control in China", by Zhang You-hui, Chinese Medical Journal, v. 97, January 1984, pp. 1-6. - 27 -

However, in China these seems to be no systematic rural-urban or income level association. In contrast, the incidence of lung cancer increased sharply during recent years, especially in urban areas and in the three municipalities (Shanghai, Beijing, Tienjin), and this appears to be due in part to high (and rising) levels of smoking.

2.53 For a long time, Chinese authorities were reluctant to admit that increased cigarette smoking may be responsible for the observed increase of lung cancer incidence. More recently, however, smoking is being appreciated as a public hazard and China's health propaganda is beginning to address the problem of smoking. Recent surveys indicate that 24 percent of boys smoke before the age of 18 in Beijing suburbs, and that 56 percent of males are smokers in Henan province; relatively few females smoke.

2.54 Smoking is banned in cinemas, theaters, libraries and hospitals. Students are forbidden to smoke in schools. The health hazards of smoking are discussed in public meetings, by well-known doctors and by the mass media. Owing to the lack of an authoritativeorganization responsible for the smoking control program, and the discontinuanceof anti-smoking propaganda,the anti- smoking campaign was less successful than expected. In the winter of 1981, the government increased the retail prices of cigarettes by about ?0 percent, and placed a limit on the amount of land for growing tobacco. - Cigarette production was 80 billion cigarettes in 1949, growing to 760 billion in 1980, a nine-fold increase. More ominous, recent trends show a very rapid increase in tobacco consumption. Chinese cigarettes are high in tar, containing 21 to 33 mg. per cigarette. Nicotine content ranges from 0.7 to 1.2 mg. per cigarette. (Today's filter cigarettes in the U.S. average about 14 mg. tar and 1.0 mg. nicotine.)

2.55 Accidents. Age and occupation-related information concerning accident mortality seem difficult to obtain, in part because accident records are maintained by the Public Security Bureau. There is little information published about this category of illness, although it represents about 10 percentof hospital admissions. In one study, undertaken in Shanghai County, the death rate due to accidents was reported to decrease by about 25 percent between 1960-62 and 1978-80, and accidents dropped from second to fifth place

1/ Nonetheless, the State Statistical Bureau's "Communique on Fulfillment of China's 1982 National Economic Plan" (Beijing Review, May 9, 1983) reports that trade in tobacco by the state increased by 40.8 percent in 1982 over 1981 levels. Levels of tobacco production show substantial year-to-year fluctuations,but the 1981 production level of 1.5 million metric tons was almost 50 percent higher than in any previous year. Chinese production, very little of which is exported,was over a quarter of the world total in 1981. In 1982 there was another major jump in production,to 2.08 million metric tons; this production increase resulted principally from a 67 percent increase in Land used for tobacco production. (See "China: World Agricultural Regional Supplement, Review of 1982 and Outlook for 1983", U.S. Dept. of Agricultura,June 1983.) - 28 -

in recorded causes of diath. (Interestingly,30 percent of accident deaths were due to drowning.) 1

LingeringProblems of Infectious Disease

2.56 Despite the major changes in mortality and morbidity since liberation,certain infectiousdiseases remain national problems, particularly in rural areas. Many of these diseases are widely distributed and progress against them still lags behind the progress that has been made with most of the other infections. Hepatitis, dysentery and tuberculosis are important examples of this category.

2.57 Hepatitis. The changes in the prevalence of hepatitis are less dramatic than in other diseases. In 1958, hepatitis accounted for 4.8 percent of the reported communicablediseases and one percent of the related deaths in this district. In 1979, despite a reduction in incidence of nearly 50 percent, the disease accounted for more than 10 percent of the reported communicabledisease cases and more than 50 percent of the related deaths.

2.58 Annex Table B-9 reports on the total number of cases registered in China between 1974 and 1981. Whereas the number of deaths resulting from viral hepatitis remained constant during that period (about 1,000 per year), the total number of cases shows an 80 percent increase, with an incidence rate increasing from 26 per 100,000 population to 43 per 100,000. Although part of this increase may be attributed to a greater accuracy in disease reporting rather than to a real increase in incidence, there is a clear trend towards a persistanceof a high prevalence of hepatitis. At the same time all the other reported communicabledisease were decreasing.

2.59 Dysentery. Dysentery - i.e. severe diarrheal disease - is a clinical syndrome not due to any specific organism. The threat to life is from dehydration. Dysentery was specificallyincluded as a target of the Patriotic Health Campaigns for the control of communicablediseases. Control measures were and still are mainly environmentalwith emphasis on education.

2.60 The trend in reported incidence of dysentery in China has been stationary since 1974 (see Annex Table B-9), around a mean incidence of 300 cases per 100,000 population. At the same time, the death toll was reduced by one half, with a case fatality rate decreasing from 0.25 percent to 0.13 percent. As a result of the reduced incidence of the other infectious diseases, dysentery is now the most frequentlyreported disease. It accounted for 78 percent of Beijing East District reports on seven communicabledisease

1/ See "Vital Statistics," by Cu Xing-yuan and Chen Mai-ling, in Health Services in Shanghai County, Supplement to the American Journal of Public HeaLth, 1982, vol. 82, p. 22. Table 2.4 also contains partial information on death due to accidents in the categories labelled 'trauma' and 'toxicosis'. - 29 -

in 1979, and for 68 percent of total reports in Shandong Province in 1981 for the same group of diseases.

2.61 The unchanged incidence of both hepatitis and dysentery in China during the last ten years indicate that fecal-born diseases are a lingering problem in the whole country, and not only in remote rural areas. A large fraction of the rural population does not benefit from safe water supply and is served by sources (open wells, pump wells, surface water) that fail to meet the safety criteria set up by the epidemic prevention stations (see Chapter 4, section 3). General sanitation deserves further attention in cities as well as in rural areas. Barefoot doctors receive no incentive for sanitation work. Manure collection and utilization should be more carefully controlled for hygiene implications.

2.62 Tuberculosis. As was indicated earlier in this chapter, tuberculosis remains an important disease problem in China even though tremendous progress has been made in reducing mort-ality from it. The first issue in tuberculosis control in China is the improvement of the quality of BCG vaccine. The present production of vaccines in China does not meet international standards. The product, a liquid solution, has a period of efficacy of 6 weeks at most, and requires storage between 20 and 80C. Laboratories have yet to turn to freeze-dried preparations, which can be utilized after several years of storage, although production has started on a trial basis. The low quality of vaccines is probably responsible for the low coverage of the target population (children under 15), which was estimated at only 50 percent in Heilongjiang. The second issue is the need for improved screening of active and infectious cases in the population. A significant decrease in morbidity can be expected if 80 percent of infectious cases are identified and treated. Present screening techniques -- including fluoroscopy, then x-ray, then sputum smears -- are difficult to apply on a mass scale, are expensive (about 125 Yuan per case detected in Heilongjiang), and affordable by enterprises only to screen their own staff. Presently recommended policy calls for screening only of high-risk patients. Screening procedures do not exist in a majority of counties, and unless substantial new resources become available, little change in the prevalence of tuberculosis can be expected in the near future. Beginning in 1984, tuberculosis control has become a national priority, and a new national survey will be conducted during the year.

Malnutrition and Child Development

2.63 The adoptiot. and increasing implementation of the one-child family policy has generated strong concern that each child have fuLl opportunity for optimal physical, mental and psychological development. Prenatal nutrition and counselling for expectant mothers is one important facet of policies to improve child development, and the empirical evidence, although highly selective, does suggest that the prevalence of low birthweight (less than 2.5 kg) is low. China's success with fertility limitation has also almost - 30 -

certainly had important benefits for the health of children actually born. - Children also seem well protected against vaccine-preventablediseases (Annex Table B-9) and, although there remain problems of diarrheal, respiratory and parasitic disease, substantial progress has been made, in much of China, in transforming these from major sources of mortality to lingering problems of morbidity. Likewise, in urban areas, progress against malnutrition has been so substantial that it can no longer be considered a problem of child development. Rural areas, in contrast, conTnue to suffer substantialamounts of moderate-to-seriouschild malnutrition.-

2.64 Rural-Urban Differences. China's 1979 16-province and municipality anthropometricsurvey provides one valuable data set for a careful assessment of urban-rural and inter-provincial differences in child malnutrition. A second data set, from 1975, provides information on a more limited sample -- nine cities (three in northern China, three in ce ral and three in southern) and the suburban areas immediately outside them. - A clear pattern of rural malnutrition can be seen in the available data, and relatively little urban malnutrition. Levels of both rural and urban malnutrition vary quite considerably from province to province as shown in Table 2.5, which reports a selection of data from 7-year olds in the 1979 survey. Table 2.5 reports both the percentage of children stunted (i.e., unduly low in height-for-age) and the percentage low in weight-for-age. Several points emerge from the table. First, there appear to be no important differences between males and females in percent malnourished. Second, in the most favored locations (urban Beijing and Tianjin) there is virtually no malnutrition. Third, rural-urban differences are marked, although somewhat less so in weight-for-agethan in

1/ If fertility limitation is in part accomplished by increased intervals between births, available data (from countries participating in the World Fertility Survey) suggest that infant mortality rates are likely to be one-third lower for a child more than two years younger than the next oldest sibling relative to those who are less than two years younger. Similar figures obtain for child mortality rates. In addition, the very fact of fewer children altogether in a household can be expected to improve health and nutrition.

2/ See Malnourished People: A Policy View by A. Berg (Washington,D.C.: The World Bank, June 1981, pp. 9-15), for an overview and references to the literature concerning adverse functional consequences of malnutrition. Data from three province-level units in China -- Beijing, Gansu and Jiangsu -- have also been analyzed to ascertain the effect of malnutrition on schoolchildren's school performance in those areas; even after controlling for whether the chiLd was in a rural or an urban school, Low height-for-age was consistently found to adversely affect performance (as measured by the number of grades behind a child was in comparison to where he should be, given his age). See "Child Malnutrition and School Retardation in China", by D. Jamison (Washington, D.C.: Population and Human Resources Division of the WorLd Bank, September 1981).

3/ Annex TabLes D-12 through D-16 excerpt results from the data published from these surveys and transform those data into various standards utilized for making comparisons across different groups (male-female, age groups, provinces, etc.). - 3 1 -

height-for-age. 1/ Finally, inter-regional variation is substantial indeed; 37 percent of rural 7-year old boys in Sichuan are stunted, in contrast to only 3.8 percent in rural Tianjin.

2.65 Sources of Differences. One potential source of the differences in prevalence of malnutrition reported in Table 2.5 is variation in genetic potential between northern and southern Chinese. However, the relatively small differences between cities in northern and southern provinces (compare Beijing and Guangdong) suggest that genetic differences are relatively unimportant; they could not explain rural-urban differences in the same province. A second and well established source of variation in growth failure is variation in disease prevalence, particularly diarrheal disease prevalence. Although the hard evidence is scant, diarrheal disease almost certainly remains an important problem in rural China, and hygienic improvements that reduce diarrheal incidence would likely have beneficial nutritional effects. Finally, differences in the quantity and quality of available food probably account for much of the rural-urban difference in prevalence of malnutrition. Urban food subsidies amounted to approximately 96 yuan per capita in 1981; there are virtually no food subsidies in rural areas (aside from foregone interest on state loans for food to communes producing below the ration level). If the urban food price subsidy is added to per capita expenditures on food, urban food expenditures total 354 yu,an per capita per annum, in contrast to rural expenditures of 114 yuan. 2 The state subsidy accounts for 40 percent of the difference between rural and urban food expenditures.

2.66 Efforts to reduce rural malnutrition will, therefore, need to address very directly the problem of providing more food, and possibly food of higher protein content, to rural children and youth. Diarrheal disease control efforts may also be important, but probably relatively less so than in many other countries. The increases in rural income that have ensued from economic reform in recent years will undoubtedly be important for many areas in providing the food required to reduce malnutrition. However, cLose surveillance of children's growth to allow targetting of food to the malnourished is a contribution the health care system can make to reducing rural malnutrition, and, where it is not now done, this effort should be a priority of the MCH system.

1/ Available data consistently show rural Chinese children to be as high (often higher) in weight-for-height as their urban counterparts. Greater stockiness of rural children may, then, be partially compensating for lower stature in reducing rural-urban differences in weight-for-age.

2/ Estimates of rural and urban food expenditures for 1981 appear in the Statistical Yearbook of China 1981, pp. 439 and 445. Annex TabLe D-5 reports levels of rural food expenditure and nutrient availability by province. - 32 -

Table 2.5: PERCENTAGE OF 7-YEAR OLD BOYS MALNOURISHED, SELECTED PROVINCES, 1979

% stunted a/ % low weight-for-ageb Province Urban Rural Urban Rural

Beijing 0.7 8.4 3.8 10.2

Tianjin 0.5 3.8 2.9 4.4

Shandong 2.1 11.9 6.2 11.3

Heilongjiang 1.3 19.5 5.9 15.4

Guangdong 1.3 19.2 6.4 23.0

Sichuan 7.5 37.1 11.1 26.4

National average 2.6 12.7 7.6 13.1 a/ A child is said to be 'stunted' if his or her height is less than 90 percent of the median height of children of the same age by the standards compiled by the U.S. National Center for Health Statistics. The percent stunted can be calculated from the mean and standard deviation of the distribution of height at a given age, assuming the distribution to be normal, which is a reasonable assumption. b/ The percent low in weight-for-age was calculated assuming a normal distribution for weight (which is not a particularly good approximation) and defines low weight-for-age as below 75 percent of the NCHS median. This corresponds to either Gomez II malnutrition (60-75 percent of NCHS median) or Gomez III malnutrition(below 60 percent of NCHS median).

Source: Supplementary Paper No. 8 to this report, which contains data for girls as well as boys from a total of 16 provincial-levelunits. - 33 -

3. THE HEALTH SECTOR AND ITS FINANCING

3.01 China' success in improving the health of its people far exceeds what could be expected at its stage of development(as was discussed in Chapter 1). Much of this success is attributableto the national health service delivery system, and both it and the policies on which it is based are described in this chapter. Other influences on health -- water supply and sanitation,food availabilityand fertilily levels are discussed in the next chapter.

3.1 Health Policies

3.02 Health policy is formed along a number of dimensions. One concerns the extent to which resources will be made available, and how provision of those resources will be financed. A second concerns the relative extent to which preventive and curative measures will be emphasized. A third concerns the extent to which responsibility for health rests with highly trained professionals,with lower-level staff and with the individual. A fourth concerns the extent to which health programs are addressed directly, through the health care system, or indirectly by, for example, improvingwater supply and sanitation or nutrition levels. A fifth important dimension of policy concerns the extent to which a broad range of health services will be "integrated"into a common delivery package for a specific geographic area, or whether separate "vertical" (or categorical) programs will address specific diseases -- tuberculosis, schistosomiasis, etc.

3.03 The Chinese have taken relatively consistent positions on these policy issues, though emphasis has changed from time to time. This section first discusses general directions of health policy in China then turns to a more explicit discussion of current directions in policy.

General Policy Directions

3.04 Resource mobilization. China's leadership placed great value on improvingthe health of the people, and as will be discussed in Section 3.5, a substantialvolume of resources has been made available to improve health -- accounting, in 1981, for about 3.3 percent of GDP. Financing is in part by the State (for government and enterprise employees), in part by communal or subcommunal levels of organization and in part by the individual. In rural areas an important mechanism for mobilizing resources (and pooling risks) has been the cooperative health insurance system; this system is, however, being eroded with the introduction of the rural production responsibilitysystem. While there is great variation in financing arrangements throughout the country, it is a fair generalization that the State and communal levels, combined with self-help, finance the greater part of the preventive measures leading to relative uniformity of their distribution around the country. Rural curative services, on the other hand, tend to be financed at the individual and brigade level, and the major nationwide income inequalitiesat these levels are reflected in the uneven quality of rural medical services provided. In urban areas far more resources are devoted to health services, over three times the rural level; even in rural areas, however, the resources available for health care are substantial relative to rural areas in other low-income countries. - 34 -

3.05 Preventive emphasis. Compared to virtually all other countries, China has strongly emphasized public preventive over curative health services. 1- Major campaigns were mounted shortly after 1949 to improve environmental sanitation; to eliminate the (then) "four pests" -- rats, flies, mosquitoes, and bedbugs; to vaccinate against and cure infectious diseases; and to control the vectors of major endemic disorders such as malaria and schistosomiasis. Mass mobilization played a key role in the success of these campaigns. The allocation of health resources to preventive activities (and to curative services in urban areas, to the extent they were provided) generated a demand for at least minimal curative services and pharmaceutical availability in the rural areas, and health policies of the Great Leap and Cultural Revolution periods responded to that concern. 2 While these vigorous preventive efforts were undoubtedly enormously successful in effecting initial morbidity and mortality reductions, the demand for curative care could be ignored only up to a point, and is receiving increased emphasis. The preventive approach to problems of communicable disease does not, moreover, seem to be playing nearly as prominent a role in dealing with today's problems of chronic disease.

3.06 Manpower policy. China's policy toward highly professionalized versus lower-level staff folLows naturally from its emphasis on public preventive relative to private curative services, and on providing at least minimal levels of curative service for large numbers. Clearly the training requirements for giving vaccinations or assisting with environmental sanitation differ substantially from those for open-heart surgery or cancer epidemiology, to take extreme examples. Preventive measures also place greater responsibility on communities and individuals for their own health conditions. As the basics of hygiene and community involvement in preventive health become more established, however, it will become necessary to upgrade the skills of the barefoot doctor to undertake (and be trusted with) more complicated tasks, and the MOPH plans, within a decade, to have upgraded 50 to

1/ This orientation is deeply imbedded in Chinese tradition. A recent western review of medical policy in China begins by noting that "The keystone of the Chinese medical tradition is the notion that medicine is the art of maintaining health, not curing disease." (See D.M. Lampton, The Politics of Medicine in China, Westview Press, 1977.)

2/ It has been argued that dramatic increases in pharmaceutical production in the immediate post-1949 years were devoted almost entirely to production of vaccines and chemicals of use in preventive medicine; this led, in rural areas, to insufficiency of even basic curative medicines. (See L. Orleans, HeaLth Policies and Services in China, 1974, Committee Report, Committee on Labor and Public Welfare, United States Senate, March 1974, n "; i 32 ) ot . ) - 35 -

60 percent of barefoot doctors to the level of assistant doctor. -/ Likewise, the increasing prevalence of chronic diseases places greater demands on the upper end of the spectrum of health care workers, and thus increases are being made in the training period for senior doctors. All these factors have combined with reaction against policies of the Cultural Revolution, when quality of services was often given inadequate attention, to lead to increased professionalization of medical staff. It should also be stressed that the intensive and active involvement of the (nonprofessional) political leadership at every level is a key element in implementing China's health policies. The Army has also played a role in providing manpower for rural medical care.

3.07 Multifaceted strategy. China's concern with prevention has also led to pursuit of a health strategy that reaches well beyong the health system per se. In particular, improved nutrition, provision of safe water supplies and sanitary and convenient means of waste disposal, fertility reduction and widespread educational improvements have been major policy objectives. These points are further discussed in Chapter 4. Underlying all facets of this health strategy have been the administrative capacity and political will of the Chinese government, which have, despite occasional setbacks, been essential to success.

3.08 Program integration. A final policy issue is that of integrated versus vertical programs. Figure 3.1 provides a schematic overview of the structure of health care delivery in China, although it should be emphasized that chere is substantial local variation in the structure and organization of the service. The three main boxes shown in Figure 3.1 are the "Vertical Preventive Programs," "Clinic Based Services," and "Birth Planning Services." Much of preventive medicine in China is public and is vertically organized, with responsibility for controlling specific communicable diseases centrally located. In addition, hygiene promotion (through the National Patriotic Health Campaign Committees) operates in coordination with political authorities in a centrally-directed fashion. The importance of these centrally-run activities can, however, be overemphasized since the preventive, vertical programs heavily utilize the clinic-based services for their implementation and would certainly be far less effective without them. Nonetheless, the strong emphasis placed on categorical programs and health campaigns (except during the Cultural Revolution) likely played an important role in China's success in dramatically reducing morbidity and mortality rates; other countries seeking to learn from China as they extend primary health care should thus pay particular attention to China's centrally initiated and directed vertical programs. An important feature of the organization of the vertical programs is that instead of having separately administered programs for malaria, smallpox, leprosy, etc., most vertical programs are the responsibility of the epidemic prevention stations of the provincial and county health bureaus. (Tuberculosis is perhaps the most

1/ It will be important to ensure that additional curative responsibilities for barefoot doctors do not interfere with their essential preventive responsibilities. Figure 3.1

Organization of Health and BirthPlanning SeMces

rProvinclcolLeveal

Vertical Prrzventive Proragrms Clinic-Bosed Medical Services Birth Poannina Progroms Manningt Unfifld odministration with Budgeting statf at the provinclol. pre-C - Urboan Responsible for fecturel ind coudnty ( lvels oun trycTrHth Snalios (anti ePidemic stations & Cont Generkt Henerol Hospita Plonning& otrgf mcrtemnol & child health Cut snrlHsiosbrhponn centers) Posponsible tov Information. edUicOlion,&Secsl

Infectious diseose t I Sp a|s1 CY!cmNncain's

s urveillance.dopr_nKn Commune-Clin iC Strarat & Workplace Licison with clinical services a voccinatbns) (middle level physicians Thre Heolth Stations Hvgienae & publc & auxiliOries) tered herath camffxigns system

Monitoeng food & t I I water qutlity & Pzoduction Brigade- Lane Health Stations envirAtmental sanitation CooperatKe medical SchaD hyglene Station (3 or 4 borefoot Industrial hygie doctor)

MateraKnl & Child Health Medica

Production Teom Institutes (Port-timre health aide) Reteroi Supervision & Training

World Bonk-26036 - 37 -

important exception to this generalization;there is a separate structure for dealing with tuberculosis).

Overview of Current Health Policy

3.09 General policy. The MOPH, like all agencies of the Chinese government,has been concerned with readjustmentof its budget and priorities in recent years. While for most agencies this readjustment has entailed substantialefforts to reduce expenditure, the MOPH budget has grown rapidly in the period 1977-81, and even moderately in the period of fiscal restraint between 1980 and 1981 (Table 3.6). In the context of seeking new directions in the post-CulturalRevolution period, the MOPH has assessed priorities for the coming years and developed the following list of objectives:!/

"According to the eight-fold policy in the readjustment of the national economy, there are at present eight objectives in health services:

(1) Carry out in earnest the policy of putting prevention first, so as to strengthen the prevention and antiepidemicwork, to launch vigorously the patriotic health campaigns and to prevent and treat those sicknessesthat seriouslyundermine the health of the people.

(2) The strengthenand consolidate health services in rural areas, to see that a good job is done in providing health services and medical care to the eight hundred million peasants. Of specific importance is the reorganizationof one third of the health institutionsat the county level, the training of barefoot doctors and the carrying out of the cooperative medical care system. At the same time, health services in the urban ar as and in mines and factories are to be

strengthened.-

(3) To enhance traditional Chinese medicine and the integration of Chinese and western ways of healing. The policy of letting Chinese ways of healing, western ways of healing and a combination of Chinese and western ways of healing coexist over a long period of time should be implemented,so that all three ways of healing can develop.

1/ The quotation comes from a translation of documents provided by the MOPH to the Rural Health and Medical Education mission. Emphasis has been added to the original quotations.

2/ In light of the stated emphases on putting prevention first and consolidation of health facilities in rural areas, it is surprising to note that in a list of 70 'top-priority'projects in China, the single health project included is construction of a major urban hospital -- the Sino-JapaneseFriendship Hospital (Xinhua, May 18, 1983). - 38 -

(4) Carry out in earnest the policy of giving guidance in family planning and strengthenmaternal and child health care.

(5) To intensify the training of professionalsin health services and the research on medical care. The training of technical and administrativepersonnel is also to be strengthened.

(6) To improve economic, technical and administrativemanagement.

(7) To see that medical care and the use of pharmaceuticals are coordinated and that there is tight control over pharmaceuticalsto ensure the quality of the pharmaceuticals.

(8) To strengthen the leadership of the party and to see that political and ideologicalwork is well carried out..."

3.10 Available documents and descriptions of policy, like the paragraphs just quoted, discuss policies with respect to procedures and inputs rather than addressing the priorities to be attached to specific classes of medical problem. Published informationconcerning health in the Sixth Five-Year Plan - (1981-85) indicates a target increase of 600,000 in professional health personnel in the Plan period; the 1980 base wis 3,500,000. The 1980 level of physician availability of 709,000 doctors 2 is to increase by 25 percent to 890,000 by 1985. Also during the Plan period the number of hospital beds is to increase by about 12 percent for a total of 250,000 additional beds; priority will go to specialized facilities in cities and to hospitals of traditionalChinese medicine.

3.11 Rural health policy. The centerpiece of rural health policy is a national program, to be completed by the year 2y00, to upgrade the health facilities of all the country's 2100 counties. - The first phase of this program aims to have completed the upgrading of one-third of all counties by 1987; this more immediate goal is known as the 'one-third county program'.

1/ See the excerpts of the Five-Year Plan published in a supplement to the Beijing Review (May 30, 1983). Health plans are treated very briefly in the excerpt in comparison to other sectors. They are likewise treated relatively briefly (and in relative generality) in Premier Zhao Ziyang's "Report on the Work of the Government"delivered June 6, 1983 at the First Session of the Sixth National People's Congress (Beijing Review, July 4, 1983).

2/ The Plan's figures for doctors apparently include doctors of western medicine, both doctors and assistant doctors of traditionalmedicine, and 'combined'doctors of western and traditionalmedicine.

3/ See "StrengtheningRural Health Work by Relying on Policy and Science", Excerpts from a speech by then - Minister of Public Health, Qian Zinzhong, in Health News, February 11, 1982. - 39 -

The one-third county program began in 1980-81 with investments of approximately Y600,000 in each of 300 counties; an additional Y1,400,000 remains, on average, to be spent in the upgrading program in each of these counties. External assistance (from the UNDP, executed by WHO) has assisted with developmentsin three pilot counties.

3.12 The major foci of the county upgradingprograms are to strengthen the four county-levelhealth institutions -- the general hospital, the epidemic prevention center, the MCH center and the training center -- and to assist in strengthening selected commune health centers. These 'major commune health centers' would become an intermediatelevel of referral between regular county health centers and county hospitals; by having them be competenc to handle moderately complicated cases, access to quality health care would become much more widely distributedand accessable in rural areas than it now is.

3.13 There exists an analysis of the financial plans fo- the one-third county program as it is being developed in Shandong province. The results of those analyses, and more detailed province-speWfic delineation of proposed investment programs, is available separately. - It suffices to note here that both the capital and recurrent cost implicationsof the investment plan seem to have been considered in light of probable resource availability,and the plans seem generally financiallyfeasible.

3.14 MOPH plans for medical manpower development 2I. The MOPH estimates that the number of doctors (western and traditional) is currently 0.8 per 1,000 population, and that this ratio can be maintained during the 1980s without increasingmedical college enrollmentbeyond what will result from the current level of about 30,000 new admissions each year. MOPH Projections of the output of graduates from the medical colleges in 1982, 1985 and 1990 are given in Annex Table C-6. 3/ Total enrollment is not expected to increase during this period, although it is planned to increase enrollment in the 1990s

1/ For detail on Shandong Province, see SupplementaryPaper Number 9 to this report, pp. 55-57.

2/ More detailed discussion of pLans for medical manpower development may be found in SupplementaryPaper Number 6 to this report.

3/ The projections for medical college graduates in Annex Table C-6 (and for secondary medical schools in Annex Table C-7) were supplied to the Rural Health and Medical Education mission by the MOPH. It is not clear whether these projections were made in the normal course of planning, or whether they are ad hoc estimates prepared in response to the mission's request. - 40 -

in order to achieve a doctor to population ratio of 1 : 1,000. In the 1980s, priority will be given to consolidation rather than growth, improving the quality of education and research, retraining staff to repair the damage of the Cultural Revolution, and building up teaching and research staff through postgraduate training. There are 92 faculties of western medicine in the medical colleges, and three new faculties are being established. The MOPH expects a 13 percent decrease in graduates between 1982 and 1985, but an increase of about 10 percent by 1990. In addition to regular enrollment, these faculties have the heavy burden of retraining the large number of doctors who graduated during the Cultural Revolution.

3.15 The numbers of graduates expected from the secondary medical school programs are listed in Annex Table C-7. The decline indicated between 1982 and 1985 is misleading, since the 1982 graduating classes are unusually large because in 1979 both health manpower needs and the resources of the medical schools to cope with expanded enrollment were overestimated. In nursing, it is planned to increase the number of graduates up to 1990, in particular to meet the needs of urban areas.

3.16 It has been decided to reduce the numbers of assistant doctors of western medicine and traditional Chinese medicine to be trained because their principal employers, commune health centers, are often unable to pay for more assistant doctors, and higher-level health services prefer to employ senior doctors. Consequently, the number of graduates in 1985 will be reduced to one-half of the 1982 output for assistant western doctors, and to one-eighth for assistant doctors of traditional Chinese medicine. By 1990, the output of both will be raised but, in the case of assistant traditional Chinese medicine doctors, to less than half the current level.

3.2 Organization of Health Service Delivery

Organization of Health Services

3.17 The three-tiered system. The primary health care system that exists today in rural China operates on three levels: the brigade cooperative medical center, the commune health center and the county general hospital (Figure 3.1). This system is based upon the idea that, in a country where it is impossible to have a fully qualified doctor in each town or village, it is feasible to have one or more paramedical workers within walking-distance of

1/ Specifically, assuming the medical college enrollment plans indicated in Annex Trble C-6, that 2.5 percent of doctors leave practice each year, and that the population in 2000 is [.2 billion, the ratio of 0.8 per thousand will not have changed. Meeting a target of I per thousand, indicated as desirable by Ministry officials, would require increasing medical college output by 12,000 per year to over 40,000, or increasing the rate of upgrading of assistant doctors. An output of 40,000 would also be roughly consistent with the 6th Plan's target of increasing the total number of doctors by 180,000 during the Plan period. - 41 -

most communities, even many that are very poor and remote. China has also simplifiedthe manpower problem by avoiding the creation of a separate health service bureaucracy; instead, it has simply imposed the health care system upon the political-economic-adminstrativestructure that already existed.

3.18 The two lower levels of the three-tieredhealth system -- the commune and the brigade -- are financed principally by the peasants, through various combinations of fee-for-service,brigade-level) cooperative health insurance and work-point subsidy for barefoot doctors. _ Some commune health centers, currently about one third, are state financed. These lower levels constitute the rural collective health system, and provide most of the medical care received by the Chinese people. In addition, production teams often have part-time midwives and health aides who link the production teams to the barefoot doctors in the brigade health post.

3.19 Almost all communes have one commune hospital or health center with about ten beds; this facility is responsible for routine curative work as well as for preventive medicine and family planning. The center typically has some assistant doctors and sometimes also some full doctors in addition to paramedical staff. All brigades, except those very close to an urban or commune center, have a brigade health post. In Sichuan in 1981, for example, there were 65,446 brigade health posts for 75,570 brigades, an 87 percent coverage. Even brigades without health posts generally have a barefoot doctor. However, the number of brigades having cooperative health insurance schemes has dropped significantly(to about 58 percent in 1981 from 85 percent in 1975) with the introductionof the new responsibilitysystems. Annex Table C-14 provides data on various aspects of brigade level health care.

3.20 At the county level, which is the top of the three-tiered system, there are three health care units -- the county general hospital, the county epidemic prevention station and the county MCH station. At this level and above, facilities are owned by the central government and funded from its budget. Under the direction of the county health bureau, each of the three units supervises and supplies technical support (including in-service training) to the commune health centers within the county in its specialized field. Typically well-staffed by college-graduate physicians, the county hospital serves as the general referral hospital for the entire county, receiving and treating cases referred to it by commune, urban and enterprise health centers. While data are unavailable for more than a few counties, it appears that 50 to 75 percent or more of the patients served by county hospitals are residents of the county town. The county hospital also provides training for the medical staff at the commune level. The county epidemic prevention station, with three to ten staff members, is responsible for preventive health and communicabledisease control for the entire county. It

1/ As the rural responsibilitysystem becomes more widespread,the work-point system is losing prominence. Fee-for-service and, in some cases, government subsidy of barefoot doctors' salaries replace the former system. - 42 -

provides technical support for and supervises the preventive health section of the commune health centers. l

3.21 Urban health services. Urban health services, like those in rural areas, operate on three levels, although the system of finance differs. Corresponding to the brigade and commune health facilities are 'street' and 'lane' health stations, staffed by paramedicals, that provide preventive and simple curative services. Street clinics play a role in urban areas similar to that of commune health centers in rural areas. They have few beds, their staff generally include doctors as well as other health workers, and they play an importayt role in public health work. Referrals from these stations go to district 2 , provincial or specialized hospitals.

3.22 Urban coLlective organizations also exist and include some hospitals, especially hospitals of traditional Chinese medicine, and street clinics. Such organizations are officially distinct from lane health stations or hospitals run directly by municipal and district health departments, but in practice the distinction is unimportant. They are operated in much the same way as government units. They pay similar salaries and, in contrast to enterprise facilities or rural collective facilities, which can obtain resources from enterprises and communes, brigades and teams depend entirely for funds on the government or on operating income.

3.23 State enterprise organization. Side by side with the network of national, provincial and local facilities which serves the whole population, there is a network of industrial and other state enterprise hospitals and other facilities that provide free services to workers in those enterprises. Little information is available on these facilities, but their importance is demonstrated in Figure 3.3, which shows that in 1981 they provided about 25

1/ China has paid relatively less attention to provision of dental care than of other medical services, although there exists a curative infrastructure that parallels that of the three-tiered system. Like that system, the dental care system makes heavy use of para-professional staff. Unlike other areas of medicine, however, relatively little emphasis has been placed on prevention (oral hygiene and fluoridation of water), and substantial improvements in preventive care seem possible. See "Dental Care Delivery in the People's Republic of China," by J.I. Ingle, Chapter 18 of J.I. Ingle and P. Blair (eds.), International Dental Care Delivery Systems, Ballinger, 1978.

2/ 'Districts' are the urban political units at the same administrative level as counties. - 43 -

percent of medical care in China. 1/ Although enterprise facilities report administratively to the health sections of various industrial departments, they also receive technical guidance from provincial and local health departments. Depending on the size of the enterprise, complicated cases are treated in its own health facilities, or referred to the government hospital system; if a patient is referred, expenses incurred at, say, a district hospital are reimbursed entirely by labor insurance. Large enterprises handle almost all their own cases, and the Railway Ministry and Army, to take extreme examples, even have their own medical colleges as well as hospitals.

3.24 Ministry of Public Health (MOPH). At the apex of the health care infrastructure is the Ministry of Public Health whose staff (numbering fewer than 500) is responsible for formulating and overseeing all aspects of health policy. Chart 1 (at the end of the report) shows the organizational structure of MOPH. As the chart shows, the MOPH is organized not only to set general policy, but also directly to manage a major hospital, vaccine production facilities, the 13 core medical colleges, and medical research institutes (Chart 2).

Health Campaigns and Epidemic Prevention Services

3.25 Patriotic health campaigns. As indicated in para. 3.05, the Chinese Covernment has made considerable use of health campaigns as a mean of attaining some of its health objectives. The campaigns take the form of the mass mobilization of people for preventive and health promotion activities. The first campaign was launched in 1951, and over the past 30 years, there has been an average of four or five campaigns a year. These campaigns have been conducted under the leadership of an organization known as the "National Patriotic Health Campaign."

3.26 Although it is sometimes difficult to separate the effects of the health campaigns from those of other programs, there is little doubt that without these campaigns, China's achievements in health over the past three decades would have been much less substantial. The reduction in the prevalence of schistosomiasis, for example, owes much to the mass mobilization of people for work which in some areas entailed not only diverting water channels from infested rivers and canals and burying the snai)s, but also collecting individual snails with chopsticks and killing them. 2, Similarly, the reduction in the incidence of malaria has been due in large measure to

1/ Data on the availability of health facilities 'under other ministries' in selected years have recently been made available (Annex Table C-13); these show that the rate of growth of personnel and facilities in the enterprise system has been substantially more rapid than for the health care system as a whole.

2/ See the article on eradication of schistosomiasis in the supplement to the American Journal of Public Health (September, 1982) on "Health Services in Shanghai in Shanghai County". - 44 -

campaigns to fill in stagnant ponds and eliminate other mosquito breeding sites. People are mobilized to clear the streets and remove rubbish and nightsoil, and the disposal of the waste is carefully supervised. A key aspect of the campaigns has been to teach people to boil drinking water, and not wash tools and containers contaminated by excreta in rivers that provide drinking water. Such campaigns to promote better hygiene have probably been as effective in improving public health as increases in the quantity and quality of water and sanitation facilities.

3.27 The key to the success of the health campaigns has been a very effective organizational network at all levels, closely linked to the network of political, administrative and economic organizations. At each level from the national through the provincial and prefectural to county, commune and brigade there is a small health campaign full-time staff which reports directly to the health campaign committees which also exist at all levels and which include high ranking party and government officials as well as representatives of ma,ss organizations such as the youth league, and the women's federation. 11 (Premier Zhou En-lai was for many years chairman of the National Patriotic Health Campaign.) The health campaign committee at the brigade level, which is often chaired by the brigade barefoot doctor, and which reports to the brigade management commitcee, mobilizes people to carry out both the programs initiated from above and any programs devised by the brigade health committee itself.

3.28 Although much has been achieved through the health campaigns, the need for them still remains. This is partly because, unless campaigns are repeated, problems may recur -- for example, areas previously cleared may become reinfested with snails and partly because new campaigns may become desirable to tackle the diseases that are becoming relatively more important. This is already happening, and current campaign objectives include food hygiene and occupational and environmental pollution. Somewhat surprisingly, however, there are as yet no campaigns to promote diet, exercise and anti-smoking programs that could help to prevent the newly important chronic diseases. The planning of future campaigns will also have to take account of recent changes in the organization of economic activities in rural areas which by giving households much more autonomy, make it more difficult for the brigade committees to mobilize people for health campaign work.

3.29 The Sanitation and Epidemic Prevention Network. One of the major health institutions operating at the county level is the Sanitation and Epidemic Prevention Station. This station is responsible for vaccination programs, control of communicable disease more generally, monitoring environmental sanitation, assisting in implementation of patriotic health campaigns (discussed above) and health education. It reports upward to the provincial level Sanitation and Epidemic Prevention Station and receives from

1/ In Sichuan, for example, the provincial committee is chaired by the provincial governor and includes the directors of all the provincial departments. - 45 -

the provincial station the vaccines it utilizes. Preventive work below the county level is usually the responsibilityof a unit within the commune health center and, below that level, of one or more of the barefoot doctors in the brigade. The county station organizes and supervises their work.

3.30 In early 1983 the State Council approved the establishment of a National Center for Preventive Medicine (CPM), which is in part being created from an amalgam of existing entities (mostly from within the Chinese Academy of Medical Sciences) and is in part being created de novo. The CPM will, to some extent, serve as the apex of the epidemic prevention network, with training and applied research among its important roles. It will also be responsible for strengtheningthe national disease reporting and surveillance system,which is further discussed below.

3.31 Morbidity and mortality reporting. A list of 25 communicable diseases has been made officially notifiable, some of them requiring immediate report by telephone. The frequency of reporting is variable depending on the area and level, usually every ten days. Some areas do report negatively; other areas apparently do not. A problem then arises in that failure to report cannot be distinguished from nothing to report. Non-communicable disease reporting officially does not yet exist in China. However, a pilot study is now underway in seventy cities and counties, with a population of about 60 million. In some of them a comprehensive surveillanceof all deaths is carried out. In other ones, surveillanceis made on a sample basis. This study reports on 53 causes of death in 13 age groups.

3.32 In comparison with other developing countries, China's reporting coverage is comprehensive because the basic reporters are the widespread, although minimally trained, barefoot doctors. However, China's statistical system did break down completely (except in Shanghai and Beijing) during the Cultural Revolution and is gradually recovering. The accuracy and the reliability of reporting is acknowledged to be a problem that varies geographicallyand may fluctuate over time. The net effect is almost certain to be under-reporting,anywhere from a factor of 2 to 10 being a reasonable range for most diseases. Of particular importance for policy, the magnitude of under-reportingis likely to be the worst precisely in those locales where the communicabledisease problems remain most important.

3.33 Partly in order to assess the accuracy of routine disease reporting, some 30 disease surveillance points have been established throughout the country by the Institute of Epidemiology and Microbiology of the Chinese Academy of Medical Sciences. The chief advantage of these surveillancepoints is that the served populationsare enumerated,which allows an accurate - 46 -

construction of rate data. I/ Plans are now underway to establish a rural and an urban surveillance point in each of China's provinces.

Traditional Medicine

3.34 Traditional medicine, as is well known, plays an important role in China. Several important types of traditional medicine are practiced -- including Chinese, Mongol, Tibetan, Ugyur and others. Because over 93 percent of the China's population are of the Han ethnic group, Chinese traditional medicine predominates, although official policy does not discriminate in favor of any particular system of traditional medicine. 2 In this report, the term 'traditional medicine' is used to include all forms of traditional medicine, and 'Chinese traditional medicine' is used when referring to that particular variety.

3.35 All forms of traditional medicine share two characteristics. The first is that their theoretical and diagnostic base,s are not (at least for the present) explicable in terms of modern biology. 3 The second is their wide variety of therapeutic measures. These include acupuncture and moxibustion in

1/ In a report of March 21, 1983, the Foreign Broadcast Information Service (FBIS) describes the purposes, structure and locations of the disease surveillance points being established. Initial emphasis will be on the legally defined contagious diseases, but plans call for gradual expansion to deal with other disorders. As of 1980, 17 of the disease surveillance points were also assessing cause of death.

2/ A recent English-language article on Tibetan traditional medicine, for example, begins with the observation that "The distinctive body of medical theory and practice developed over the centuries on the Tibetan plateau is today a precious medical heritage of the Tibetan people and an important part of Chinese traditional medicine as a whole." See "Tibetan Traditional Medicine", by Cai Jingfeng, China Reconstructs, March 1982.

3/ The current relation of the theoretical system of Chinese medicine to biological science is well put in a document recently prepared for the World Bank by the Beijing College of Traditional Chinese Medicine: "Traditional Chinese medicine is imbued with rich clinical experience through ages and it is a unique theoretical system difficult to understand because its theory (is] confined by the development of science in ancient China and is combined with the ancient philosophy and explained by the philosophical terms. It has not integrated with modern science and technology and some of the theories still cannot be made clear by modern science. For this reason, it is difficult for the students to understand since there are no objective parameters to reveal the essence of Chinese medicine." - 47 -

Chinese traditional medicine 1/ and a wide variety of herbal and other medical preparations in each of the traditional systems. Important efforts are now underway to improve biochemical knowledge of the active agents in these preparations, and attempts to initiate scientific efforts to assess the therapeutic efficacy of traditional procedures enjoys strong support from the Ministry of Public Health. Ancient Chinese medical writings also contained accurate dietary advice concerning avoidance of important micronutrient deficiency diseases (beri-beri, xeropthalmia and goiter) 2/, and current dietary and exercise guidelines from traditional medicine accord well with research findings on prevention of chronic disease.

3.36 The number of practitioners of traditional medicine in the post-1949 period; rose from 276,000 in 1949 to 361,000 in 1959, then declined sharply to 206,000 in 1972 (Annex Table C-10). Since then, numbers have been growing steadily and, in 1981, 290,000 traditional doctors were practising. In recent years, the Government has encouraged traditional medicine, and the number of hospital beds for traditional medicine increased by 35 percent between 1979 and 1981, compared with a 6 percent increase in general hospital beds and a 1 percent decrease in commune clinic beds (Annex Table C-9). An increase in the number of doctors of traditional medicine is one of the priorities for health manpower development. The priority accorded to both traditional medicine and rural health care is reflected in the fact that traditional practitioners are almost as numerous in proportion to population in rural as in urban areas -- there are .26 practitioners per thousand in rural areas and .46 in urban areas. In contrast, senior medical staff are about seven times as numerous in proportion to population in urban areas as in rural areas.

3.37 Traditional medicine will continue to play an important role in in modern China. A national conference in March, 1980, endorsed a continuati3 7 of a three-fold approach to health care -- Chinese, western and integrated -- each of the three strands being expected to continue "...over a long period of time".

1/ A particularly clear exposition of what is known about the analgesic and therapeutic effects of acupuncture and moxibustion may be found in Science in Traditional China, by J. Needham, chapter 4 (Harvard University Press, 1981).

2/ See "A Brief Overview of the History of Nutrition in China," by Xa Da-dao, mimeo, 1981.

3/ Integrated western and Chinese medicine is an important development of medical care in China, but this conference explicitly did not endorse the notion that all care should ultimately be integrated. At present only about 2000 practitioners are fully qualified in both Chinese and western medicine (Annex Table C-2). - 48 -

3.3 Inputs to Medical Services

3.38 Table 3.7 provides estimates of the fraction of health care resources devoted to personnel, facilities, equipment and pharmaceuticals;it suffices here to note the predominanceof expenditureon pharmaceuticals(58 percent of total recurrent health expenditurewas on western and 9 percent on traditional drugs). These inputs to medical services are discussed below.

Personnel: Categories,Training and Growth in Numbers

3.39 Historical background. The first schools of western medicine in China were established late in the 19th century. Western medicine was introduced more systematically in 1917. By 1949 there were 56 medical colleges and faculties in China, many of them small. Some were run by state or provincial governments and others by missionaries or foreign organizations. The courses ranged from three to eight years and the curriculumwas strongly influencedby the background of the organizers. Their graduates were labelled "doctors of western medicine" to distinguish them from the doctors of traditional medicine. The most influential of the early medical colleges was the Peking Union Medical College (PUMC) established in 1924 under strong influence from the medical education reform movement then underway in the U.S. Although only 313 doctors graduated from PUMC in the 24 years before 1949, the graduates of this college have has a profound impact on medical education and scientific researwh in China and have risen to positions of leadership in the medical system. 1 Most of the medical colleges were in urban areas, particularly in coastal cities, and the number of graduates averaged only 500 per year (9449 doctors graduated between 1928 and 1947). Consequently, few people had access to western medicine. The remainder, particularly the rural population, received medical care from traditional practitionerswho had perpetuated their art by apprenticeship for more than 2000 years. Secondary medical schools trained nurses and midwives for hospitals and for work in rural areas: it is estimated that 41,437 students graduated from these schools up to 1949.

3.40 After 1949 the Government of China initiated a massive program to expand and upgrade the training of health personnel, to relocate facilities in order to provide better distributionof health professionals,to give greater emphasis to prevention and to integrate traditional medicine and western medicine. Small medical colleges were amalgamated in Shanghai, Guangzhou and Shenyang; others were relocated to provinces without medical colleges; and strong medical colleges helped in the development of new institutions. (E.g. Shanghai First Medical College assisted the development of Chungking Medical College; Shanghai First Medical College and Shenyang Medical College established Sinkiang Medical College in Xinjiang autonomous region; and Beijing Medical College establishedBeijing Second Medical College.)

1/ For a history of PUMC that traces the continuing influence of its graduates see An American Transplant, by Mary Brown Bullock, University of California Press, 1980. - 49 -

3.41 By 1957 the number of independent medical colleges had increased to 37; formal training in traditional medicine had, for the first time, been provided for in separate colleges, of which five were created in 1956; and the training of paramedicals, assistant doctors and nurses was expanded more than five-fold in 182 secondary medical schools. With the "Great Leap Forward" in 1958, many new institutions were added, academic standards were relaxed, enrollment was rapidly increased, and part-time medical education was encouraged. This sudden expansion overstretched the resources of the educational institutions. Following a brief period of consolidation in the early 1960s, the system was subjected to the protracted and calamitous disruption of the Cultural Revolution from 1966-1975. The colleges were closed from 1966 to 1969, but students were permitted to graduate on schedule although they attended no classes. When the colleges reopened in 1970, the three-year courses did not go beyond the secondary medical school level, the educational process was politicized and students, often with no more than lower middle school training, were selected by non-academic criteria. Teachers and hospital doctors were sent to the countryside, research was stopped and academic resources such as libraries were damaged or neglected. Almost a full generation of teachers and scientists was lost.

3.42 The process of rebuilding began in 1975. By 1977, the five-year program of medical studies had been reestablished in most colleges, the academic orientation was restored and students were admitted from upper middle schools primarily on the basis of academic performance. At the same time the slower process of reestablishing the scientific capability of the institutions commenced with retraining of staff, and rebuilding of the libraries, research laboratories and other academic resources.

3.43 Below the medical colleges are secondary medical schools. Since 1949 secondary medical schools have produced 947,000 graduates. There are now 556 secondary medical schools, which enroll approximately 60,000 students each year in ten specialty courses. Half of the students are trained as nurses. The other main courses are for assistant doctors in western medicine, public health, maternal and child health and traditional Chinese medicine, assistant stomatologists, assistant pharmacists, midwives, radiographers, and laboratory technicians. Since 1980, secondary medical school-trained assistant doctors may be promoted to senior doctors on the basis of five or more years of experience, in-service training including television courses, and by passing a qualifying examination. It has been estimated that up to 20 percent of assistant doctors may have become senior doctors in this way.

3.44 Levels of Training. There are three levels of salaried staff. Higher level personnel are trained in medical colleges, with specialized undergraduate programs in one or more of the subjects of western medicine, public health, high-level nursing, forensic medicine, pediatrics, stomatology, pharmacy, traditional Chinese medicine and traditional Chinese pharmacy, and massage and acupuncture. From 1985, undergraduate programs will be added in hospital nutrition, health economics and management, and health statistics. Middle level health personnel are trained in secondary medical schools as assistant doctors of western or Chinese medicine or public health, nurses, assistant stomatologists, assistant pharmacists, laboratory technicians, - 50 -

radiographers, etc. Primary level health workers and barefoot doctors are trained through refresher courses and in-service experience in county hospitals, epidemic prevention stations and maternal-child health stations. Primary health workers and assistant doctors with several years' experience in practice may take refresher courses and examinations to qualify as middle level and senior doctors respectively. Table 3.1 summarizes the different categories of health personnel and their typical training. Promotion based on experience and examination is an important alternative to formal training in a medical college as a source of doctors, particularly in rural areas.

3.45 Continuing education. In general, the MOPH principle that higher institutions should take direct responsibility for retraining lower echelons appears to be well established. A very large amount of in-service training, covering a very high proportion of staff, was reported at all levels, particularly the county. Inservice training responsibilities are distributed as follows:

(a) Provincial and Prefectural Hospitals. The principal teaching role of the larger referral hospitals is to provide short full-time courses or part- time courses for medical personnel of the county hospitals. Much of this training is of the refresher type, and is especially directed to practitioners whose training was impaired by the cultural revolution. The latter often also follow televised preclinical science courses. The larger hospitals also provide lecturers and teaching teams to visit county hospitals.

(b) County Hospitals. As a general rule, county hospitals visited offer a regular in-service training program for 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. In addition, they provide opportunities for commune medical staff and sometimes barefoot doctors to attend training courses in the hospital. Mobile teams also visit commune hospitals regularly for advisory, supervisory and teaching assignments.

(c) Commune Health Centers. In-service training conducted by the smaller commune health centers is mainly for barefoot doctors. Members of the hospital staff also visit the production brigades at least quarterly for supervisory and in-service education purposes.

(d) The County Health Training Center. While the principal function of these centers is to provide basic training for barefoot doctors, pharmacists, technicians and nurses, they also retrain barefoot doctors for periods of from 3-12 months to qualify as the rural doctors. About two-thirds of Shandong's barefoot doctors, for example, have reached this standard.

(e) Sanitation and Epidemic Prevention Stations. These stations train barefoot doctors in preventive activities in water and sanitation control, epidemic surveillance, immunization, pest control, food hygiene and environmental protection. They also provide training in epidemic prevention for field sanitation workers, health aides, sanitary campaign committees, human waste collectors, food handlers and in hygiene for the general public. - 51 -

Table 3.1: SELECTED HEALTH CARE WORKERS - EDUCATION AND ROLE

Position Education Typical role

Non-salaried workers

Barefoot Doctor Highly variable, primary Service in brigade education (or more) plus health station 3 to 6 month special course plus continuing education

Rural Doctor Upgraded barefoot doctor Service in brigade health station

Middle-Level Salaried staff

Assistant Doctors Specialized senior secondary Play assisting roles in (of western and school city hospitals, roles of Chinese medicine) greater leadership in commune health centers.

Nurses Specialized senior secondary Support role in school hospitals

Senior Salaried Staff

Western Doctor Varied over time; currently County general 5 to 8 years post-secondary hospitals; urban and enterprise hospitals

Doctor of Chinese Currently 5 years post- County and district Medicine secondary general hospitals; hospitals of Chinese medicine

Public Health Doctor Same as western doctors Staff and manage county except for less clinical and provincial anti- training and more public epidemic stations health

Note: There are many more types of personnel in each of the categories listed, and there is an additional category of primary-level salaried staff. Most workers are, however, of one of the types listed here. - 52 -

(f) The Maternal and Child Health Center. These centers retrain female barefoot doctors and midwives in modern hygienic childbirth and family planning technique. They also provide instruction in preventive pediatrics for kindergarden teachers and child supervisors.

3.46 Numbers of health care workers. There has been a rapid increase in the number of health care workers of most types; to illustrate the general trend, Figure 3.2 gra hs the growth since 1949 of numbers of western and traditional doctors. - (Figures for doctors of traditional medicine include assistant doctors as well as doctors.) Map 5 illustrates the per capita availability of hospital beds and salaried health workers in 1979 by provinces and Annex Table C-17 shows the urban-rural distribution of health resources.

3.47 Table 3.2 compares the availability of health care workers in China with the WHO estimates of availability in other countries. As that table clearly indicates, the situation in China is relatively very good for most categories of personnel, one important exception being dentists.

3.48 Table 3.3 shows that the rate of production of medical manpower in China is also very good. This table reinforces the observation made in section 3.1 to the effect that an important aspect of China's health policy has been a serious commitment of resources.

3.49 The source of the extremely rapid increase in the number of senior western doctors in recent years presents an important puzzle. Unfortunately, the question of the origin of all the doctors who joined the system in the past few years remains unanswered. Table 3.4 indicates that the number of western doctors and pharmacists increased by 225,000 between 1976 and 1981, although the medical colleges produced only 87,681 graduates in those specialities. The number of assistant doctors of western medicine increased by about 50,000 in the same period, and the output of assistant western doctors from secondary medical schools was unlikely to have been more than 60,000. It seems unlikely that more than 35,000 assistant doctors were promoted to doctor, so that 102,000 (or 45 percent) of the increase in senior western doctors remains unexplained. (Given that promotions in China were frozen for about 20 years, however, it is possible that there were an exceptional number of promotions when restrictions were relaxed.) The MOPH is planning improvements in its statistical and planning system that will allow such apparent anomalies to be explained.

Facilities

3.50 The growth in the availability of facilities has paralleled that of health manpower, and Annex Table C-10 shows the growth in the numbers of various types of health facilities and of hospital beds in different types of institutions. Table 3.5 shows the growth in numbers of beds of selected types

1/ See Annex Tables C-ll and C-12 for figures on the increase over time in the numbers of health care workers of different types. - 53 -

Figure3.2 Total Number of Doctors of Westernand Chinese TraditionalMedicine (Per 1,000Population)

1.3 -

1.2 -

1.1 Total Doctors (Traditional& Westem)

1.0

0.9

0.8

Q 0.7

0.6 0

0.5

0.4

Doctorsof Western Medicine 0.3 -

0.2

0.1 _

0.0 I I I I I I I I I I I I I I I I I I I I I I I I I I i I I I 1950 1955 1960 1965 1970 1975 1981 Year

Wodd Bonk-25709 - 54 -

Table 3.2: AVAILABILITY OF HEALTH CARE PERSONNEL -- CHINA AND OTHER DEVELOPING COUNTRIES

Number per 1000 population

World Averages, About 1975 China Developed Personnel_ategory 1980 Developing Countries Countries

1. Doctors of Western Medicine .45 .33 1.9

2. Medical assistants (in China, assistant doctors of western medicine) .45 .11

3. Traditional medical practitioners, (in China, including pharmacists of traditional medicine) .38 .35

4. Nurses and assistant nurses .71 .65 4.6

5. Dentists .007 .06 .42

Sources: 1. For China, rows 1-5, Annex Table C-12; row 5, data provided to Rural Health and Medical Education Mission. All figures for China exclude military personnel.

2. For World average figures, Sixth Report on the World Health Situation, p. 268. (Geneva: The World Health Organization, 1980.) -55 -

Table 3.3: MEDICAL SCHOOL, UNIVERSITY AND SECONDARY ENROLLMENTS -- CHINA AND OTHER COUNTRIES

Enrollments (Graduates) per 100,000 Population

Other Low-Income Middle Income Indicator China Countries Countries

University Enrollees 92.00 136.89 933.10

Secondary Enrollees 79.00 13.37 41.26

Medical School Graduates 3.29 1.16 5.24

Medical School Enrollees 25.37 4.90 29.06

Sources: University Enrollees, (1978). Education at the third level: enrollment per 100,000 in habitants, Statistical Yearbook, Unesco, 1981, p. 111-270.

Secondary Enrollees, (1970-79). Per Cent gross Enrollment ratio, Statistical Yearbook, Unesco, 1981, p. 111-28.

Medical School Graduates, (1979). Graduates per 100,000 population, WHO World Directory of Medical Schools, 5th Edition, Geneva.

Medical School Enrollees, (1979). Enrollees per 100,000 population, WHO World Directory of Medical Schools, 5th Edition, Geneva. - 56 -

Table 3.4: MEDICAL SCHOOL GRADUATESAND INCREASES IN SENIOR MEDICAL MANPOWER, 1977-81

Number of Increase in Number Western of Western Doctors Number of Graduates Doctors and and Pharmacists in given year Year Pharmacists over Preceeding Year (medicine and pharmacy) (a) (b) (c)

1981 546,446 73,917 8,441

1980 472,529 57,447 14,587

1979 415,082 39,813 10,861

1978 375,269 32,123 22,785

1977 343,146 21,713 29,528

1976 321,433 ------

Total 225,013 86,202

Sources: Column (a) comes from Annex Table C-l1 and is the sum of the numbers of Doctors of Western Medicine and Pharmacists.

Column (b) comes from subtractingsuccessive years in column (a).

Column (c) comes from Annex Table C-5, and is the number of graduates minus the number of graduates in traditionalmedicine. In fact, the number of graduates during this period was 87,681 according to informationmade available to the World Bank by MOPH in February, 1984. - 57 -

Table 3.5: INCREASES IN NUMBERS OF HOSPITAL BEDS, 1979-81

Number of Beds Percent Increase, 1979-81

Type of Hospital 1979 1981

General Hospital 907,998 968,041 6.2%

Commune Clinic 771,231 763,114 -1.01%

Source: Annex Table C-19.

between 1979 and 1981. The decline in the number of commune clinic beds is at variance with government policy, which is to increase the proportion of cases that can be handled at the commune level, without referral to county facilities. It is, however, consistent with the analysis sug sting that the smaller a commune health center the less well utilized it is. - A decline in the number of commune clinics could thus be interpreted as a result of decreased demand for their services, reflecting a tendency to bypass them in favor of the county hospital. Efforts to establish and strengthen 'major commune health centers' should help alleviate this problem.

Pharmaceuticalsand Medical Equipment

3.51 Production of pharmaceuticalsand medical equipment. Pharmaceuticals and medical equipment in China are principally produced and distributed by three corporationsforming part of the State PharmaceuticalAdministration of China, which is one of five independentorganizations reporting to the State Economic Commission. 2/ These are the China National Pharmaceutical Corporation (280,000 employees), the China National Herbal Medicine

1/ For the statistical analysis underlying this observation, see SupplementaryPaper No. 11 to this report.

2/ Chart 3 indicates the organization of the PharmaceuticalAdministration and the companies under it. There are more than 20 bureaus-under the direct supervision of the Economic Commission and, in addition to the PharmaceuticalAdministration, there are the following independentgeneral bureaus or administrations: the General Bureau of ConstructionMaterials, the General Bureau of Patterns, the National Standards Administration,and the China Measurement Administration. An up-to-date (although brief) account of pharmaceutical production in China may be found in "China's Pharmaceutical Industry," by Jin Tongzhen and Ma Ding, in Xue Muqiao (Editor-in-Chief),Almanac of China's Economy 1981 (Hong Kong, Modern Cultural Co., Ltd., pp. 565-572). - 58 -

Corporation (80,000 employees) and the China National Medical Equipment Production Corporation (80,000 employees). The total value of the annual output of the three producing corporations is about 7.7 billion yuan per year (see Annex Table F-3). Adding distributioncosts, the total comes to slightly over 10 billion yuan a year for pharmaceuticals and medical equipment, of which about 90 percent is for pharmaceuticals. As distribution markups (typically 15 percent) cover the operating costs of the National Drug Corporation 1 , and each of the three production companies returns a profit to the state, drug production and distribution is not subsidized. China imports very little in the way of pharmaceuticals, and the annual value of its pharmaceuticals exports is about 600-700 million U.S. dollars. Thus the consumption of pharmaceuticalsand domestically produced medical equipment is about 8.7 billion yuan per year, or 8.7 yuan per capita per year. (To this must be added the unknown value of Chinese traditional medicine that is locally produced and the also unknown value of chemical pharmaceuticals produced for their own consumption by hospitals.)

3.52 Each province has its own pharmaceutical bureau, which receives technical guidance from the Pharmaceutical Administration but is under the administrative control of the province. The Pharmaceutical Administration also operates three colleges (the Shenyang College of Pharmacy, the Nanjing College of Pharmacy, and the Shanghai College of Medical Equipment); in addition, there are 13 technical middle schools of pharmacy operated by provinces.

3.53 The PharmaceuticalAdministration directly operates three research institutes and one design institute; in addition, there are 33 provincial research institutes. Research responsibilities are divided roughly as follows: the PharmaceuticalAdministration for research into production; the MOPH for research into the clinical aspects of pharmaceuticalmatters; and the Shanghai Institute of Materia Medica of the Chinese Academy of Medical Sciences for basic research. In practice, there appears to be overlapping and duplication.

3.54 The MOPH is responsiblefor drug quality control and for licensing of new drugs. The MOPH produces serums and vaccines at six regional institutes of biological products. Serums and medicines used in curative medicine are distributed through the National Drug Corporation;those used in anti-epidemic work are distributed by the MOPH. In 1982 the six institutes produced 140 different biological products including 500 to 600 million doses of vaccines; the total value of output was about 50 million yuan.

3.55 The National Pharmaceutical Industrial Corporation also produces contraceptivesin quantities requested by the State Family Planning Commission

1/ The National Drug Corporation (310,000 employees) distributes pharmaceuticalproducts throughout the country. Distribution is through 5500 pharmaceuticalwholesale departments (at county and district level, typically) and over 50,000 drugstores below the county level. Hospitals sometimes purchase pharmaceuticals directly from a factory rather than from wholesale distributors. - 59 -

and the MOPH. The contraceptives are then sold to the National Drug Corporation, which receives government funds for this purpose, and which distributes them free of charge to the public through its network of distributioncenters and retail shops.

3.56 Drui production is growing at present rate of six to seven percent per annum. I Current production is about 14 times greater than in 1957, and prices have remained stable. Domestic sales increased 7-fold between 1955 and 1981, and exports increased 20-fold. The Cultural Revolution slowed the rate of growth of production and weakened quality control. In recent years there has been a very rapid increase in production of drugs for the treatment of tumors and cardiovascular disease. Further, new antibiotics are being introduced in the place of old.

3.57 Drug administration. Immediately after 1949, organizations of drug administrationwere set up in the Ministry of Public Health of the central government as well as in the public health sectors of local governments;and drug administration became an important part of the public health service. Its main tasks are as follows: (i) to enforce the drug laws and regulations, work out detailed guidelines,and supervise and check up their implementation; (ii) to review the drugs manufactured by the pharmaceutical factories and their drug quality specifications;(iii) to control new drugs; (iv) to inspect the quality of drugs and withdraw the drugs which have greater adverse reactions but doubtful effectiveness; (v) to seize and destroy misbranded or adultered drugs; (vi) to test, examine and supervise imported drugs; (vii) to control poisons, narcotics and psychotropic drugs; (viii) to control pharmaceuticalpreparations made in hospitals; and (ix) to take disciplinary sanctions against the organizationsor individualswho have violated the drug regulations,and appeal to judicial organs for punishment in case the health of people has been seriously injured.

3.58 In 1950, the central government established the National Institute for Drug Control and the Drug Division within MOPH. The Drug Division was successively changed into the Drug Bureau in 1953 and the Pharmacology Administration in 1957. Drug Bureaus and Institutes for drug control were also establishedunder the administrativecontrol of provinces, municipalities and autonomous regions. Then one by one, the health sectors of districts, prefectures and counties established drug administration organs and drug control institutes,or assigned officers in charge of drug affairs. The staff members of drug administraton and drug control increased rapidly, and by the end of 1982, the administration staff of the whole country had amounted to 1383 persons, the institutes for drug control has totalled 1186 'and the staff of all the institutes had reached 13,029 persons. In 1950, MOPH engaged medical experts to organize the Committee of Chinese Pharmacopoeiawhich is responsible for the compilation of national pharmacopoeia. The Committee has

1/ The Chinese Medical Journal of September, 1982, reports that average annual per capita spending on medicines rose from 7 yuan in 1979 to 8.37 yuan in 1981, an increase of 19.6 percent. This exceptional increase was attributed to rising peasant incomes and increased demand for traditional Chinese medicines. - 60 -

successively drawn up the 1953, 1965 and 1977 editions of the Chinese Pharmacopoeia and other drug specifications approved by MOPH.

3.59 During the Cultural Revolution drug administration and drug control were slandered as 'supervision, restriction and coercion', personnel were discharged, laws and regulations were abolished and the work of drug administration was completely neglected. In recent years there has been a return to normalcy, and in 1979, MOPH and the State Pharmaceutical Administration jointly issued 'Rules for the Control of New Drugs (draft)'. In June of the same year, the 'Report on the Streamlining of Pharmaceutical Factories' - written by MOPH, the State Planning Commission, the National Economic Commission, the Ministry of Chemical Industry, the Ministry of Agriculture, the Ministry of Commerce, the General Logistics Department and the State Pharmaceutical Administration -- was circularized by the State Council. The task of streamlining pharmaceutical factories and screening pharmaceutical products was completed in 1982 by MOPH in collaboration with other ministries and departments concerned. Altogether 2471 factories have been involved. Among them 633 factories were either closed or merged into other factories, and 1239 factories were licensed. All the drugs manufactured by these factories were registered and re-examined; in the course of this work it was found that more than 1100 drug products, 4000 pharmaceutical preparations and 3000 traditional crude drugs and over-the-counter drugs were produced in the whole country. In September 1982, MOPH made a decision to abandon the production and use of 127 drugs which were considered to have adverse reactions or doubtful effectiveness in the light of clinical studies. In order to guide the production and clinical use of drugs, a book titled "National Essential Drugs" was published, and detailed instructions were given for the clinical use of 278 drugs grouped into 28 categories. Finally, in 1983, 14 institutions were designated as centers for research in clinical pharmacology to strengthen the control of new drugs and raise the Level of new drug research.

3.4 The Impact of Health Resources

3.60 The preceding sections have discussed the policies guiding health resource allocation in China and the growth in availability of hospital facilities and health personnel. The general interpretation of China's successes in the health sector has been that the manner in which resources were deployed -- at least as much or even more than the extent to which doctors and hospitals were available -- has accounted for the achievements. Specifically, China's emphasis on prevention has been viewed as particularly important. Analysis of the correlate,s of various measures of morbidity and mortality tend to support this view. 1

1/ The discussion in this section is based on the analysis described in Supplementary Paper No. 4. - 61 -

3.61 Data on life expectancy, crude death rate and age-adjusted cancer mortality rate by province were used to examine factors influencing mortality. The following provisionalconclusions emerge from the analysis:

(i) A strong positive relation exists between provincial income levels and life expectanciesestimated for 1973-75; a ten percent (14 yuan) increase in income is estimated to correspond to an increase of about 8 months in life expectancy. Consistent effects are found in the analysis of 1981 crude death rates. There is also evidence that, controlling for income, provinces with higher indicated education levels have longer life expectancies. When the effect of urban income is assessed separately from that of rural income, however, a slight negative impact of urban income on life expectancy is observed.

(ii) For cancer mortality, on the other hand, income increases are associated with increases in age-adjusted mortality rates for cancer. To the extent that this adverse relation between income and mortality (age-adjusted)holds for cardiovascular and other chronic diseases as well as for cancer (and it is found to hold for hypertension morbidity), the estimated positive effects of income on life expectancy understate the beneficial effects of income improvementson communicabledisease control.

(iii) There appear to be no significantimprovements in life expectancy that are associated with higher per capita availability of barefoot doctors, hospital beds, or other health resources in a province. This finding must be viewed as very tentative, although it is consistent with some (but not all) of the literature from other countries. One explanation for the finding would be that preventive activities account for much of the mortality improvements, and that these activities are more uniformly distributed than income. Barefoot doctors as well as salaried health workers and hospital facilitiesmay, nonetheless, have important roles in providing access to care and in reducing morbidity and its adverse consequences. The geographical distribution of future increases in the quantity of health resources will, of course, determine the extent to which they contribute to further improvementsin access to care.

3.62 The analysis suggests that limited further gains in life expectancy are to be expected from quantitative increases in health facilities and manpower of the sort studied in this analysis; further, as the disease profile moves more toward chronic and away from communicable disease, income improvements are likely to cease having the beneficial effects on life expectancy that they have had in the past. This suggests the priority for seeking affordable public policies for postponing the onset and managing the consequences of chronic disease in the population, with concomitant qualitativechange in the education and function of health personnel. - 62 -

3.5 Health Sector Financing and Expenditures -

3.63 This section analyses the mobilisation and allocation of resources in the Chinese health sector. Total health expenditure in 1981 is estimated at approximately Y15.0 per capita, of which Y14.3 is for recurrent expenditure and YO.6 for cap' al construction. This represents 3.3 percent of GDP per capita in 1981. - Figure 3.3 shows the results of dividing up recurrent expenditure in three separate ways: by sources of finance, by expenditure on resource inputs and by delivery system. The top frame of Figure 3.3 shows that financing comes in about equal amounts from three main sources -- private outlays (32 percent), labor insurance (31 percent) and state budget expenditures (30 percent). Production brigades finance the residual seven percent. The bottom frame of Figure 3.3 shows that the structure of health services delivery is essentially tripartite. The rural collective system, principally brigade and commune health facilities, delivers the largest share of health services, valued at approximately 40 percent of the total; the government system delivers about 32 percent; and the enterprise system, which benefits enterprise 3 ?mployees and dependents exclusively, delivers 25 percent of total services. - Private medical practice has recently been authorized, and some exists, but it is (currently) of little significance. Of all resource inputs into the health sector, shown in the middle frame of Figure 3.3, pharmaceuticals are by far the most important, accounting for 58 percent of total expenditure.4/Western drugs alone consume 49 percent of total health expenditure outlays. Z

1/ An expanded treatment of the subject of this section may be found in Supplementary Paper No. 5 to this report.

2/ GDP per capita in 1981 was Y455. See IBRD Report No. 4072-CHA, Statistical Appendix Table 2.1

3/ It should be noted that enterprise employees can either receive medical services from facilities operated by the enterprise or they can be referred to county or municipal hospitals that are part of the government delivery system; in either case all expenses are covered by labor insurance.

4/ The cost of unpaid labor time, either voluntarily or otherwise mobilized, is not included in the discussion here because virtually no relevant data exist. Anecdotal accounts suggest, however, that substantial amounts of unpaid labor contribute to the success of many preventive efforts, particularly those associated with environmental sanitation. For example, it has been estimated that the economic cost of voluntary Labor mobilised to work in the schistosomiasis control campaign in Shanghai County was approximately Y8 million between 1953 and 1978, equivalent to nearly double the financial costs incurred for drugs, surgery, molluscicides and salaried personnel. See Chen et al (1982), "Eradication of Schistosomiasis", American Journal of Public Health 1972 (9), Supplement: 50-51. - 63 -

Figure3.3 RecurrentExpenditure on Health, 1981:Sources of Finance, ResourceInputs and DeliverySystems

SOURCESOF FINANCE

D/ X . .- . > A PrivateExpenditure 32% B LaborInsurance 31% B C StateBudget 30% \...... ::::::::::::::::::::::...... D Brigades(including rural cooperative health insurance] 7% \ . ,...... > A

C ... _ RESOURCEINPUTS

E A WesternPharmaceuticals 49% B SalariedPersonnel 20% F C HospitalBeds 13% D TraditionalPharmaceuticals 9% ::::.:::-:::::::::::::::::::i. E Equipment 5% F BrigadePersonnel 4%

C DELIVERYSYSTEMS

B A RuralCollective System 40% \- 1 D B GovernmentSystem 32% ...... C EnterpriseSystem 25% ...... D Medical Education 3% .v :...... : -PrivatePractice negligible

A - 64 -

3.64 A remarkable feature of the financing profile is the high proportion of total expenditure that is mediated through insurance schemes. This reflects the high degree of health insurance coverage, which constitutes one of the major achievements of the Chinese health system. As shown in Figure 3.4, it is estimated that only about 30 percent of the population are completely uninsured. Most (but not all) of the uninsured are rural dwellers, and considerable urban-rural differentials in health expenditure exist in China (Figure 3.5). Urban expenditure is estimated at Y33 per capita, more than triple the rural expenditureof Y9 per capita.

3.65 Also striking are the patterns of public expenditures on health. State subsidies for health in urban areas exceed by a factor of almost ten those for rural areas -- approximatelyY26 per capita compared to less than Y3 per capita. Private expenditures per capita amount to less than Y3 in urban areas but over Y5 in rural areas. Given the stated emphasis in China on preventive medicine, as discussed in Chapter 3.1, it is of interest to note that less than 5 percent of total health care resources are directed to prevention and over 95 percent are directed to provision of curative services. (It should be noted that, since virtually all financial outlays for prevention are provided by the state, much more than 5% of the state health budget goes for prevention; MOPH estimates that 13.8% was spent on epidemic prevention stations and parasitic disease control in 1981.) Traditional medical practice, receives a more substantialallocation -- perhaps 14 percent of the total.

Health Sector Finance

3.66 The State Budget. State budget expenditureson health comprise three types of expenditure undertaken at all levels of government, both central and local: expenditure through the Ministry of Public Health (MOPH) on health services delivery and medical education, expenditure through the Ministry of Finance on the government insurance scheme for government employees and expenditure (through provincial budgets) on medical education in the provincial medical colleges. (MOPH expenditures, as we use the term, also include expendituresby provincial and county bureaus of health.)

3.67 State budget expenditures through the MOPH have increased steadily since the 1950s, reaching a total of Y3,881 million in 1981 (Table 3.6), of which 84 percent was for recurrent expenditure and 16 percent for investment in capital construction. Only about 5 percent of total recurrent expenditure and 10 pfecent of capital construction is financed out of the central MOPH budget, - the remainder being appropriated through local Bureaus of Public Health at provincial, prefectural and county levels. In nominal terms, per capita expenditure increased by three-quarters between 1977 and 1981, from Y2.22 to Y3.92. In recent years the growth in nominal MOPH expenditure has been especially rapid, equivalent to about 16 percent per year for recurrent and capital expenditurecombined between 1977 and 1981, compared to only 6

1/ Central MOPH expenditure is estimated as the residual between aggregate MOPH expenditure and total provincial MOPH expenditure (Annex Tables E-1 and E-7 respectively). - 65 -

Figure3.4 Distributionof Populationby InsuranceStatus, 1981

C B D INSURANCESTATUS . . ./ > A RuralCooperalive Insurance 48% B Uninsured 29% ... :.:-::.:.F C LaborInsurance 12% ...... ED CommuneCollectiveIndustryIndustry InsuranceInsurance 4%5%

/...... E CFGovernment Insurance 2%

Figure3.5 Urban-RuralDifferentials in RecurrentHealth Expenditure, 1981

Y32.46per capita

StateSubsidies Y26.19

Y9,64per capita StateSubsidies Y2.76 Private______Expenditure Y2.76Prvt Y2.76 ~~~~~~~~~Expenditure

Other Y5,07 Other Y3.51 ___1_ Y1.81

URBAN RURAL - 66 -

Table 3.6 MINISTRY OF PUBLIC HEALTH EXPENDITURE, 1977-1981

Total Expenditure Per Capita Expenditure Recurrent Capital Total Recurrent Capital Total (million yuan) (Yuan)

1977 1,809 273 2,082 1.93 0.29 2.22 1978 2,242 321 2,563 2.36 0.34 2.69 1979 2,602 421 3,023 2.70 0.44 3.13 1980 3,016 571 3,587 3.09 0.56 3.67 1981 3,274 607 3,881 3.31 0.61 3.92 Av. growth rate (%) 14.8 20.0 15.6 13.5 18.6 14.2

Source: Annex Tables E-1 and E-4. These figures include expenditures by provincial and county health bureaus. percent for total state budget expenditures during the same period. 1/ The rate of growth in real terms has also been substantial, the implicit Net Material Product deflator having registered an average annual increase of only 2.4 percent between 1977 and 1981.

3.68 There are very substantial regional differentials in the distribution of MOPH expenditure. In general, per capita expenditures tend to be much higher in more heavily urbanised provinces and in the autonomous regions; furthermore, MOPH expenditures are strongly positively reated to urban income levels and, even more strongly, to rural income levels. -

3.69 The Government Insurance scheme, originally introduced in February, 1951, provides free outpatient and inpatient health services for life (excluding the cost of hospital meals) to government employees, college teachers and students. In general, only primary members are covered by the scheme, and dependents receive no benefit entitlements. The scheme is financed exclusively by the state budget, with no individual prepayment by its beneficiaries. Government insurance is administered by the Ministry of

1/ While expenditure figures for 1982 are not yet available, it is consistent with apparent budgetary priority given to health that the state allocated 230 million yuan in 1982 as a special fund for "...improving medical and public health facilities and for strengthening disease prevention and treatment and family planning." (Beijing Review, July 11, 1983, Supplement p. VIII.)

2/ See Supplementary Paper Number 4 for a statistical analysis of determinants of the distribution of MOPH expenditures on health and on the distribution of health facilities. - 67 -

Finance with guidance from the Ministry of Public Health concerning what items should be covered by insurance. The level of financing within the state budget is decentralised according to the level of employment of the beneficiary. Thus, benefits for government employees at national level are financed out of, the central government budget and benefits for those at provincial level are financed out of provincial budgets. It is of interest to record that these insurance benefits were introduced at a time when state cadres were paid only a minimal cash allowancye but have been retained despite the adoption of salary remuneration in 1956. -

3.70 Total state budget outlays on the Government Insurance scheme have increased slightly faster than MOPH recurrent expenditure, at an average annual rate of 15.3 percent during 1977-1981, reaching a total of Y789 million in 1981. (Outlays exceeded Y900 million in 1983.) This accounted for about 24 percent of MOPH recurrent expenditure and 20 percent of total MOPH outlays on recurrent and capital expenditure combined. Thus, the Government Insurance scheme exerts a sizeable claim on total fiscal subsidies to the Chinese health sector. There are currently about 18 million primary members of the Government Insurance scheme, or about 1.8 percent of the entire population. Annual expenditure per member averaged Y44 in 1981, representing a significant transfer to relatively high income individuals, equivalent to five percr7t of the average annual wage of employees of state-owned units (Y812 in 1981 - ).

3.71 It is plausible that expenditure levels under the Government Insurance scheme represent a sub-optimal use of health resources. Since government insured benefc,iaries face a zero price for utilising health services (except for food - and travel costs), they have an obvious incentive to utilise services at levels at which the marginal benefits are substantially lower than their marginal costs. The MOPH is aware of the inducement to inefficient utilisation, and is working with the Ministry of Finance to experiment with alternatives to improve efficiency. For example, in Shandong Province the MOPH attempts indirectly to influence utilisation by offering a Y60,000 incentive payment to counties in which average expenditure per beneficiary does not exceed a Y30 norm. The incentive is weak, however, since the payment is a lump sum independent of the extent of the cost saving, and there are no penalties for exceeding the norm. Only 10 of the 106 counties in the province qualified for the incentive payment in 1981.

1/ See Chen (1976), Population and Health Policy in the People's Republic of China, Occasional Monograph Series No. 9, Interdisciplinary Communications Program, Smithsonian Institution, Washington, D.C.

2/ Statistical Yearbook of China: 1981, p. 431.

3/ A recent study reported average food costs at approximately YO.5 per hospital day, equivalent to about 9 percent of average daily charges for drugs and services. See Henderson and Cohen (1982), "Health Care in the People's Republic of China: A View from Inside the System", American Journal of Public Health 72 (11): 1238-1244. - 68 -

3.72 Provincial Bureaus of the Ministry of Education finance the cost of medical education provided in the provincial medical colleges. These appropriationsare for the medical colleges only. The state subsidy for their affiliated hospitals is appropriated through the hospital services budget of the provincialBureaus of Public Health. No data are available on Ministry of Education allocations to the provincial medical colleges, by an indirect estimate can be constructed;the result is about Y148 million. -

3.73 Labor Insurance. Workers and staff employed in state enterprises with more than 100 employees are insured by the Labor Insurance scheme, which was first introducedin February, 1951. Like the Government Insurance scheme, the Labor Insurance scheme entitles primary members to free health care for life. In addition, their dependents are entitled to 50 percent reimbursement of health care costs. There are no official data on the coverage of the Labor Insurance scheme, but a rough estimate can be made. The number of primary members in 1981 can be est ated as the number of staff and workers in state- owned units, 84 million - , minus the number of government employees, 18 million, that is, a total of 66 million primary members. In addition, it can be estimated that there are about 51 million dependents of primary members, based on the 1 : 0.77 ratio of employees to dependents reported in the 1981 Household/Income and Expenditure Survey of Staff and Workers in Urban Areas. - These estimates imply a total coverage in 1981 of 117 million persons including dependents, or about 12 percent of the total population. This esti qte is consistent with a previous estimate of 10-12 percent

coverage.-

1/ There are 106 provincialmedic!'l colleges (excluding the 13 core medical colleges financed by the central MOPH), with a total enrollment in 1981 of 116,596 undergraduate and 1,707 graduate students. The calculation assumes a unit cost per student of Y1,250 per year, which is approximately equal to the unit recurrent cost in all conventional universities, both central and provincial, financed by the Ministry of Education. (This is slightly higher than the Y1,185 unit cost excluding part-time students estimated for Qingdao Municipal Medical College in 1981 and substantially lower than the Y2,268 unit cost in the core medical colleges -- estimate derived from enrollment data in SupplementaryPaper No. 6 and expenditure data in Annex Table E-6.) Thus the total fiscal cost of recurrent expenditure can be estimated at Y148 million per year. This figure excludes the joint cost of running the affiliated teaching hospitals, which is financed by provincial Bureaus of Public Health.

2/ StatisticalYearbook of China: 1981, p. 106.

3/ Statistical Yearbook of China: 1981, p. 438. This ratio is higher than the ratio of 52,000 members to 30,000 dependents (1:0.58) estimated for Shanghai County by Ye et al. (1982), "Introduction to Shanghai County", American Journal of Public Health, 72 (9) Supplement: 13-18.

4/ Hu (1981), "Issues of Health Care Financing in the People's Republic of China", Social Science and Medicine, 15C: 233-37. - 69 -

3.74 In addition to the Labor Insurance scheme, many smaller county collective, commune and brigade enterprises voluntarily organize insurance schemes for their employees. These schemes generally offer lower reimbursement rates than the Labor Insurance scheme, typically around 70-80 percent for primary members and partial coverage for dependents. There are no accurate data on the total numbers covered by these schemes, although a maximum estimate for primary members would be the number of staff and workers employed in collective units, about 26 million in 1981, plus the 14 million workers employed in commune enterprises in 1980. The maximum number of dependents can be estimated at 20 million plus 30 million for the county collective and commune industry schemes respectively,based on the ratios of dependents to wage earners reported in the 1981 urban and rural household surveys.

3.75 The financingof the labor insurance funds for health care is treated as an addition to the enterprise wage bill, with no individual prepayment by the employee. There are no precise data on the total expenditurefinanced by these schemes. However, the MOPH estimates that approximately Y4.4 billion was spent by the compulsory and voluntary schemes (includingcounty collective and commune industries but excluding brigade enterprises) combined in 1981. This estimate includes the cost of health workers and small equipment for health facilities owned by the enterprises themselves, as well as reimbursementfor services provided by government health facilities.

3.76 It is officially estimated that Y11.7 billion was spent on state subsidies for free medical services for state employees between 1979 and 1981. Since a total of Y2.018 billion was spent on Government Insurance during this period, it can be assumed that the residual Y9.682 billion was spent on the compulsory Labor Insurance scheme. The cumulative number of primary members of the Labor Insurance scheme can be estimated at 192 million between 1979 and 1981. This suggests that annual expenditure per Labor Insurance member averaged approximately Y50 between 1979 and 1981. This is higher than under the Government Insurance scheme, as would be expected since dependents are eligible for 50 percent coinsurance. This, in turn, implies that annual expenditure per primary member of the voluntary cfynty collective and commune industry insurance schemes averages about Y28, - substantially lower than under the compulsory scheme. These indirect estimates are broadly consistent with fragmentary evidence available for Shanghai Municipality and Shandong Province. Reported expendituresper beneficiary in these areas range from Y34 to Y42 under the compulsory scheme, from Y29 to Y30 for county collective industries, and from as little as Y12 to as much as Y47 for beneficiaries of commune industry insurance schemes. The generally lower levels and higher variance in the expenditures of the voluntary schemes clearly reflect their voluntary character and dependence on enterprise profitabilityfor financing.

1/ An annual average expenditure of Y50 per primary Labor Insurance beneficiary yields an estimated total expenditure in 1981 of Y3.3 billion for the 66 million primary members. Subtracting this from the estimated total Y4.4 billion spent by the compulsory and voluntary schemes in 1981 implies a residual Y1.1 billion averaged over the 40 million primary members of the county collective and commune industry schemes. - 70 -

3.77 Rural Cooperative Insurance. Implementation of the rural cooperative insurance system began in 1968, and represents a unique example of community health financing in developing countries. Although individual details vary considerably throughout China, the cooperative insurance schemes generally take the form of a pre-paid medical insurance plan, organised at the level of the production brigade. Thus, they provide only a limited pooling of risk and provide no opportunity for redistributive subsidies from richer to poorer brigades. The insurance fund is typically financed jointly by annual prepayments paid by individual members of the brigade and by annual appropriations from the brigade's welfare fund. The services of barefoot doctors in the brigade health stations were until recently financed separately on the basis of workpoint claims on collectively distributed income. Increasingly barefoot doctors receive fees for services. In at least 14 provinces, barefoot doctors als receive a modest fiscal subsidy paid out of the provincial health budget - , but this is only a very recent innovation designed to prevent the collapse of the cooperative system. Beneficiaries enrolled in the cooperative insurance scheme are generally entitled to substantially reimbursable services and drugs at the brigade health station and also at higher level referral units (if they are referred to the higher- level rather than brigade-level facilities).

3.78 There is substantial variation among brigades in the benefit entitlements offered by the cooperative insurance schemes. In general, cooperative insurance outlays appear to be highly income-elastic, indicating that much of the variance in benefit entitlements is explained by variations in income levels. For example, an analysis of grouped data from 116 brigades in Qu Fu County, Shandoyn Province, indicates an incoTm elasticity of insurance outlays of .54. - The data for Shanghai County - reveal that the majority of brigades reimbursed 100 percent of the cost of services delivered at the brigade health stations. The lowest reimbursement rate for brigade level services was 50 percent, provided in eight percent of brigades. In addition, a majority of brigades, 56 percent, reimbursed 50 percent of referral costs incurred at higher levels. Reimbursement rates for these costs ranged from 40 percent (one percent of brigades) up to 100 percent (14 percent of brigades). In addition, 32 percent of brigades imposed an absolute limit to the value of costs reimbursed for any one diagnosis. This threshold varied from Y40 to Y100, the modal value lying in the range Y25 to Y100.

1/ The level of this subsidy varies widely. For example, in Ningxia Autonomous Region the government pays Y35-40 per month for doctors with a rural doctor certificate working in mountainous areas, Y30-35 per month for doctors with a rural doctor certificate working in irrigated areas, Y15-20 per month for barefoot doctors with a barefoot doctor certificate working in mountainous areas, Y10-15 per month for doctors with a barefoot doctor certificate working in irrigated areas, and Y5-7 per month for barefoot doctors with no certificate.

2/ See Supplementary Paper No. 11 to this report.

3/ Chao et al. (1982), "Financing the Cooperative Medical System", American Journal of Public Health, 72 (9) Supplement: 78-80. - 71 -

3.79 The coverage of the rural cooperative insurance system reached a peak of 85 percent of brigades in 1975, but has since declined substantially to only 69 percent in 1980 and 58 percent in 1981 (Annex Table C-14). With an average 1,140 persons per brigade in 1981, this implies a total coverage of approximately 474 million, equivalent to 48 percent of the Chinese population. As a result, nearly half of the rural population has to pay the full cost of health services, with no formal co-insurance to alleviate catastrophic risks. Regional variations in this trend are difficult to assess because of the lack of relevant data, but it is clear that recent experience has been mixed. Data for Ningxia Hui Autonomous Region indicate that in Wuzhong County the cooperative insurance schemes have almost completely collapsed, the proportion of brigades with insurance schemes having fallen from 99 percent in 1975 to only one percent in 1982. In Pingluo County, the corresponding proportions fell from 97 percent to 83 percent. The degeneration of the rural cooperative system is attributed primarily to the introduction of the production responsibility system in the rural sector. The weakening of collective organisation in the countryside has impaired the mobilisation of collective resources to finance basic needs. It has also generated a substantial increase in rural incomes, which appears both to have raised the opportunity cost of barefoot doctors' services and also to have stimulated a demand for higher quality health services not perceived to be available through the cooperative system.

3.80 The extreme variation between brigades in annual insurance prepayments per member precludes an accurate estimation of the total value of health expenditures mediated through the rural cooperative insurance system. A rough estimate can be made by assuming that the mid-point of the Yl.00 to Y3.00 range observed in Shandong is representative. This assumption is reasonably plausible, given that average rural income (as proxied by household expenditure) in Shandong Province is more or less equal to the national average. With an estimated total coverage of about 474 million persons, this implies an aggregate value of rural cooperative health insurance expenditures of Y948 million in 1981.

3.81 The total value of barefoot doctors' services, financed independently of the cooperative insurance scheme, is also difficult to estimate accurately. The per capita value depends on the number of barefoot doctors per brigade, the extent to which they work full-time, and their annual wage, all of which vary enormously even within individual communes. For example, the annual income of 448 barefoot doctors in 12 communes in Shanghai County, Shanghai Municipality, averaged Y614 in 1980, but ranged from less than Y500 (18 percent) to over Y1000 (2 percent). In Shandong Province, mean annual incomes are much lower but vary over an even wider range. The annual income (excluding sideline income) in 1981 of 133 barefoot doctors in Qu Fu Counjy averaged Y347 in 1981, varying from only Y108 to as much as Y1044. Assuming that the Qu Fu County data are reasonably representative, it can be estimated that the total value of collective distributed income paid by individual brigades to the 1.4 million barefoot doctors in China was approximately Y485 million in 1981, equivalent to roughly half of the total

1/ See Supplementary Paper No. 10 to this Report. - 72 -

outlays of the rural cooperative health insurance system. In addition, part- time rural health aides and midwives are often paid in workpoints. In Yexian County, Shandong Province, annual payments to health aides averaged Y30 in 1981.

3.82 Private expenditure. Since a large porti n of the Chinese population is eitl r uninsured or faces coinsurance rates - substantiallygreater than zero, - it is evident that direct private outlays on health care must be considerable. However, there are no systematic data on private health expenditures in China. The 1981 Sample Survey of Household Income and Expenditure of Peasants provides no information on outlays for health. The 1981 Sample Survey of Household Income and Expenditure for Staff and Workers in Urban Areas records an average cojnrodityexpenditure on medicines and medical articles equivalent to Y2.76 - per capita per year, but does not identify non-commodity expenditureson health service fees. This represents only 0.6 percent of average total expendituresby urban households, reflecting the fact that most urban residents benefit from enrollment in the Government Insurance or Labor Insurance schemes, which entitle beneficiaries to very low average coinsurance rates.

3.83 A sample survey in Shanghai County, Shanghai Municipality, indicates a much higher level of personal outlays on health care, averaging Y5.80 per person in 1980 across the different insurance systems. Despite the low average coinsurance rate for government-insuredbeneficiaries, members of the Government Insurance scheme spent the highest amount per capita in direct outlays, about Y9 or nearly one-fifth as much as insured outlays. Beneficiariesof the Labor Insurance scheme spent the lowest amount at Y3 per capita, less than one-tenth of insured expenditure. On average, members of the rural cooperative insurance schemes spent nearly Y7 per capita. As would be expected from the substantiallyhigher coinsurancerates in these schemes, private outlays were equivalent to around 50 percent of insured expenditure.

3.84 It would be quite misleading to assume that the levels of private expenditure reported for Shanghai County are representative of China as a whole, s47ce average income levels are much higher than the national average. - However, alternative estimates in other areas are scarce and unreliable. Nonetheless,a rough estimate for China as a whole can be made by deriving private expenditure as a residual, after netting out expenditure by all other sources of finance from total health expenditure. By this method it

1/ The coinsurance rate is the proportion of the price that has to be paid by the patient after deducting the proportion paid by the insurance scheme.

2/ A maximum of only 124 million persons, or 12.5 percent of the total population are fully insured primary members of insurance schemes.

3/ See Statistical Yearbook of China: 1981, p. 439 and pp. 441-450.

4/ In 1981 rural household expenditure per capita in Shanghai Municipality was Y390, more than double the national average of Y190. See Statistical Yearbook of China: 1981, p. 445. - 73 -

is estimated that private expenditure averaged Y4.60 per capita in 1980, of which YO.48 represents individualprepayments into rural cooperativeinsurance schemes and Y4.12 direct private outlays. Private expenditureaccounted for about 30 percent of total recurrenthealth expenditurein 1981.

3.85 Factors influencing health resource availability. Rural and urban income levels serve as important determinants of the availability of state budgetary 1resources for health, with elasticities of 2.7 and 0.6 respectively. - Likewise, income levels and urbanisation are exceptionally powerful predictors of the availability of salaried health workers and hospital beds in a province. Most importantmedical facilitiesare located in urban areas but are intended to serve adjacent rural areas as well; our analysis suggests, however, that availability of facilities is principally determined by the size of the urban population with the size of the rural population being relatively unimportant. Statistical analysis suggest state expenditure of Y15.1 per capita in urban areas, but only Y2.9 per capita in rural areas; they suggest 13.1 salaried health workers and 5.5 hospital beds per thousand population in urban, but only 1.5 and 1.6 respectivelyin rural areas.

Health Sector Expenditures

3.86 Expenditureson inputs. Approximate estimatesof the total recurrent expenditures on the major health sector inputs in 1981 are given in Table 3.7. Although only approximations,the aggregationof these input costs provides the only available method of estimating total health expenditures in China. Comment here is confined to the two major inputs, salaried health personneland medicines. The average salary of health personnel is assumed to be equal to the average annual wage of staff and workers in state-ownedunits in the science, culture, education and public health sector in 1981, Y759 per year. This is probably a reasonably accurate approximation, although in Shandong Province the average salary of state health personnel was slightly lower at Y704 per year in 1981. Detailed data on the average salary paid to different categories of health manpower are not available (salary ranges for Shandong Province are given in Statistical Annex Table E-9). Data on drug production refer to the gross value of output produced by the China National PharmaceuticalCorporation (Western medicines) and the China National Herbal Medicine Corporation (traditional medicines). Although some Western and traditional medicines are produced locally outside of the state enterprise sector, for example by hospitals, commune health centers, and brigade enterprises,there is no direct evidence of its magnitude, but it appears that the value of local production is relatively small.

3.87 The most striking feature of the input structure revealed in Table 3.7 is the very high proportion of total costs contributed by drug consumption. In aggregate, 58 percent of total health expenditures are attributed to drug costs, with Western medicines alone accounting for almost 50 percent of the total. Although comparisonswith other countries are

1/ See SupplementaryPaper No. 4. - 74 -

Table 3.7 ESTIMATED DISTRIBUTION OF RECURRENT EXPENDITURE BY INPUT, 1981

Unit Cost Per Number Cost Total Cost Capita Share (millions) (Yuan) (million Yuan) (Yuan) (%)

Barefoot doctors 1.397 347 485 0.49 3.4 Health aides 2.007 30 60 0.06 0.4 Rural midwives 0.585 30 18 0.02 0.1 Salaried personnel 3.796 759 2,881 2.91 20.3 Hospital beds 2.017 912 1,840 1.86 13.0 Western medicine ...... 6,900 6.98 48.7 Traditional medicine ...... 1,300 1.32 9.2

Medical equipment ...... 700 0.71 4.9 TOTAL 14,184 14.35 100.0

complicated by relative price differentials, I/ the extremely high drug consumption share of total expenditure does suggests an inefficient use of drugs, which is consistent with impressions by physicians of widespread overprescription of drugs in the Chinese health system.

3.88 Expenditures at different times. Utilizing information on the level of health resource inputs available in 1957, it is possible to calculate that per capita health expenditures were Y2.9, in contrast to the Y14.9 estimated for 1981 (both expressed in 1982 yuan). The implied per capita growth rate of 7 percent substantially exceeds the growth rate in GDP over this period, with the result that health expenditures as a percent of CDP grew from about 2.3 percent in 1957 to about 3.3 percent in 1981.

3.89 Allocation between delivery systems. Rough estimates of the distribution of recurrent expenditures on health between different service delivery systems was shown in Figure 3.4. The collective health system comprising brigade and commune level services for the rural population is the major delivery mechanism, accounting for about 40 percent of total expenditure. The government system, which serves all segments of the population, is the second largest with a 32 percent share of total expenditure. Most surprising is the importance of the enterprise health system which benefits exclusively the 12 percent of the population which are

1/ For example, wages paid to Chinese health personnel are relatively Low by international standards. Thus, labor probably receives a lower weight and other inputs, especially drugs, a correspondingly higher weight in aggregate expenditure than in other countries. - 75 -

primary or dependent beneficiaries of the Labor Insurance scheme, and which delivers about 25 percent of total health services. This of course understates the benefits accruing to labor insurance beneficiaries, since they also utilise government health facilities. Approximately two-thirds of total labor insurance expenditure finances the enterprise health system and one- third the utilisation by its beneficiaries of the government system. Although private health services do exist they are relatively insignificant, accounting for less than one percent of total expenditure.

3.90 Urban-rural expenditure differentials. There are very substantial urban-rural differentials in health expenditure in China, which are significantly exacerbated by public expenditure patterns. Approximate estimates of the urban-rural distributions of total expenditure and its state subsidy component suggest that per capita expenditure is more than three times as hjih in urban than in rural areas, approximately Y33 compared with Y10. - A recent Chinese study estimated the health care costs of raising a child tp age 16 in urban areas to be Y481, whereas in rural areas it was only Y73. The substantially regressive urban bias of public expenditure is chiefly responsible for these wide disparities. State subsidies per capita are nearly ten times greater for urban residents than for rural residents. At Y26 per capita in urban areas, the state subsidy for health expenditure is equivalent to five percent of urban income per capita. In stark contrast, the state subsidy to rural residents averages less thyTY3 per capita, or only one percent of average rural income per capita. - In urban areas, state subsidies finance more than three-quarters of total health expenditure and private outlays contribute less than one-tenth of the total. In rural areas, private expenditure pays for more than half of total outlays and state subsidies contribute less than one-third. Thus in China, as in every other developing country, the rural majority receives less health care and pays more for it than their advantaged urban counterparts.

International Comparisons

3.91 Available data suggest that per capita health expenditure in China is relatively high for a country at its low per capita income level. Comparisons with 19 LDCs with 1975 per capita GDP lower than US$2000 are presented in Table 3.8. For these LDCs, the relationship between per capita health expenditure and per capita GDP is very close to log-linear, with an estimated income elasticity of health expenditure of approximately 1.2. At constant 1975 prices, per capita health expenditure in China is estimated at US$7.1,

1/ This estimate for rural expenditure is very close to a recent estimate of per capita health expenditure in a rural brigade in Yexian County, Shandong Province. See WHO/UNICEF/IBRD/PRC Interregional Seminar on Primary Health Care, Yexian County, Shandong Province, 13-26 June 1982.

2/ This study is cited in China: Demographic Billionaire (p. 35), by N. Yuan Tien (Washington, D.C.: Population Reference Bureau, 1983).

3/ Urban and rural incomes per capita averaged Y500 and Y223 respectively in 1981. See Statistical Yearbook of China: 1981, pp. 438 and 441. - 76 -

which is 25 percent greater than the US$5.7 per capita expenditure level predicted from the LDC sample.

Table 3.8: INTERNATIONAL COMPARISONS OF HEALTH EXPENDITURE

Health Expenditure GDP Health Expenditure LDC Sample (1975) per capita per capita share of GDP (US$) (US$) (Z)

Malawi 2.1 138 1.5 Kenya 8.9 241 3.7 India 3.4 146 2.3 Pakistan 7.2 189 3.8 Sri Lanka 4.1 185 2.2 Zambia 16.6 494 3.3 Thailand 14.8 350 4.2 Philippines 8.7 376 2.3 Korea 16.3 583 2.8 Malaysi 21.1 781 2.7 Colombia 23.2 564 4.1 Jamaica 43.9 1406 3.1 Syria 16.5 718 2.3 Brazil 44.2 1149 3.8 Romania 48.0 1742 2.8 Mexico 64.3 1465 4.4 Yugoslavia 72.6 1663 4.4 Iran 48.4 1587 3.1 Uruguay 66.3 1308 5.1

Mean 27.93 794 3.3

China (1981)

Actual 7.1 214 3.3 Predicted 5.7

Notes:

a/ Derived from Kravis et al (1982), World Product and Income: International Comparisons of Real Gross Product, Baltimore: Johns Hopkins University Press, Summary Multilateral Tables 6-1 and 6-3.

b/ Estimates of 1981 values (Table 3.7) converted to 1975 constant dollar prices.

c/ Prediction based on the following OLS equation esiimated for the LDC sample: LN HLTHEXP = -4.525 + 1.166 LNGDP, R = 0.936. t-statistics are given in parentheses. - 77 -

4. BEYOND THE HEALTH SECTOR: OTHER FACTORS INFLUENCING POPULATION, HEALTH AND NUTRITIONAL STATUS

4.01 The initial section of Chapter 3 stressed that a central feature of health policy in China is the existence of activity in complementary sectors that contributes favorably to improving health status. This chapter (briefly) discusses activity in three related areas -- food availability, water supply and sanitation, and family planning. The (relatively) high levels of literacy in China in 1949, combined with massive subsequent efforts to improve education levels, have also undoubtedly contributed importantly to China's capacity to implement public health policies. This report discusses education policies no further, except to note the importance of strong basic education as a building block for training of health professionals and as a fact?l predisposing the population to effective adoption of good health practices. -

4.1 Food Availability and Food Policy

4.02 Trends in food availability. Food production /has been greatly increased and the distribution system improved since 1949. 2 Table 4.1 shows that, despite wide fluctuations, per capita food energy availability increased greatly between 1950 and 1982. Average daily per capita nutrient availability grew rapidly after 1949, and by 1958 approached 2,200 kcal per day. A sharp decline of agricultural production -- due partly to bad weather conditions in 1960 and 1961, and partly to the failure to gather what should have been a good harvest in 1959 because of the chaos created by the "Great Leap Forward" -- then caused nutrient availability to fall below the 1952 level. The situation was made worse by a delayed response in China's international agricultural trade: substantial exports of foodstuffs continued throughout 1960 (in part to repay debt to the USSR) and imports were not increased until 1961. Per capita nutrient availability did not return to the 1958 level until the mid-1970s. In the last six years, however, it has surpassed requirements by a significant marS1 n, and this situation is expected to continue for the rest of the century. -

1/ For a general discussion of this point see the World Bank's World Development Report 1980; a review of the relevant literature may be found in "Parental Education and Child Health: Intracountry Evidence", by S. H. Cochrane, J. Leslie and D. J. O'Hara (Health Policy and Education, 1982, v. 2, pp. 213-250).

2/ For a detailed analysis of food production, see Supplementary Paper No. 7. Annex Tables D-1 to D-3, drawn from that paper, document the growth in food (D-1 and D-2) and nutrient (D-3) availability in China from 1950-82.

3/ Figures presented in Table 4.1 indicate that energy requirements in 1979 were 2185 kcal per capita per day, an increase of 8 percent over requirements estimated for 1953 at 2024. Energy availability per capita in the three-year period 1979-81 increased by about 27 percent over availability in the period 1952-54. In consequence, energy availability increased from 95 percent of requirements in 1953 to 118 percent in L979. - 78 -

Table 4.1: TOTAL DAILY PER CAPITA FOOD ENERGY AND PROTEIN AVAILABILITY AND REQUIREMENTS, SELECTED YEARS

Year Energy Availability Protein Availability As % of As % of kcal Requirement gm Requirement

1950 1614 43

1953 1924 95 51 155

1960 1462 40

1965 1997 54

1970 2092 53

1975 2226 55

1977 2248 56

1978 2370 58

1979 2572 118 65 180

1980 2496 64

1981 2526 65

1982 2729 68

Source: Annex Table D-3 and calculations from Annex Tables D-8, D-9, D-10 and D-11.

4.03 Since food is unevenly produced and distributed, the nutritional status of a population may not be directly calculated from per capita nutrient availability; a large segment of a population may suffer malnutrition despite a level of average per capita nutrient availability that exceeds average nutrient requirements. The extent to which a given margin of nutrient availability over requirements will lead to insufficient availability in a portion of the population depends both on the distribution of income and the income elasticity of demand for the nutrient. Limited data from China confirm the standard finding that the income elasticity of demand for protein far exceeds that for energy. Hence it cannot be concluded from Table 4.1 that there are likely more individuals suffering energy than protein deficiency. In any case, for whatever reason, there appears to be a strong positive relationship between overall nutrient availability and health. Figure 4.1 illustrates the strong negative relationship between the infant mortality rate (IMR) and per capita food energy availability in China during the period 1950- 82. The 1959-64 food crisis caused great human suffering, reflected in a Figure 4.1 Infant MordaltyRates and TotolDalty PerCapita Food EnergyAvoNbHIltV. 1950-82

_ 0

(- Wnt m/cwtaodfttrate

Wo\\J~~~~~~~~~~~~~~~\\,,1(p

2100 220

(kVant mcyktott ccapdafood ere'gv ioer lDOW ay.okia in Ivstco t h _ 1GklocoboeS) I ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~-.

150 2-00/

/00

){/~~

?~~I'- Food EnMgy.6 O I _ ~ ~~I I/ ,c

t950 *9 t19M t%2 1%64 1970 1974 1978 1WV

SouC Apo _ kOMA-2 *D-3 ' /-23 - 80 -

sharp increase in IMR and an actual decline in the total population in one year. The long term decline in IMR resumed after the food crisis with the recovery of growth in per capita nutrient availability during the last two decades.

4.04 Food policy. In order to remedy deficiencies of food supply in particular areas, government procurement of grain and urban rationing and rural grain transfer programs were introduced in the 1950s. Rural agricultural units pay an agricultural tax, mostly in terms of grain, and are also required to deliver measured quotas of foodgrains and certain other products to the government purchasing agency according to administered prices. Deliveries in excess of quotas are paid for at premium prices. The foodgrains procured by the government are then available for distribution to urban and grain deficit rural areas.

4.05 A rationing system has been in operation in urban areas since November, 1953. Under this system most households 1- receive ration coupons for grain and certain other basic foodstuffs, which are heavily subsidized. This urban food subsidy is estimated (Table 5.1) to have been worth Y96 per urban dweller in 1981, and absorbs 4.2 percent of GNP, i.e. almost one and one third times total expenditures on health care. Grain rations vary by age, sex and occupation, and from one area to another (Annex Table D-7).

4.06 In rural areas there is no formal rationing, but grain is transferred from surplus to deficit areas and the government guarantees to provide people with minimum supplies if they live in poor areas or are affected by natural disasters. The quantity guaranteed varies, however, from province to province and, within provinces, from county to county. Typically, the guaranteed minimum is 200 kg of unprocessed A,ain per capita per annum in rice growing areas, and 150 kg in other areas. _

4.07 Although the system of food production, procurement and distribution has many weaknesses which the government is trying to remedy, it has certainly greatly increased the proportion of the Chinese population whose basic food needs are met. It is important to emphasize, however, that the system does not satisfy everyone's food needs. This was most noticeably the case during the food crisis of 1959-64. Throughout the past three decades, however, although there have been substantial variations from one province to another in per capita grain production, interprovincial grain trade has generally been

1/ In 1980 there were an estimated 9.3 million non-agricultural workers officially classified as contract or temporary workers who were not entitled to rationed food. For further information on the implications of the rationing system, see N. Lardy, "Agricultural Prices in China" (Washington, D.C.: World Bank Staff Working Paper No. 606, 1983).

2/ A rice ration of 200 kg (unmilled) per annum would provide 1,400 kcal per day of energy and 25 grams of protein -- approximateLy 64 percent and 69 percent, respectively, of the 1979 level of daily requirements in China. A wheat ration of 150 kg (unmilled) per annum would provide 1,250 kcal per day and 35 grams of protein, 57 percent and 97 percent of requirements. - 81 -

quite limited, so that, as 1- imports have been relatively small, per capita grain consumptionhas varied widely between provinces; Map 6 illustrates this for 1979. Average per capita nutrient production was below requirements in eight provinces in 19,/9 (Shanxi, Henan, Ningxia, Gansu, Yunnan, Guizhou, Qinghai and Xizang). 2 In Guizhou Province, average daily food consumption per head in 1976 was about 1,700 kcal, clear undernutrition,and in Gansu3 /nd Ningxia peasants in some counties harvested only 100 kg of grain per head.- The situation has improved substantiallywith the introduction of the rural responsibilitysystem, but it nonetheless appears likely that there remains a substantial number of peasants whose basic subsistence needs are unmet. Anthropometric data on rural children (presented in Chapter 2.5) provides further evidence of localizedmalnutrition in rural China. There is an urgent need to remedy this situation. In addition, the Government needs to look closely at the implicationsof the new economic responsibilitysystems for the food consumption of different groups, including how the food needs of groups such as old or handicapped people are going to be met.

4.2 Water Supply and Sanitation

4.08 The health campaigns have helped to promote health by substantial improvemi4ts in water and sanitation facilities and practicesover the past 30 years. - Of the 242 major cities, 221 now have piped water. Fifty percent of the urban population now has access to piped water (either through public standpipes or in-house connections) compared with less than 10 percent in 1949. In most cases these water supplies are treated and chlorinated. Urban sanitation has been greatly improved: household wastes are collected in garbage cans placed in streets and lanes; recoverable waste is collected by salvage centers and by door-to-doorcollecting groups; and excreta is disposed of either through sewerage systems (as in parts of Shanghai and Guangzhou) or, more commonly, through nightsoil cartage and treatment systems. Although rural areas are more backward in these respects, individualcommunes, brigades and production teams have taken steps to improve water supply and sanitation. Relatively clean water in sufficient quantity is now available to 350 million people or 40 percent of the rural population,of whom 15 percent are provided with piped water and the balance with water from drinking/ irrigation wells, sand filter wells, hand-pumped wells and improved open wells. Many rural areas now make use of centralized excreta vats, fermentation-settingtanks or biogas tanks for processingnightsoil.

1/ Total interprovincialgrain trade was less than five million tons in 1979.

2/ See Annex Table D-5.

3/ See article by Vaclav Smil on China's food in Food Policy, May, 1981.

4/ The National Patriotic Health Campaign, for example, holds responsibility for China's participationin the ongoing InternationalDrinking Water and Sanitation Decade. Experience from outside China would suggest that the close association of hygiene promotion (through health campaigns) with provision of improved water supplies is probably important in realizing the health benefits of water supply improvement. - 32 -

4.09 Nevertheless, much remains to be done in the field of water supply and sanitation, especially in rural areas, where the most urgent problems are those of water shortage (affecting an estimated 40 million people), high fluoride content water (affecting 45 million people), and bitter alkaline water (affecting 60 million people). In total about 500 million rural people require improved water supply, including 150 million who drink untreated surface water. In many areas, chemical contamination is becoming more important than biological contamination as a health problem. Substantial improvements in rural sanitation, including the further development and use of biogas tanks, are also required.

4.10 In urban areas there is a need to provide piped water to the population lacking this service and to improve the quality of the water provided by some systems. There is also a need for improved treatment of industrial wastes, sanitary severage in certain areas, better equipment for the collection and transport of nightsoil, and improved treatment of nightsoil.

4.11 Improvements in water supply and sanitation call not only for the allocation of additional resources by the central government and by communes and brigades, but also for better planning and technology and improved monitoring and information systems. There is scope, for example, for better hand-pumps in rural areas, and the technology is being developed by the Chinese Academy for Agricultural Machinery Science with the support of the UJNDP. Epidemic prevention stations, which are responsible for monitoring the quality of drinking water and the operation of nightsoil treatment plants, need strengthening in terms of equipment, staff and reporting systems. This is especially important in rural areas, where the new system for allocating responsibility for production may offer an incentive to revert to such unsanitary practices as the use of untreated nightsoil on vegetable crops.

4.3 Population Policy and Fertility Decline

Population Policy

4.12 Early Attempts at Family Planning. The fall in the birth rate since 1970 results from the whole-hearted pursuit of a population policy that differs markedly from any pursued elsewhere, and which has been, in terms of its objectives, extremely successful. This was not, however, China's first attempt -- it was preceded by two earlier campaigns which, in spirit and achievement, were much closer to comparable efforts in other countries. The ComrmunistGovernment adopted an anti-natalist policy only after it had been in power for a few years, having initially taken the orthodox Marxist view that, under a communist regime, population growth was no source of anxiety. The results of the 1953 census, however, and the evidently rapid population growth prompted some rethinking, and in 1956 Zhou Enlai personally endorsed a family planning campaign explicitly designed to reduce population growth, as well as to preserve the health of women and children.

4.13 There is general agreement that this campaign had littLe, if any, demographic impact. In spite of the use of mass media and a stress on education and on the use of public health facilities and personnel, the campaign faced too many handicaps. it preceded the introduction of the - 83 -

contraceptive pill and of modern IUDs. Conventional contraceptives were in short supply. There were few paramedical workers in rural areas who could be readily trained to provide information and services, and was soon abandoned when the euphoria accompanying "Great Leap Forward" fostered the illusion that production problems were being solved.

4.14 The widespread famine of 1959-61 painfully and emphatically refuted this view. In 1962 another family planning campaign began, with less emphasis on mass media but more on contraception, sterilization, and abortion. While the delivery of services, which relied heavily on mobile medical teams, remained the responsibility of the public health system, political cadres were expected to organize local committees, meetings, exhibitions and so on, to provide information and encourage the adoption of these methods of family planning. New IUDs and vacuum-suction methods of abortion were introduced. Sterilisation was widely publicised, and conventional contraceptives were made readily and freely available. It has been estimated that, by th e end of 1965, some 14-15 million women were practising contraception. 1 This was equivalent to 10-11 percent of the women of childbearing age and, by the international standards of the time, a high proportion of such a large population. (For comparison, India, with an older and more continuous family planning program, took until about 1970 to reach a comparable level of contraceptive practice.) Nonetheless, the campaign had only a limited demographic impact. Following the famine, the birth rate rose, and -- the offic\al rates for 1963, 1964 and 1965 all exceed any others reported since 1949.

4.15 Although the 1950 Marriage Law set 18 and 20 as the minimum marriage age, much later marriage cane to be advocated. At first, stress was placed on the advantages to the couple in terms of improved health and economic conditions -- rather than reduced fertility and population growth. Men were urged to wait until they were at least 25 -- some recommended 28 -- and women until they were 23. By the 1960s, however, later marriage was seen as an important aspect of the family planning campaign.

4.16 Birth Planning Since 1971. The Cultural Revolution swept aside the family planning campaign, as so much else and, among other things, disrupted the production and distribution of contraceptives. There was some resumption of family planning activities in 1969 and, in 1971, a new birth planning campaign was Launched, on very different lines from before. A hierarchy of birth planning institutions was established, headed by the "Birth Planning Leading Group" reporting to the State Council, with corresponding committees at each governmental level down to the brigade or its urban equivalent. Since 1981 the program has been run by the State Family Planning Commission which has ministerial status. Senior party officials provide leadership in the local birth planning committee, which is served by a local office which supervises the Local program. The local committee also has links with mass

1/ Joan Kaufman, A Billion and Counting: Family Planning Campaigns and Policies in the Peoples Republic of China (San Francisco: San Francisco Press, Inc., 1983), p. 26. - 84 -

organizations such as the Women's Federation. There are now nearly 100,000 full time family planning staff.

4.17 The birth planning system is thus administratively independent of the health system, though dependent on it for services. In several provinces the family planning program is now establishing some delivery services of its own. In particular, some provinces have opened "family planning stations" at county level or below, to provide information and contraceptive services, including surgical services, rather than rely on the local health facilities to supply these on a reimbursement basis. Other countries have set up family planning "delivery systems" separate from health service networks, but usually because at the time there were no grass-roots public health services available. This is clearly not the situation in China. No such scheme has ever approached the thoroughness of the present Chinese family planning program, and indeed only a few can be said to have been successful. So while it is understandable that the family planning program would like to increase its own sense of self-reliance, the establishment of a large network does appear to be potentially duplicative of other services.

4.18 The 1971 State Directive establishing the new policy did not specify a target growth rate for population, but provincial administrators soon did. Since the mid-1970s, a national population growth target has been translated into a maximum rate of natural increase allowed for each province, taking into account its devplopment and ethnicity (minority areas are permitted higher birth rates). 1 In turn (at least in principle) the province assigns each county a birth quota, the county allocates this among communes, and so on down to production teams or urban residential units, which give permission to individuals to have children. At this level policies are reinforced by part- time family planning workers. The extensive network of work and residential groups, established to study and discuss economic and social issues and policy, has facilitated peer pressure on couples to accept community birth planning decisions. The virtual impossibility of migration and the dependence of individual income on collective decisions must, in rural areas at least, have provided a real sense of the social implications of individual fertility decisions, and encouraged the community to take the task of collective birth planning seriously. Such groups could also be enlisted to discourage marriage until the age of 28 and 25 for men and women respectively in cities, and 25 and 23 in rural areas. Individual local governments sometimes promulgate regulations to enforce such minimum marriage ages.

4.19 This description of the birth planning process probably exaggerates the degree of central control. There has clearly been a good deal of local participation in the establishment of local targets. At present more emphasis seems to be given to approving the plans of individual and lower level units to see that they conform reasonably to the norms of the one-child family

1/ Population policies have been distinctly more lenient in minority areas. Data given to a World Bank health project mission show that several of the counties in Ningxia Autonomous Region still had birth rates of over 40 in 1981 (two were 45) -- which, with reported death rates of around 8, gave reported population growth rates of up to 3.7 percent. - 85 -

policy (etablished in 1979), or its permitted exceptions, than to imposing an external target on local groups. Women who marry at 23 or later seem normally to be allowed to have one child as soon as they wish, but in principle are discouraged from having a second. Those who marry before 23 may be discouragedfrom having a child immediately.

4.20 For couples without permission to bear a child, contraceptives, sterilisation and abortion are widely available free of charge. The most widely used contraceptive is the IUD, probably used by about 50 percent of contraceptive users, followed by sterilisation (30 perce7t, female sterilisation accounting for about 60 percent of the total). ' Although abortion may sometimes be carried out by paramedicals in remote brigades, patients are normally referred to county or commune hospitals.

4.21 The One Child Family Policy. The remarkable fall in the birth rate in the 1970s undoubtedly reflefts the success of the birth planning program, particularlyin urban areas. 2 In 1979 Sichuan instituted a policy designed to persuade married couples to have no more than one child. This policy was backed by a system incentives to parents who agreed to have no more than one child, and penalties for those who persisted in having more than two. This soon became a national policy, and all provinces have now adopted such incentiveand disincentivesystems.

4.22 Main responsibility for financing the incentives falls on the work units of the father and the mother, which are expected to share equally. There is therefore considerable local variation in the rewards offered to parents with one child who pledge to have no more, and in the penalties attached to having two or more children. A typical package offers parents of a single child an allowance, or "health care subsidy", of 60 yuan per year in urban areas J and an equivalent amount in rural areas, until the child is 14. Preference is given in the allocation of urban housing to one child families,which receive the same space as families with two children. An only child may receive adult rations and count as 1.5 or two persons in the allocation of private plots. Maternity leave benefits are more generous for the first child. Parents are promised that an only child will get priority in education and employment; that special physical checks will be provided by hospitals; that special events may be organized for only children; and that their own living standardswill be maintained when they become old or widowed.

I/ Pi-chao Chen and Adrienne Kohls, "Population and Birth Planning in the People's Republic of China". Population Reports, Series J, March 25, January-February1982, p. J-590. This report as a whole is a very useful source of information.

2/ Birth rates in rural areas remain consistentlyhigher than those in urban areas. The mission's analysis of data from the 1982 census estimates rural crude birth rates at 24.8 per thousand and urban rates at 13.5 per thousand.

3/ This is equivalent to about 8 percent of a typical urban wage. - 86 -

4.23 People rapidly qualified for such benefits. By the end of 1979, some six million out of 14 million couples with one child had received official certificates of one child family status; by the end of 1980 the number was 11 million ou/ of 20 million and by mid-1981 it was 12.5 million out of 22 million. -

4.24 Penalties also vary. Couples who have a second child must return any bonuses obtained for the first child. In some areas there may be other disincentives -- for example, a couple ha7ing a second child may be required to pay a large amount for the privilege. 2 Of course, second children may be permitted for a special reason -- for example because the first child was defective. Grain for a second child born outside the plan may in some localities have to be purchased at a higher price while in others this penalty may be imposed only on third and later children. Additional penalties on the third child are likely to include a tax of 5-10 percent of income, and the elimination of medical and maternity leave benefits.

4.25 Chinese attempts to reduce fertility have of course always had to struggle with the traditional preference for sons. For the one-child family the problems are magnified. Considerable attempts are being made to counteract such feelings; for example, posters usually show the only child as a girl. Attempts are made to persuade new husbands to join the wife's household instead of vice versa, as tradition prescribes, but it is thought that they have had little success. In some places larger incentives have been offered for an only daughter than for a son. But it is clearly an uphill struggle. A November 1982 article in a Chinese paper, Youth News, said that reports of infanticide and abandonment of girl children were so widespread that there was a danger that the sex ratio might be significantly altered, and today's newborn boys might have difficulty in finding marriage partners. There have also been reports of the use of amniocentesis ti,determine the sex of the child, followed by the abortion of female fetuses. - The mission was informed that it is now illegal for physicians to report the sex of the fetus to the parents after amniocentesis.

4.26 Attempts are being made to eliminate any pro-natalism in the allocation of resources or benefits to individual households, which in the past has often been on a per capita basis. Of particular importance is the allocation of land, especially under responsibility systems which make the household, rather than the team, the beneficiary of higher output. A recent

1/ Beijing Center of Communications and Family Planning, Topics in Population Theory (Renkou Li Lun Xuan jiang), p. 40.

2/ In a brigade in the Beijing municipality visited by the mission, several couples had been willing to pay Y 750 for a second child. This was over twice the per capita distributed collective income (but this was a brigade where sideline income appears to be large).

3/ The New York Times, August 1, 1982, citing a Chinese publication, Health News. - 87 -

article complained that in some areas farmland was distributed soleAy on a per capita basis, and that this was discouraging family planning. - Official policy, however, is that family planning should be explicitly linked to the adoption of a production responsibility system, and in some places contract between a household and the team cover both production and childbearing. 2 Failure to meet either target results in a substantial fine.

4.27 Couples who are not deterrred by the penalties from having an unpermitted second or third pregnancy become subject to considerable pressure from local family planning authorities and others to have an abortion. It is clearly not official policy, at least at the central level, to push this pressure to the extent of requiring compulsory abortions, sterilisation, or the insertion of IUDs. But there are widespread reports of local abuses -- e.g. of abortion campaigns which included third trimester abortions. Indeed, it is impossible to imagine that all local cadres would know exactly where to draw the line between friendly counselling and unreasonable coercion.

Recent Changes in Fertility

4.28 Although the State Statistical Bureau has not itself published a birth rate for 1980, the 1982 Census report of a 1981 birth rate of 20.9 undoubtedly suggests a real rise from the 1981 level. The World Bank's demographic model estimates the total fertility rate have held constant at 2.5 from 1978 to 1980, but to have risen to 2.8 in 1981. Why did this increase occur?

4.29 There was undoubtedly a significant rise in the number of marriages. 3/ This does not reflect an increase in the proportion of people reaching marriageable age -- the late 1950s and early 1960s was a period of a falling birth rate, and the cohorts born in the peak birth years of 1962-8 would not affect the numbers marrying until 1982 at the earliest. This rise in marriages appears to have reflected a misunderstanding in some areas, where it was thought that policies to promote late marriage - defined as three years later than the legal minimum - had been dropped. People with late marriages can have a child right away. Others are subject to a need for permission, though there is a problem that often contraceptive information is inadequate at the time of an early marriage. Most places, however, make an attempt to follow these up. But postponement of the first child is counter to tradition

1/ People's Daily, February 5, 1982.

2/ Directives on Population Control issued by the Communist Party Central Committee and the State Council, March 13, 1982.

3/ It is not quite clear how large this increase was. Chen and Kohls (p.d- 607) cite3 data which indicate that in the first half of 1981 there were 6.37 million marriages compared with 3.26 million for the first half of 1980 and 7.45 million for the whole of 1980. Data supplied by the Stat-. Family Planning Committee was less dramatic. Based on the 1982 fertility survey, it is roughly estimated that there were 8 million marriages in 1979, 9.71 in 1980, and 10.73 million in 1981. - 88 -

and may be difficult to enforce. Insofar as the higher fertility of 1981-2 reflected earlier marriage it may be offset by a fall in the next few years; preliminary reports of the 1983 birth rate suggest that it was below 20 per thousand compared with 21.1 in 1982. I/

4.30 It is also likely that the one-child poLicy was less successful in 1981. For example, the Sichuan family planning authorities told the mission that the proportion of first-order births was lower and that of second order births higher in 1981 than 1980. 2/ This they attributed to the introduction of the responsibility system in agriculture. In his 1981 report on the economic situation to the Fourth Session of the Fifth National People's Congress, Premier Zhao Ziyang f so attributed the reported rising birth rate to the responsibilitysystem. _ The back-slidingdoes not, however, seem to be universal. In Shandong the proportion of first births rose from 67 percent in 1980 to 76.9 percent in 1981; in Jiangsu it rose from 68 percent to 72 percent; and in the provinces o4 Liaoning, Jilin and Heilongjiang,it exceeded 70 percent for the first time. -

4.31 Several reasons have been advanced to explain how the production responsibilitysystem could discourage family planning. Since the allocation of land under the production responsibility system is -- in many areas at least -- not a once-and-for-allaffair, many peasants may feel that larger families will entitle them to more land. It has been suggested that parents view the potential contribution of children to family income as a reason for wanting more of them. Analysis in other countries suggests that if there are alternative possibilities for saving, even with fairly low interVst rates, children are a poor investment (though parents may not know this). - A much more powerful reason in rural areas may be a desire for children, especially sons, as a source of possible support in disability or old-age. This results

l/ Beijing Review, March 26, 1984.

2/ In 1981, 67 percent were first order; 21 percent second-order, and 12 percent were higher order. Unfortunately the available figures for Sichuan add to 89 percent only, so the comparison is hard to make. It is also difficult to interpret such figures. With an increase in the marriage rate it is inevitable that there will be a rise in the proportion of first births, unless there are offsetting changes in the reproductive patterns of the already married.

3/ Zhao Ziyang, China's Economy and DevelopmentPrinciples (Beijing: Foreign Languages Press, 1982), p. 62.

4/ Beijing Review, November 1, 1982, p. 3.

5/ Mead Cain, "Risk and Insurance: Perspectiveson Fertility and Inequality in Rural India and Bangladesh", Population Council, Center for Policy Studies Working Papers, No. 67, April 1981, p. 51. Robert C. Repetto, "Direct Economic Costs and Value of Children", in Ronald C. Ridker, Population and Development: The Search for Selective Interventions (Baltimore: Johns Hopkins Press, 1976), pp. 77-97. - 89 -

from the limited return available on savings, the likelihood that one's daughter will live outside one's village, and the natural reluctance to place a burden on one's neighbors, especially if the effect of the responsibility system is to reduce collectivewelfare funds. But the simplest incentivemay also be the strongest -- parents get pleasure from their children, and their children's accomplishments,and are reluctant to center all their hopes and aspirations on one child. The responsi ility system has raised incomes, and has made it easier to afford children. 1 With higher incomes, the incentives offered to a one-child family have also become relatively less attractive and, indeed, preliminary analysis of 1982 census data suggests that the normal finding that fertility is lower in higher income locales no longer holds in rural China and, further, that in urban aeas higher income may actually be associated with higher fertility levels. - If so, it can be expected that even more vigorous efforts on the part of public authoritieswill be required to keep the total fertility rate from continuing to rise.

4.32 It is also possible that, at least in some areas, family planning efforts have slackened. It is well-known that it has proved difficult for many brigades to retain barefoot doctors, and that they have often returned to full-time farming. Women's cadres at the production team level who carry principal responsibilityfor arranging meetings, checking on family planning practice and reporting on pregnancies to the brigade women's leader, may also have been devoting more effort to production and less to family planning. It has also been reported that the reduction in collective funds has caused some brigades to abolish their women's work cadres, who were previously been responsible for birth planning in the brigade and supervising the family planning activities of the barefoot doctors. Data on the proportion of women of reproductive age who are practicing family planning show a rise from 74 percens,in 1979 to 82 percent in 1980, followed by a fall to 74 percent in 1981. - Some places have responded to these problems by introducinga "birth control responsibility system" which provides bonuses for family plann47g activities in excess of target quotas, and penalties for poor performance.-

4.33 In sum, the new policies have suffered from the fact that they attempt to increase centralized social control in one field, while reducing such control in others. It is clear that the government'sproven ability to influence fertility is not unlimited even in China, and it is therefore misleading to believe that fertility is under push-button government

1/ For an analysis of the economic consequences of the one-child family policy, as well as for more detailed treatment of all the issues raised in this section, see SupplementaryPaper No. 2 to this report.

2/ See SupplementaryPaper No. 3.

3/ Beijing Center of Communicationand Education for Family Planning, Topics in PopulationTheory, p. 40.

4/ Xin Dan and Peng Zhiliang, "The Experience Gained in Carrying Out the Birth Control Responsibility System in Peng County, Sichuan", Population Study (Renkou Yanjiu), June 1982, pp. 29-31. - 90 -

control. Nevertheless, fertility is remarkably low for a country at China's level of development. Aside from the important economic benefits of controlled fertility, a greater fraction of single child families and low- parity births has undoubtedly contributed to the reductions in infant and child mortality in China in the past 20 years. - 91 -

5. PROBLEMS AND ISSUES

5.01 China's approaches to improving health care, and its resulting successes, have influenced the thinking of health care professionals around the world. The documentation of China's achievements that was presented in Chapter 2 indicates that China's influence abroad was welIearned, and factors underlying the achievements were analysed in Chapters 3 snrd 4. In essence, large-scale and sustained efforts at environmental improvement combined with preventive medical measures (e.g., health campaigns, immunization) have greatly reduced the incidence of communicable disease .r imost of China. Improved food distribution (and a reduced disease burde.n) substantially reduced the prevalence of malnutrition, which in turn., along with widely diffused improvements in basic curative medicine, greatly reduced the mortality rates from those infections that did occur. Thhem factors combined to yield the long term and dramatic increase in life expectancy that was illustrated in Figure 2.1. This success might welL be labelled the first Chinese health care revolution.

5.02 China's first health care revolution has left in its wake two distinct sets of remaining problems. First, success to date has been uneven: Health conditions in cities are very good indeed, and many rural areas lag the cities by only 5 or 10 years in life expectancy. But the health conditions of scores of millions of rural Chinese -- perhaps as many as 100 to 200 million -- remain today more like those prevailing in typical developing countries than like those of their compatriots. These peopLE live in poor and remote parts of China; economic and administrative infrastructure is lacking; education levels are probably low. The problem of improving their health conditions will be neither an easy nor an inexpensive one to solve.

5.03 The second set of problems is that of the emargiing prevalence of chronic disease. The discussion in Chapter 2.5 of current disease problems indicated that the pattern of cause of death in China is veryr much like that of the industrialized world -- heart disease, cancer and stroke lead the list of causes of death. The approaches to treatment of these diseases developed in the West tend to be extremely costly and of limited efficacy; yet very natural demands by patients for treatment -- and efforts by physicians to supply the best available cure -- have led to expenditure of vast resources with relatively little health impact. In the United States, for example, approximately half of all1 xpenditures on health are for individuals in the last year or two of life. -

1/ As the United States now spends 11 percent of its GNP orn health, and GNP in 1980 was about $2.5 trillion, approximately $280 billion (or almost the GNP of China) was spent on health care in the U.S. Life expectancy in urban areas of China is almost as high as in tne U.S,, suggesting very limited returns, in reducing mortality, to many types of costly investment. - 92 -

5.04 In light of these problems, two priority challenges now face the health sector in China:

(a) The first challenge is that of completing the first Chinese health care revolution by extending the methods that have been successful in most of China to those areas where mortality rates remain high and the burden of morbidity is still heavy; and

(b) The second challenge is that of forging a second Chinese health care revolution that would develop and implement approaches to management of chronic disease that would combine prevention, low-cost treatment, rehabilitation and humane care. The problems to be overcome in forging this second revolution are massive -- but success, even partial success, would be of immense value not only to China, but also to an international community that looks to China for leadership in public health.

5.05 This Chapter's first two sections deal further with the problems and challenges just raised. The next sections then raise a number of specific issues in the areas of rural health and medical education that bear on the extent to which current operational and policy directions are likely to meet the above two challenges.

5.1 Health Services for the Rural Poor: Completing the First Chinese Health Revolution

5.06 The first major problem facing the health care system of China is the continuation of major disparities among regions and between rural and urban areas in availability of health services and in health status. Table 5.1 documents rural-urban differences, which, despite recent gains in rural areas, show dramatic differences in favor of urban areas. Map 1, which is based on data from the 1982 census, shows that substantial interprovincial variation in both mortality and fertility rates also remains. Available data also show great variations among rural areas within a province in income levels and birth and death rates. Estimated urban life expectancy2 Jn 1975 is 72 years; rural life expectancy is estimated at only 57 years. 2 Per capita state expenditures for health care were estimated at 26 yuan per capita in urban areas, almost ten times the rural level. Other indicators reflect the same pattern. Effective health care delivery has been basically consolidated in urban areas; vigorous efforts to extend those gains to rural China would seem to be the next priority, and it appears to be recognized as such by the Ministry of Public Health.

2/ See Supplementary Paper No. 4. - 93 - Table 5.1: Rural-Urban Differences Related to Health

Urban _/ Rural Total

Health Status

Crude death rate, 1981 (per thousand) b1 4.8 7.1 6.6 Life expectancy, 1975 (years) 72 57 59

Nutrition Status

Percent of 7 year old boys nutritionally stunted, 1979 2.6% 12.7% ---

Fertility Levels

Crude birth rate, 1981 (per thousand) b/ 13.5 24.8 20.9 Total fertility rate, 1981 ci 1.5 2.9 2.6

Health Service Availability (per 1,000 population)

Doctors of Traditional Medicine 0.38 0.27 0.29 Senior Medical Staff 2.05 0.28 0.67 Middle Level Medical Staff 2.99 0.73 1.16 Lower Level Medical Staff 1.41 0.61 0.78 All Salaried Health Workers 7.04 2.01 3.04

Health Expenditure (Yuan per capita)

State Subsidies 26.19 2.76 7.58 Private Expenditure 2.76 5.07 4.60 Total Expenditure 32.46 9.64 14.34

Food Subsidies (Yuan per capita) d/ 96.10 negligible ---

Notes: a/ Population denominators estimated by applying the 1982 Census distribution (20.6 percent urban) to the estimated 1981 mid-year population (Statistical Annex Table A-1). b/ Estimates of the urban an rural levels of crude birth and death rates in 1981 were made by the mission on the basis of statistical analysis of provincial-level data from the 1982 census. c/ These figures come from a 1982 sample survey, a summary of the results of which was released in April, 1983, by the State Family Planning Commission -- "Report on a Sampling Survey of the Fertility Rate per Thousand of the Population". d/ Urban Food subsidies are currently YO.2 per kilo of grain, Y1.6 per kilo of cooking oil and some subsidies for other food and vegetables. The value of these subsidies totalled Y36.8 billion between 1979 and 1981, equivalent to 59 percent of total state subsidies to urban residents. It is assumed that this ratio applies to the Y164 total urban state subsidy per capita in 1981 (Beijing Review, No. 43, October 25, 1982, p. 7).

Other sources: This report and supplementary papers. - 94 -

5.07 An important aspect of rural-urban differences, and one that will likely assume increasing importance in coming years, is that of ensuring the healthy physical and mental development of every child. This objective has always been important in China, but the one-child family policy makes it particularly so now. Dramatic gains have been made in child health; indeed they underlie much of the improvement in life expectancy documented in Chapter 2. Nonetheless, available data indicate that, at least in rural areas, there is a substantial fraction of children who are malnourished; analysis of data from a 1979 survey in 16 provinces found 12.7 percent of rural 7-year olds to be stunted (Table 2.5). Stunting is a condition of being malnourished to the point that the child is sufficiently low in height (given his age and genetic potential) that adverse consequences for health, psychomotor development or intellectual development are likely to occur. Lesser degrees of malnutrition may also be expected to have adverse developmental consequences. While the health care system can provide only partial measures to combat malnutrition, it can monitor child growth carefully, mount selective interventions and help in the formulation of general policies to ensure optimal child growth. In addition, to malnutrition, it is very likely that high levels of communicable disease and parasitic infection affect children in poorer rural areas; addressing these problems is also a priority.

5.08 A particularly important new factor in rural health care in China is the unravelling of the rural cooperative health insurance system along with other concomitants of the dramatic changes in rural public finance that have accompanied introduction of the responsibility system in agriculture. As was discussed in Chapter 3.5, 85 percent of production brigades had cooperative insurance in 1975, but this figure had declined to 58 percent by 1981, and further declined in 1982 and 1983. In consequence, nearly half of the rural population was in the position of having to pay the full price for any medical services sought, and this proportion will very likely continue to increase. Even though rising rural incomes are increasing the total financial resources available for rural health, the breakdown of cooperative finance has two highly undesirable consequences. First, there are major gains in welfare to be achieved through the sharing of risks that health insurance schemes provide. While the rural cooperative systems had many defects, including incapacity to share risks over large numbers of individuals, they nonetheless provided an important basic service. Second, fee-for-service approaches to health care finance inevitably fail to invest sufficiently in public preventive measures, that is, in precisely the measures that have played so substantial a role in China's success. A frequent concomitant of the introduction of the rural responsibility system is an undermining of the fiscal mechanism that had previously financed preventive activities of the barefoot doctor. Simultaneously, peasants are acquiring much greater private incentive to work their own fields rather than contribute their time to collective preventive measures such as environmental clean-up or snail eradication to control schistosomiasis. These factors could lead to a resurgence of infectious diseases and, indeed, there are recent reports of substantijl increases in the prevalence of schistosomiasis or its snail vector. - It will be particularly important for disease surveillance systems in China to monitor communicable diseases carefully so that any upturns in prevalence can be promptly corrected.

1/ See "Analysis of the Recent Situation of Oncomelania Snails in Jiangsu Province," by S.Y. He et al, Jiangsu Medical Journal, 1982, 8 (4). - 95 -

Figure 5.1 ProjectedPopulation over 50 Years of Age, 1980- 2030

600

500

400

Population Over 50 (Millions)

300 -

200

100

1980 1985 1990 1995 2000 2005 2010 2015 2020 2025 2030

Year

Wof1dBank-25320 - 96 -

5.09 Finally, there remain several communicable diseases that are important problems either nationally (e.g. hepatitis, dysentery and tuberculosis) or in specific geographic areas (e.g. leprosy and malaria). Further progress against these diseases will be an essential aspect of completing the first Chinese health care revolution.

5.2 Addressing the Emerging Problems of Chronic Disease: Tasks for a Second Chinese Health Care Revolution

5.10 Success in the control of communicabledisease has transferred the burden of China's health problems to the middle-aged and older population. Figure 5.1 shows the growth over time of China's population aged 50 and older, based on the World Bank's demographic model. The number doubles to about 300 million by the year 2005 and almost doubles again in the subsequent 25 years. Individuals in this age group are particularly vulnerable to such chronic disorders as heart disease, stroke and cancer. These three categories of disease now account for almost two thirds of the deaths in China. Prevention is relatively difficult for most non-communicable diseases, and development of effective yet low-cost strategies for dealing with these disorders is, after the task of completing the first health care revolution, perhaps the second health care priority in China today. By the same token, the major pitfall to avoid is the inevitable temptation to emulate high-cost curative approaches that have proved relatively inefficaciousand that, even in high-income countries, have resulted in a massive drain on national economic resources.

5.11 One simple but important example of an increasinglyprominent chronic disease in China is hypertension, and the growing problem of hypertension exemplifies that of other chronic diseases. Hypertension (or high blood pressure) is a condition that greatly increasesan individual'spropensity to heart failure, kidney failure and stroke; its 1980 age-adjustedprevalence in China is about 8 percent of the population 15 years of age and over, or 53 million cases. The prevalence would be 10.5 percent if China'~ population had the same (older) age distribution as that of the U.S.- However, as Table 5.2 indicates, demographic factors alone will dramaticallyincrease the number of hypertensives in the coming 25 years; indeed, even if age-specific prevalence remains unchanged, the number of cases will more than double by the year 2010. Analyses also indicate, however, that hypertension prevalence in China increases with increasing income levels, so the doubling of the number of hypertensioncases that Table 5.2 projects for the next 25 years is almost certainly an underestimate unless strong preventive measures are adopted. These figures for hypertension exemplify the general problem of a rapidly increasingburden of costly chronic disease.

1/ In Western societies hypertension afflicts 10-20 percent of the adult population,with different societies having quite different prevalencesof the disorder. - 97 -

Table 5.2: HYPERTENSION PREVALENCE IN CHINA, 1980-2010

Year Number of Cases Prevalence

1980 53,000,000 8.1%

1990 69,000,000 8.2%

2000 87,000,000 9.3%

2010 110,000,000 10.8%

Source: Mission calculations using age-specific hypertension prevalence rates reported from a 1979 national survey. Calculations were undertaken using World Bank projections of population size and age distribution. Hypertension was defined to include confirmed and marginal cases, i.e., blood pressure in excess of 140/90 mm Hg.

5.12 Neither preventive nor curative measures to deal with hypertension and other chronic diseases can be expected to have the dramatic impact on life expectancy that the control of communicable and infectious diseases has had for at least 80 percent of China's population. The life expectancy gains from control of communicable and infectious disease come principally from mortality reduction among infants and children; tragic as these early deaths may be, the emotional and economic cost, to family and society, of premature death of productive adults is far greater. Programs to deal with chronic disease may be expected, then, through reducing the burden of morbidity to result in welfare gains that are more than proportionate to their inevitably limited effect on life expectancy.

5.13 A number of approaches to prevention of chronic diseases were discussed in Chapter 2.5. While there are important steps that can be taken with little further analysis -- particularly control of salt intake and tobacco consumption -- a major theme of that discussion was that much work needs to be done to identify and field test appropriate preventive strategies. The task is inherently far more difficult than is that of prevention of communicable disease. An essential ingredient of a second health care revolution in China will be to recognize the difficulty and importance of that task and to commit substantiaL resources in a sustained way to its solution.

5.14 Another important ingredient to the second health care revolution will be development and widespread implementation of strategies for dealing with the large number of cases of chronic disease that will, inevitably, occur. These strategies must include capacity for treatment where treatment holds promise of results and can be afforded; they must pay careful attention to affordable plans for rehabilitation of individuals partially or wholly incapacitated by non-communicable disease; and they must be concerned with - 98 -

humane care for the terminally ill (an area in which there have been major and quite affordable advances in western medical practice).

5.15 A third ingredient of the second health care revolution will be that of designing an insurance and financing structure that encourages prevention and discourages current tendencies toward overuse of facilities. Such an insurance structure should both provide strong disincentives for introduction of the high-cost procedures that would necessarily be available to only a fraction of the population; and it should (through inclusion of substantial deductibles and co-insurance rates) create incentives for both patient and doctor to utilize health resources prudently.

5.16 Assembling the above three ingredients will, inevitably, prove to be a major challenge; but, to the extent that success is achieved, China will have become a world leader in the effective and humane handling of the burden of chronic disease without succumbing, as other countries have, to endlessly costly investments in medical technologies of limited efficacy.

5.3 Issues in Rural Health Care

5.17 Within the context of the general problems and challenges just discussed, a number of specific issues can be identified. The emphases of the mission whose findings are reported in these pages were on rural health and medical education, and the discussion of issues is limited to those two areas. Issues concerning rural health care are summarized first.

5.18 Financing health care in poor areas. While the state shoulders the burden of financing health care in urban areas, a policy of 'self-reliance' (i.e. local and individual finance) is implemented in rural areas. This has been satisfactory for well-off rural areas; in poor parts of rural China, however, the predictable result has been that even minimal services are often unavailable. An important policy question for the government is that of whether to postpone sustained concern for health care improvements in poor areas until after further gains have been made in cities and well-off rural areas. Although a policy of actively assisting poor areas would require central government finance, the impact of health investments in these areas would likely exceed those elsewhere with the result that efficiency considerations would reinforce equity ones for such a policy.

5.19 Prevention of chronic disease. Despite the policy importance attached to 'putting prevention first' relatively little effort has been put into developing a capacity for prevention and secondary prevention of cardiovascular disease, cancer, chronic respiratory disease, etc. Even in most rural areas, these disorders accounc for most deaths. A clear priority is to establish (or designate) institutions with responsibility for survei3lar.ce and prevention of chronic disease; in contrast to the situation concernling communicable disease, no such institutions now exist.

5.20 Monitoring health outcomes. Counties (and higher level entities) need to supplement their ongoing communicabLe disease surveillance programs with a capacity to assess chronic disease prevalence and mortality, and child _99 -

growth and development. The careful assessment and monitoring of the local health problems is a prerequisite for the success of the present decentralisation policy, which calls for plans developed at the county level to meet better the needs of the population in addition to implementing government's general guidelines. How best to gather and interpret data concerning chronic disease prevalence or child malnutrition is a question that needs further analysis, but the establishment of pilot surveillance points by the Center for Preventive Medicine is an important initial step.

5.21 Child development. The one-child family policy enforced by the government results in a set of new priorities. The main relevant task of health services is to ensure that this single child will be reasonably healthy. Thus, prevention of birth defects becomes a priority, with the possibility of prenatal diagnosis and abortion for genetically defective embryos. Likewise provision of better obstetrical services and pediatric care is important. Tight control of micronutrient deficiency disease combined with efforts to reduce stunting from 12 percent to less than, say, 3 percent of rural children should also be priority objectives of MCH center activity. This goal might be achieved by introducing growth monitoring as standard practice for every child, combined, where necessary, with directed nutrition education and supplemental feeding.

5.22 Major commune clinics. It is current government policy to encourage creaticn of major commune clinics with better equipment and improved technical skills of their medical personnel so that they can meet many demands that a group of communes might otherwise place on the county hospital. Creation of these clinics -- which might often be small (50 to 150 bed) hospitals with 3 to 8 doctors -- is perhaps the highest priority in improving access to curative care in rural areas, many of which are remote from county hospitals. Further, they would relieve the mounting pressures the referral system is placing on county hospitals. Staffing of these major clinics with appropriately qualified personnel will be a delicate task, particularly in light of the Cultural Revolution experience with forced rustication of doctors. It will thus be important to ensure adequate positive incentives for staff of these clinics including, importantly, satisfactory equipment and working conditions.

5.23 Drug utilization. There is evidence of polypharmacy and substantial overprescription as well as of a high rate of drug misuse. - For both financial and medical reasons, improved procedures for distribution and utilization of drugs are a high priority.

1/ Studies undertaken at the Faculty of Pharmacy, Hunan Medical College, found approximately 28 percent of prescriptions to be irrational in a hospital setting; possibly the problem was greater in less controlled environments. In a companion study, 43 percent of hospital admissions due to toxicosis were caused by drugs, of which 39 percent were traditional prescriptions. - 100-

5.24 Health Administration. Chinese authorities are aware of the need for strengthening administrative procedures in the health sector. WHO already agreed to provide support and to organise several workshops for managers. Some main issues are as follows:

(a) There exists a need for a more rational selection and utilization of sophisticated equipment, much of which may not be cost-effective.

(b) There exists a need for increasing the quality of basic equipment, such as X-ray machines and sterilization sets, in county hospitals and major commune clinics. Much of what is now available is inadequate in terms of efficacy or safety, and, too often, nothing at all is available.

(c) The introduction of professional quality control as both a management and training tool is another administrative priority. Often there are no analyses of the accuracy of diagnosis or of the proportion of diagnoses that have been confirmed or revised after hospital stay; no discussion among physicians of the accuracy of chemotherapy in relation to the proposed diagnosis; no information on surgical deaths and the proportion attributed to the disease itself or to the medical interventions (infection, anesthesia).

(d) There remains a need for establishing standard procedures in, for examples, inpatient wards, laboratory examination and organization of emergency rooms; this would include preparing a standard list of drugs and material, immediate availability of emergency equipment, and delineation of support staff roles. As a result, many tasks could be assigned to nurses rather than to doctors or assistant 1/cosoasitn 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.

(e) There exists clear need for development and administration of nutrition policies that can be implemented within the health sector.

5.25 Reform of health insurance. Both the compulsory and voluntary health insurance schemes exhibit markedly inefficient characteristics. The compulsory Government and Labor Insurance schemes offer full insurance coverage to primary beneficiaries. Since these beneficiaries face a zero net price for utilising health services, there is no constraint on their demand for services. Nor is there any constraint on service providers to restrict their supply of services to these beneficiaries. There are strong indications of excessive prescription of pharmaceuticals in the health system. The relaxation of demand constraints through insurance reimbursement, especially under the compuLsory schemes, encourages inefficient utilisation of

1/ 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. - 101 -

pharmaceuticals, particularly because coinsurance rates are typically the same for fees and drug charges. This coinsurance structure differs from that usually found in Western insurance systems, which impose higher coinsurance rates for drugs than for fees and thus discourage overconsumption of drugs. !/ Since there are no incentives to restrain the consumption of health services by these privileged beneficiaries, there is good reason to suppose that their utilisation rates exceed socially optimal levels. It is plausible not only that the marginal benefits of health service use by these beneficiaries are well below their marginal costs, but that they may even be zero. Certainly the very high relative expenditures per beneficiary under these schemes are consistent with this hypothesis. Beyond these problems, there is the increasingly important problem, noted in Chapter 5.1, of the breakdown of the rural cooperative health insurance system.

5.26 Considerations of equity and efficiency thus suggest the following areas for reform of the insurance system.

(a) For efficiency reasons it would be desirable to introduce coinsurance rates higher than zero, or at least a significant deductible for primary beneficiaries of the compulsory Government and Labor Insurance schemes. Positive coinsurance rates for at least non- catastrophic or elective procedures, and zero coinsurance rates for catastrophic or non-elective treatment would discourage inefficient utilisation of health services. By shifting some of the financing burden onto the beneficiaries, this would confer the additional advantage of releasing scarce fiscal resources for more productive uses.

(b) Efficiency considerations also argue in favor of policies to facilitate increasing the membership base of the voluntary insurance schemes in order to exploit scale economies in the pooling of health risks. Reorganisation of county collective industry, commune industry and cooperative insurance schemes at commune, county, prefecture or even province level could be expected to lower average insurance prepayments and net prices to these beneficiaries.

(c) Finally, efficiency arguments commend the introduction of higher coinsurance rates for drugs than for service fees and the adoption of standardised reimbursable unit costs per diagnosis in order to control more effectively the plausibly inefficient behavior of health service providers.

5.27 Equity considerations reinforce the above recommendations. Regressive state subsidies for the compulsory insurance schemes, which benefit the higher-income urban population, could be redirected in part to poorer rural residents by requiring members of the Government and Labor Insurance

!/ Higher coinsurance rates imply that the patient pays a higher percentage of costs. - 102 -

schemes either to pay higher coinsurance rates than efficiency reasons would suggest or, alternatively, by requiring these beneficiaries to pay a substantial prepayment as a condition for enrollment in the schemes. One natural way to provide equalisation would be to finance rural health insurance schemes by a fixed percentage tax on agricultural (or agricultural plus sideline) production. Poorer brigades would, then, automatically have less to pay.

5.4 Issues in Medical Education

5.28 China's medical colleges are now emerging from the after effects of the Cultural Revolution and initiating a period of reconstruction and redefinition of purpose. The policies that guide them in the next five or ten years are thus of major importance, and clear leadership from the Ministry of Public Health will be essential to ensuring that the colleges contribute their full potential to meeting the challenges facing health care in China. Important issues divide naturally into those concerning teaching methods and those concerning curriculum content.

Teaching Methods

5.29 Overemphasis on complex equipment. Most medical college laboratory apparatus is outdated and cumbersome. More basic equipment is certainly required, but students will gain more from an understanding of scientific method, biological variation, observer error and principles of biological behavior than from working with expensive and complex equipment. Thus while equipment upgrading is important both to improving teaching quality and to research, there is some evidence that a number of individual faculty members may overemphasize the importance of complexity versus usability in equipment selection.

5.30 Didactic teaching. Teaching is almost entirely didactic with limited scope for individual learning, elective courses, problem-oriented learning and other techniques which stimulate active student participation in the educational process. This problem, which is shared with most institutions of higher education in China, is one that MOPH is actively addressing.

5.31 Shortage of learning aids. Learning aids for students are in short supply, but even the limited assortment of books and journals in the libraries does not seem to be used for reference by undergraduates. Library management is, in general, poor and facilities are open to students for much shorter periods than in academic institutions outside China. Anatomical and pathological specimens are of good quality but are not correlated with case histories and radiographs. Some schools are well supplied with audio-visual equipment, but it is not always used effectively by teachers. The training of teaching staff to make the best possible use of resources is as important as the provision of new equipment.

5.32 Examinations. A pilot national, multiple choice, computer-marked examination was introduced in a small number of medical colleges in 1982, with - 103 -

the intention of extending it subsequently to the entire system. There will be separate examinations in western medicine, traditional medicine, public health, pediatrics, stomatology and pharmacy. In view of the profound influence of degree examinations on the curriculum, teaching and the attitude of students, it is essential that such examinations reinforce instead of undermine the educational objectives of the colleges and the MOPH. In particular, the MOPH objective of orienting medical education towards the understanding of general principles and the development of problem-solving capacities has important implications for the design of examinations; examinations stressing factual knowledge, for example, could defeat these objectives. It should be emphasized that the problem is not one of the use of multiple-choice format or computer scoring; both these techniques can be used with examinations that test grasp of principles and problem-solving skills.

5.33 Public health and epidemic prevention. The training in medical colleges and secondary medical schools, and the service functions at all levels for public health and preventive medicine are separate from those for clinical medicine. The separate but parallel systems offered certain advantages when the chief task of preventive medicine and public health was control of infectious and parasitic diseases. While some infectious diseases persist as national problems (for example, dysentery, hepatitis and tuberculosis), the burden of illness has shifted markedly to non-infectious diseases, which require different primary and secondary preventive methods, often closely linked to clinical care. What are the resulting implications for the training of senior and assistant doctors of western medicine and public health? Should public health be a postgraduate clinical specialty of medicine, as is proposed for pediatrics?

5.34 Proliferation of weak graduate programs. Most medical colleges are trying to conduct too many post-graduate courses unrelated to projected manpower demands, and which are on too small a scale to permit the concentration of effort and resources necessary for programs of high quality. The proliferation of graduate programs involving only a few students in a subject at a given institution is highly inefficient.

Curriculum Content

5.35 Strengthening preventive strategies for non-communicable diseases. Improvements in life expectancy, control of many common infectious diseases, the one-child family policy and other changes require new approaches to the teaching of preventive medicine and health promotion in medicine, public health and pediatrics. These specialties are at an early stage of adapting their practices to the prevention of the common, serious non-communicable diseases such as hypertension, chronic obstructive pulmonary disease, cancer and heart disease; to the protection and optimal development of the child during both the antenatal and postnatal periods; and to the prevention of illness and rehabilitation of the elderly. The current emphasis on strengthening laboratory sciences in medical colleges and affiliated hospitals may lead to the neglect of community-based learning experiences, both in medicine and public health, as an important part of training in these fields. It may also lead to neglect of study of dietary and behavioral causes - 104 -

of chronic disease and the efficacy of interventions to change those behaviors.

5.36 Gaps in knowledge base. Certain subjects, for example, molecular genetics, immunology and virology, the social and behavioral sciences, nutrition, child development, gerontology and rehabilitation have received little attention in China. Epidemiology is narrowly linked to infectious disease, although they have recently been separated in some centers. Pharmacology needs strengthening considering the importance of western and traditional Chinese drugs in medical care. The teaching of public health and preventive medicine is dominated by environmental monitoring and infectious diseases, and fails to take sufficient account of the diminishing importance of infectious disease. In contrast, advanced epidemiological research in cardiovascular diseases and cancer is being conducted in the national research institutes, but the results remain to be incorporated into the teaching program.

5.37 Scientific evaluation capability and health systems research. The evaluation of new scientific methods and the effectiveness of new and traditional techniques of diagnosis and treatment is everywhere assuming much greater importance because of the high cost of modern medical technology. Key medical colleges should develop evaluation capability, since they are commonly pioneers in introducing new medical techniques. The development of such capability within colleges of traditional medicine is of special importance in view of the different theoretical basis and professional sensitivity to external evaluation. It is important that these epidemiological principles be extended not only to non-infectious diseases, but also to the comparative evaluation of disease control measures, and the quality of care and resource allocation in the health system, i.e. health systems research. This is as important in clinical medicine, both western and traditional, as it is in public health.

5.38 Management. The MOPH has recognized the importance of strengthening managerial and administrative capability, and three national training centers, established by 1981, now offer programs in management and training. As previously indicated, the MOPH ultimately plans to have seven of these centers. In view of the task of upgrading more than 300,000 administrators, it is of high priority to provide a greater number of well qualified teachers of health management and to expand training to prepare managers at the institutional level for routine administration, but also to use simple management information systems to assess health needs, to plan resource allocation, to monitor progress and to evaluate results. The training should encourage a more rigorous and analytic approach to the identification of problems and the design of programs. These skills are important at all levels of the health system, from the MOPH and provincial bureaus down to the county and commune levels.

5.39 Management and economic issues at a higher level are also of major importance; questions remain concerning whether health expenditures should rise as a percentage of GNP, whether reform of insurance is due, whether major investments should be made in prevention and secondary prevention of chronic - 105 -

disease. It will be important that some training (and background applied research) be offered to assist high-level MOPH staff (or Planning Commission and State Council staff) in addressing these issues.

5.40 Impact on health care. The need to restore teaching and research capability within the medical colleges may divert attention from continuing medical education and health system impact. Since continuingeducation is the most immediatemeans by which the medical college can influence the quality of health care, it is one of the most important elements in the justificationof investmentin strengtheningthe core medical colleges.

5.41 The core medical colleges see in expensive and complex equipment an important means of improving medical education. But the acquisition of sophisticated equipment will have little positive benefit, and possibly negative effects, unless it is selected for carefully thought-out programs that support the major objectives of the MOPH. The prospect of significant investment in the next 5 years should challenge the core medical colleges to define their objectives, to prepare programs to meet these objectives, and to decide how to execute these programs, taking into account the resources available. The clear setting of priorities and careful planning are necessary to ensure that new investmentshave maximum impact throughout the health care system and, ultimately,on the health of the populationas a whole.

PART II

STATISTICAL ANNEXES

Page No.

List of Annex Tables...... 107 - 111

A. DEMOGRAPHIC AND ECONOMIC INDICATORS ...... 112 118

B. HEALTH STATUS INDICATORS...... 119 - 141

C. HEALTH FACILITY AND MANPOWER AVAILABILITY INDICATORS. . . . 142 - 161

D. FOOD AVAILABILITY AND NUTRITIONAL STATUS INDICATORS . . . . 162 - 178

E. ECONOMIC AND FINANCIAL INDICATORS ...... 179 - 187

- 107 - LIST OF ANNEX TABLES

ANNEX A: DEMOGRAPHICAND ECONOMIC INDICATORS

A-1 Population Totals, Birth, Death and Increase Rates, 1949-1982: Official and Semi-OfficialData

A-2 Population Totals, Vital Rates, Total FertilityRates, Infant Mortality Rates and Life Expectancy, 1950-1981:World Bank Model

A-3 Age Distributionof the Population,Censuses of 1953, 1964 and 1982

A-4 ProvincialEconomic, Social and Demographic Indicators,Recent Years

A-5 ProvincialDemographic Data: Population Totals and Rates of Natural Increase,Various Years, 1964-1982

A-6 Birth and Death Rates for Urban and Rural Areas, 1954-1979: Official and Semi-OfficialData

A-7 Population Projections: Medically Vulnerable Population (years 0-1, 1-5, 50-64, 65+)

ANNEX B: HEALTH STATUS INDICATORS

Mortality

B-1 Principal Causes of Death, Rural and Urban Areas, 1980

B-2 Principal Causes of Death in Rural and Urban Areas, Selected Years

B-3 Major Causes of Death, 1973-1975

B-4 Age-SpecificMortality Rates in Urban and Rural Areas, by Age Group and by Sex, 1957 and 1975 (%)

B-5 Mortality Data by Disease Category,Number of Deaths, Rate and Percentage, from 28 Rural SurveillancePoints, North and South of the Chang Jiang, 1981

B-6 Mortality Data by Disease Category, Number, Rank Order and Mortality Rate, ShejinsanDistrict, Beijing, 1956-1959and 1974-1978

B-7 Major Causes of Death, Beijing (East City District), 1979 - 108 -

Morbidity

B-8 Mortality Rates and Relative Frequency of Selected Malignant Neoplasms, 1973-1975

B-9 Reported Cases, Deaths and Incidence from CommunicableDiseases, Nationwide,1974-1981.

B-10 Progress on Selected CommunicableDiseases

B-11 Leading causes of morbidity in Patients Discharged from Selected City Hospitals

B-12 Incidence and death rate of seven communicablediseases in Eastern District, Beijing, 1958-1979

Provincial Data

B-13 Life Expectancyby Province, 1973-1975

B-14 HypertensionMorbidity: Confirmed, Marginal, and Total Cases; Number of Cases and Percent; by Province, 1979-1980

B-15 Cancer Mortality by Province, 1973-75

B-16 TuberculosisPrevalence by Province, 1979

B-17 Incidence and Case Fatality Rates of Water-RelatedDiseases, by Province, 1981

ANNEX C: HEALTH FACILITY AND MANPOWER AVAILABILITYINDICATORS

Data for Recent Years

C-1 Number of Hospitals, Hospital Beds and Staff, Nationwide, 1981

C-2 Number and Type of Health Personnel, 1980 and 1981

C-3 Graduates of SecondaryMedical Schools, by Specialty, 1979-1981

C-4 Distributionof Health Resources by Ownership, 1981 - 109 -

C-5 Medical Colleges, 1977-1981: Institutions,Students, Enrollmentsand Graduates

C-6 Medical Colleges: Projectionsof Manpower Supply

C-7 SecondaryMedical Schools: Projections of Manpower Supply, 1982-1990

Historical Figures

C-8 Selected Types of Health Facilitiesand Manpower, Various Years, 1949-1981

C-9 Number of Hospital Beds by Type of Hospital - 1979, 1980 and 1981

C-10 Number of Hospital Beds and Health Personnel, by Type and Level, 1949-1981

C-11 Salaried Technical Health Staff, Various Years, 1952-1981

C-12 Salaried Health Staff, All Levels per Population,Various Years - 1950, 1952, 1965 and 1980

C-13 Health Facilitiesand Personnel Under Other Ministries,Various Years

C-14 Health Services in Production Brigades, 1970, 1975, 1980 and 1981

C-15 Number of Brigades having Cooperative Medical Services (CMS) and Part-Time Health Personnel, Selected Years, 1970-1981

C-16 Distribution of Health Personnel by Technical Category, Various Years, 1949-1981

C-17 Numbers of Salaried Health Workers by Level, Urban and Rural, Various Years, 1952-1981

Provincial Data

C-18 Hospital Beds by Province, Including Total Number of Beds, ComprehensiveHospital Beds and Commune Health Center Beds, 1979, 1980 and 1981

C-19 Hospital Beds by Province, All Categories of Hospital, 1980

C-20 Distributionof Medical Personnel,by Province, 1981 - 110 -

ANNEX D: FOOD AVAILABILITYAND NUTRITIONAL STATUS INDICATORS

Food and Nutrient Availabilityand Prices

D-1 Per Capita Availabilityof Grains and Other Crops, 1950-1982

D-2 Per Capita Availabilityof Meats and Other Animal Products, 1950-1982

D-3 Daily Per Capita Nutrient Availability, 1950-1982

D-4 Food Availabilityby Province, 1979

D-5 Provincial Per Capita Nutrient Availability,1979-1980, And Rural Food Expenditures,1981

D-6 Food Prices, Selected Locales, 1981

D-7 Food Rations, 1982

Estimates of Nutrient Requirements

D-8 Per Capita Food Energy Requirements,1953

D-9 Per Capita Food Energy Requirements, 1979

D-10 Safe Levels of Per Capita Protein Intake, 1953

D-11 Safe Levels of Per Capita Protein Intake, 1979

AnthropometricData

D-12 Nine City Survey of AnthropometricStatus, Urban and Suburban Areas, 1975

D-13 Malnutrition:Percentage of Children Stunted, Various Ages, 1975

D-14 Heights and Weights of Young Adults in Urban Areas of Sixteen Provinces, 1979

D-15 Heights and Weights of 7-Year old Children in Urban and Rural Areas of Sixteen Provinces, 1979 (PhysicalMeasures)

D-16 Heights-for-Ageof 7 Year Old Boys, Rural and Urban Areas of 16 Provinces, 1979

D-17 Major MicronutrientDeficiency Diseases - ill -

ANNEX E: ECONOMIC AND FINANCIAL INDICATORS

General Data

E-1 State Budget Expenditureon Health, 1957-1981

E-2 Allocation of Recurrent State Budget Expenditureon Health, 1981

E-3 Health Sector Budgetary Ratios, 1957-1980

E-4 Per Capita State Expenditure on Health, 1957-1981

E-5 Cost and Revenues of Medical College AffiliatedHospitals

E-6 Expenditureson Medical Colleges by the Ministry of Public Health, 1980-1982

Provincial Data

E-7 Provincial Distributionof State Health Expenditures,1979-1981

E-8 ProvincialDistribution of State Health Expendituresper Capita, 1979-1981

E-9 Salaries of County-LevelHealth Personnel, Shandong Province, 1982 - 112 -

Table A-1: POPULATION TOTALS, BIRTH, DEATH AND INCREASE RATES, 1949-82: OFFICIAL DATA

(1) (2) (3) (4) (5) (6) Rate of Year-end Crude Crude natural Census Year totals birth death increase totals ('000) rates rates (3)-(4) ('000)

1949 541,670 36.00 20.00 16.00 1950 551,960 37.00 18.00 19.00 1951 563,000 37.80 17.80 20.00 1952 574,820 37.00 17.00 20.00 1953 587,960 37.00 14.00 23.00 580,603 1954 602,660 37.97 13.18 24.79 1955 614,650 32.60 12.28 20.32 1956 628,280 31.90 11.40 20.50 1957 646,530 34.03 10.80 23.23 1958 659,940 29.22 11.98 17.24 1959 672,070 24.78 14.59 10.19 1960 662,070 20.86 25.43 -4.57 1961 658,590 18.02 14.24 3.78 1962 672,950 37.01 10.02 26.99 1963 691,720 43.37 10.04 33.33 1964 704,990 39.14 11.50 27.64 694,582 1965 725,380 37.88 9.50 28.38 1966 745,420 35.05 8.83 26.22 1967 763,680 33.96 8.43 25.53 1968 785,340 35.59 8.21 27.38 1969 806,710 34.11 8.03 26.08 1970 829,920 33.43 7.60 25.83 1971 852,290 30.65 7.32 23.33 1972 871,770 29.77 7.61 22.16 1973 892,110 27.93 7.04 20.89 1974 908,590 24.82 7.34 17.48 1975 924,200 23.01 7.32 15.69 1976 937,170 19.91 7.25 12.66 1977 949,740 18.93 6.87 12.06 1978 962,259 18.25 6.25 12.00 1979 975,420 17.82 6.21 11.61 1980 987,050 n.a. n.a. n.a. 1981 1,000,220 20.91 6.36 14.55 1982 1,015,410 21.09 6.60 14.69 1,008,175 a/

a/ This figure includes military personnel.

Source: Statistical Year-Book of China, 1983. State Statistical Bureau, Beijing. - 113 - TABLE A-2: POPULATION TOTALS, VITAL RATES, TOTAL FERTILITY RATES, INFANT MORTALITY RATES AND LIFE EXPECTANCY, 1950-1982: WORLD BANK MODEL

Mid-Year Population (in millions) Rate of Total Infant Expectation Interim Final Birth Death Natural Fertility Mortality of Life Year Model a/ Estimate b/ Rate Rate Increase Rate Rate at Birth

1950 576.3 602.8 42.0 33.5 1.05 6.1 252 32 1951 586.4 609.3 43.5 32.4 1.11 6.3 246 33 1952 598.2 616.8 45.0 31.5 1.35 6.5 240 34 1953 611.1 625.6 45.5 30.7 1.48 6.6 233 34 1954 624.7 635.5 46.5 29.9 1.66 6.7 225 35

1955 638.1 646.4 44.0 26.6 1.74 6.4 216 36 1956 651.0 658.0 43.0 24.7 1.83 6.2 207 37 1957 665.0 671.3 45.0 23.4 2.16 6.5 200 38 1958 677.8 683.9 41.5 25.8 1.57 6.0 214 36 1959 684.8 690.6 35.0 31.4 0.36 5.1 252 32

1960 683.4 687.8 24.5 36.0 -1.15 3.6 330 25 1961 680.2 684.9 26.5 23.5 0.30 4.2 246 33 1962 685.7 693.4 41.0 19.5 2.15 6.5 193 39 1963 700.2 710.8 47.7 19.6 1.81 7.5 175 42 1964 717.7 729.3 43.5 20.2 2.33 6.6 180 41

1965 735.7 746.8 41.5 17.5 2.40 6.2 165 44 1966 755.0 764.9 39.4 15.5 2.39 5.8 155 46 1967 774.3 783.4 37.5 13.5 2.40 5.5 139 48 1968 795.4 803.7 39.3 12.2 2.71 5.7 132 50 1969 817.7 825.1 36.9 11.4 2.54 5.2 122 52

1970 838.9 845.7 34.0 10.1 2.39 4.8 109 55 1971 858.6 865.1 31.0 9.6 2.14 4.4 104 55 1972 877.1 883.5 30.1 9.4 2.07 4.3 100 56 1973 894.7 901.1 28.3 9.4 1.89 4.0 91 58 1974 910.4 916.9 25.1 9.4 1.57 3.6 87 59

1975 924.0 930.5 23.2 9.4 1.38 3.3 84 60 1976 936.0 942.0 20.1 9.3 1.08 2.8 75 62 1977 947.0 952.0 19.2 8.9 1.03 2.6 64 64 1978 957.9 962.0 18.7 8.0 1.07 2.5 59 66 1979 968.9 972.5 18.7 7.8 1.09 2.5 57 66

1980 979.6 983.1 18.5 7.8 1.07 2.5 53 67 1981 991.3 994.8 20.9 7.8 1.31 2.8 48 66 1982 1008.2 1008.2 45 69

a/ The mid-year populations from the 'interim model' are those used for calculating per capita levels of various variables in World Development Report 1983 and in Annex Tables B-9, C-12, D-1, D-2, D-3, D-4, D-5, D-9, D-11, E-4 in this report. The interim model has been revised to the values indicated under 'final estimate'. b/ The 'final estimates' of mid-year population are based on same demographic model that yielded estimates reported in this table for other variables.

Source: "Demographic Trends in China, 1950-81," by Kenneth Hill, Supplementary Paper Number 1 to this Report. - 114 -

Table A-3: AGE DISTRIBUTION OF THE POPULATION, CENSUSES OF 1953, 1964 AND 1982 (x)

1982 1953 1964 (3 provinces) b/

Age Group Males Females Males Females Males Females

under 1 1.7 1.6 2.1 2.0 1.1 1.0 1 - 2 3.6 3.3 3.4 3.2 1.8 1.7 3 - 6 5.4 5.0 4.6 4.2 4.0 3.8 7 - 15 9.3 8.1 11.9 11.0 11.6 10.9 16 - 20 4.7 4.4 4.4 4.1 5.9 5.8 21 - 25 4.1 3.9 3.7 3.5 4.0 3.8 26 - 35 7.1 6.8 7.3 6.5 8.2 7.6 36 - 45 6.1 5.6 5.6 5.2 5.3 4.7 46 - 55 4.7 4.4 4.0 4.0 4.5 4.0 56 - 60 1.8 1.8 1.5 1.6 1.7 1.6 61 + 3.0 3.6 2.4 3.1 3.2 3.8 unknown - - 0.4 0.1 - -

51.5 48.5 51.3 48.7 51.3 48.7

Total (in thousands) 291,970 275,480 356,520 338,060 51,520a/ 48,850a/

a! The 'total' population for 1982 is the number of people in the 10% sample survey.

Sources: Figures for 1953 and 1964 are from the Statistical Yearbook of China, 1983, State Statistical Bureau, Beijing. Figures for 1982 are from the results of the 10% sample of the 1982 Census released by the State Statistical Bureau late in 1983. - 115 -

Table A-4: PROVINCIALECONOMIC, SOCIAL ASD DEMOGRAPHICINDICATORS, iRECENTYEARS

7uiconoic and Stocial Date De,gr-phic LSt.

V.1-~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Value of total agricultural induntrill aoriculturol & Par capita output output Population indoatria. ootput inco_ Illiter-Cy X urb-n pop dlotlocd/ Ctude birth Crude death den ity 2 Se Rtiot Type of (Io yuan) (io Y.ri) Rate bl a. X of natiunal overage a192 rate r.te (proplef/kn) X ae proviocon Politicul t 181 1981 */ 1982 1979 1979 1981 Cenus 1980 1991 19O 1981 1981 1981

NATIONALAVERAGE 757 270.7 23.5 100.0 100.0 13.2 13.9 20.6 15.35 20.91 6.16 6.36 104 51.3

North Iebgon

deijing l.lcipality 2,629 420.7 15.1 186.9 512.8 53.4 55.4 64.7 15.57 17.55 6.30 5.78 537 50.7 Tiacilo eunloipolt 2,980 3699 17.3 283.7 697.9 50.7 51.7 68.7 13.76 18.60 6.05 6.10 675 50.9 Hbeli province 3 212.8 30.1 108.9169 83.7 8.9 9.2 13.7 15.66 23.99 6.46 6.05 281 51.2 Shovei province 690 206.4 25.2 101.5 91.3 13.0 13.9 21.0 i5.68 20.31 6.69 6.54 161 52.3 N,K Moogol anorpofo region 540 261.4 35.0 97.1 62.9 22.1 23.4 28.9 16.48 23.11 4.95 5.77 16 52.3

Noetheaao8egion

LiU.onig provioc- 1,524 343.3 17.2 131.4 256.6 31.4 33.5 42.4 14.09 18.53 5.38 5.32 243 51.0 Jilit prorVinv 860 328.5 23.4 115.2 120.0 29.1 29.6 39.6 15.81 17.67 5.79 5.32 119 51.2 Heiloogjiueg province 1,058 289.1 33.0 133.2 140.9 30.3 31.7 40.5 13.56 19.79 4.86 4.95 69 51.3

East R7gion

Shoaghai nnitipolily 5,55 4671.0 15.7 234.6 1.106.4 57.0 57.7 58.9 11.79 16.14 6.48 6.44 1,880 49.8 JIcuges provi-c_ 1 128 277.0 37.0 141.5 138.4 11.7 12.3 15.9 12.15 18.47 5.90 6.10 586 50.7 Zhbeicug provi-ce 860 320.1 33.2 123.7 86.3 9.6 10.8 25.7 12.98 17.93 5.91 6.27 380 51.8 Anhni pro rice 499 241.1 53.1 82.3 50.5 9.0 9.6 14.3 15.16 18.73 4.52 3.20 356 51.8 Fujlao province 552 252.1 40.6 89.7 58.5 11.7 12.2 21.2 15.19 22.07 5.92 5.97 213 51.6 Jiaenlg province 511 247.5 34.6 99.6 51.1 11.0 12.0 19.1 15.69 20.02 6.38 6.54 193 515 Shundong provi_ce 739 225.3 37.6 101.0 87.3 7.2 7.7 19.1 13.90 18.96 6.40 5.26 493 50.7

Central South Region

Rerun prurlnc- 501 210.2 39.8 83.4 50.0 7.3 7.9 14.1 15.84 23.64 6.1 6.01 4543 50.9 Nobel provioco 764 239.1 33.1 120.3 85.9 12.7 13.6 17.3 15.58 20.17 7.00 7.33 253 51.3 Hvn. province 577 258.2 23.6 133.6 63.2 9.2 9.7 14.4 15.81 71.11 6.98 7.03 253 51.9 Coongdong pro iloe 634 324.1 2461 86.7 78.6 12.3 12.7 18,7 20.34 24.99 5.36 5.54 278 51.2 .Can.noguvvo region- -oa4 631 225.8 27.0 78.8 57.3 8.1 8.2 11.8 22.30 27.25 5.80 5.61 157 51 5

South-et RE loc

Sichua. province 473 233.9 34.3 79.7 53.6 9.0 9.3 14.3 11.20 17.96 6.75 7.02 175 51.4 Oniahoo provinco 303 211.0 53.5 65.1 35.6 9.3 9.3 19.7 59.97 27.89 6.83 8.68 160 50.9 Y.eouo prononce 607 193.8 53.7 69.7 40.3 8.1 9.3 12.7 17.76 20.36 7.36 8.60 82 50.3 Tifbt autonoaoua region 398 569.5 78.3 127.5 '/ 9.6 8.3 9.5 23.04 31.05 8.26 9.92 1.5 48.9

Niortheet Region

Shasei province 544 205.9 36.6 86.6 79.6 11.5 12.6 19.0 11.58 23.35 6.84 7.10 139 51.9 G... pronin-a 523 195.8 54.0 67.9 92.3 11.0 11.4 15.3 16.03 20.12 5.15 5.72 43 51.7 Qieghal pro-ince 526 249.8 58.0 97.0 78.3 16.3 17.1 20.5 21.16 26.65 5.61 7.48 5 51.6 aliguia autopoou- regior 528 214.3 53.4 81.6 80.0 14.1 15.1 22. 5 2.95 39.65 4.22 6.08 58 51.7 Xfnjieng uotoo a region 580 266.7 37.6 113.7 54.1 21.3 22. 29 8 51.2

*/ Incom par capita i donned aa the population - aighted avrga of urban and rur-l i-.o per capita in a-ch proninca. Urban itroa- per ctoplctin.acaaordua the edtitaed ab.erage urban e rate in each pro,inca wightad by 1981 national avaraga abehu participation rataa. Noral incoee per capita 1S aeti.otnd by inflating provincial collectina diatributed Onooe per capita and rural hboahold eopeaditrre per capita repe-ti-ely by the .elvant anitnal 1981 ra_ire of coral net 1ooe- to theee varIable..

iTheillite.tcy rate ia va1clatod by dinidieg the euber of indi.idale nvar 12 y.ara of age nh. ore 1lliterote or seni-lireruto, aa aeveetaicod frot the 1982 -enu., by the total population of tn. pronioce.

0/ Thea. dote not -nailabla, bot are kRowe to be eary Su-.

STe. data for 1979 and 1981 are taken from Table 1.4 nf ChM-t Recent tcenomio Teenda nd Policy Denlope_nta. World 7Jok Report No. 4072-CRA, Norch 1983. The dafieitiue of 'urba' u.ed in tba 1982 cae -aa diffe.eat and -r incluelee th rte one need for the 1979 fig.ree.

Nourl-o: The data fnr the 1979 Relatine Agriceltral and Reltina Induetri-l Optput aea fro- China Socialiat -cIno.i Dtenelop-ent, Wold BNok 7port No. 6072-CA, June 1981, p. 54.

Th, data for rho 1981 Tntal Output Value from thb Stata Statieticl Eor.- ora quoted in DiRet-tgeetRilotoe in Chi..,' BNilini.g R-ia, AuguSr 16, 1982. p. 24.

The data for tho 1979 Pacoontage Eeban Population ner pro.iddd to the 1979 World Nohn ec-nomiv siaeo by the State Statietiol Ruroao

The data for the 1980 Crude irth and Death ktne ee from The Noijig Ceetae for Cnu.ictiun and Education for Family Planoing, Tnpica io Pupol.tion Theory (Renko Li Lt. Xoan Jiang), p. 184-la5. The 1981 Crude Nieth and anth Note arel ras Mele Fiurei of thb Third Chine-e Pupnlation Cenmus, Population Cen-u. Ofice of the Stet- Council, Noijting, Otuber 1982.

Site data for thb 1981 Perveetaga Lrban Popultion. Population Ren.ity ad S.a Xtioe are fros Chin - 1981 Chiae.e St.tnetical Yeerbaok, Stato Statletit1cal Buea, Niling, p. 90. - 116 -

Table A-5: PROVINCIAL DEMOGRAPHICDATA: POPULATION TOTALS AND RATES OF NATIURALINCREASE, VARIOLIS YEARS, 1964-1982 (in millions)

Mid-year Census Totals (midyear) Year-end Estimates RNI f/ RNI f/ --- end-1979 to Provinces 1953 a/ 1964 1982 1979 1982 1979 1980 1981 e/ 1964-1982 mid-1982

NATIONAL AVERAGE 583.00 691.22 h/ 1,003.94 c/ 970.71 1011.17 c/ 964.19 977.28 990.54 2.10 1.35

North Region

Beijing (4.53) 7.57 9.23 8.71 9.19 g/ 8.61 8.81 9.02 1.11 2.32 Tianjin (4.53) 6.28 7.76 7.29 7.78 7.20 7.38 7.57 1.18 2.50 Rebel (33.74) 39.41 53.01 51.05 53.56 50.67 51.44 57.22 1.66 1.51 Shanxi 14.31 1R.01 25.29 24.47 25.46 24.31 24.A3 24.96 1.9( 1.32 Nei Mongol (3.53) 6.24 19.27 aj 18.51 di 19.37 18.36 18.66 18.96 n.a. 1.61

Northeast Region

Liaoning (22.27) 29.50 35.72 34.43 d/ 35.92 34.18 34.48 35.20 1.07 1.47 1i n (12.61) 17.89 22.96 21.85 ! 22.58 21.71 21.99 22.27 1.30 1.28 Hei long iiang (12.68) 21.39 32.67 31.69 T7 33.81 31.50 31.89 32.27 2.38 1.22

East Region

Shanghai (9.42) 10.82 11.86 11.32 11.81 9! 11.21 11.43 11.64 0.51 1.86 Jiangsu (37.71) 44.50 60.52 58.93 60.89 58.62 59.24 59.88 1.72 1.06 Zhejiang 22.87 28.32 39.88 37.92 39.24 37.73 38.11 38.49 1.78 1.00 Anhui 30.66 31.24 49.67 48.33 50.16 47.71 48.35 49.01 2.61 1.34 Fujian 13.14 16.76 25.87 24.80 26.04 24.58 25.02 25.47 2.49 1.7R Jiangxi 16.77 21.07 33.18 32.29 33.48 32.11 32.47 32.82 2.56 1.09 Shandong (50.14) 55.52 74.42 72.31 74.94 71.90 72.73 73.57 1.64 1.15

Central South Region

Henan (43.91) 50.32 74.42 71.89 75.20 71.39 72.39 73.40 2.20 1.38 Hubei 27.79 33.71 47.80 46.32 48.01 46.03 46.61 47.20 1.96 1.26 Hunan 33.23 37.18 54.01 52.23 54.52 51.88 52.58 53.29 2.10 1.34 Guangdong 34.77 42.80 59.30 56.81 59.87 56.32 57.30 58.29 1.83 1.72 Guangxi 19.56 20.84 36.42 34.70 36.84 34.37 35.04 35.72 3.15 1.94

Southwest Region

Sichuan 65.69 67.96 99.71 97.74 100.22 97.35 98.13 98.92 2.15 0.80 Guizhou 15.04 17.14 28.55 27.31 28.75 27.07 27.55 28.05 2.88 1.78 Yunnan 17.47 20.51 32.55 31.15 32.83 31.12 31.59 32.06 2.70 1.50 Tibet 1.27 1.25 1.89 1.83 1.R9 1.82 1.84 1.87 2.32 1.29

Northwest Region

Shaanxi 15.88 20.77 28.90 28.07 29.04 27.91 28.23 28.57 1.85 1.17 Gansu (11.29) 12.65 19.57 18.94 dl 19.75 18.82 19.06 19.32 2.45 1.31 Oinghai 1.68 2.14 3.90 3.72 3.93 3.69 3.76 3.83 3.39 1.89 Ning.ia (1.64) 2.16 3.90 3.64 3.93 3.59 3.69 3.79 3.34 2.76 Xinjiang 4.87 7.27 13.08 12.56 d/ 13.16 12.46 12.66 12.87 3.31 1.62

a/ Absolute population totals for 1953-78 are given according to the provincial boundaries that existed from July 1969 to Julv 1979. Figures for 1953 that are given in parentheses were adjusted by Foreign Demographic Analysis Division, 11.S.Census Department, to take account of boundary changes and to achieve approximate comparability for the figures in the 3 central municipalities and their surrounding provinces. In July 1979, the areas added to Nei Monggol were returned to the 5 adjacent provinces from which they had been taken. Aird, John, "Recent Demographic Data from China: Problems and Prospects," quoted in China Tlnder the Four Modernizations, Selected Papers submitted to the Joint Economic Committee, T1.S. Congress, August 13, 1982.

b/ The Government recently released a national census total of 694,581,759 for 1964. The census total presumably includes the military, whereas the China Atlas total did not.

c/ This total does not include the military. The year-end 1982 estimate including the military is 1015.41.

d/ These figures are not comparable with previous years due to boundary changes. e/ The mid-1981 totals were estimated on the basis of the rates of natural increase between end-1979 and mid-1982.

f/ RNI is the rate of natural increase of population in % increase per annum.

I/ The statistical Bureau gives no reason for this year-end estimate which is lower than the mid-year census figure.

Sources: 1953, 1964 and 1979. China Atlas, reported in John Aird, "Recent Provincial Population Figures, The China Ouarterly, March 1978, no. 73, p. 3.

1982: Statistical yearbook of China, 1983, State Statistical Bureau. - 117 -

Table A-6: BIRTH AND DEATH RATES FOR URBAN AND RURAL AREAS, 1954-79; OFFICIAL DATA

Urban Rural Total

CBR a/ CDR b/ CBR a/ CDR b/ CBR a/ CDR b/

1954 42.45 8.07 37.51 13.71 37.97 13.18

1957 44.48 8.47 32.81 11.07 34.03 10.80

1962 35.46 8.28 37.27 10.32 37.01 10.02 1963 44.50 7.13 43.19 10.49 43.37 10.04 1964 32.17 7.27 40.27 12.17 39.14 11.50 1965 26.59 5.69 39.53 10.06 37.88 9.50 1966 20.85 5.59 36.71 9.47 35.05 8.83

1971 21.30 5.35 31.86 7.57 30.65 7.32 1972 19.30 5.29 31.19 7.93 29.77 7.61 1973 17.35 4.96 29.36 7.33 27.93 7.04 1974 14.50 5.24 26.23 7.63 24.82 7.34 1975 14.71 5.39 24.17 7.59 23.01 7.32 1976 13.12 6.60 20.85 7.35 19.91 7.25 1977 13.38 5.51 19.70 7.06 18.93 6.87 1978 13.56 5.12 18.91 6.42 18.25 6.25 1979 13.67 5.07 18.43 6.39 17.82 6.21

1981 16.45 5.14 21.55 6.53 20.91 6.36 1982 18.24 5.28 21.97 7.00 21.09 6.60 a/ Crude birth rate (per thousand). b/ Crude death rate (per thousand).

Note: Urban areas are the 203 population centers denoted as "urban" by the State Council in 1979, plus county towns, of which there are about 2,300. The 1982 census defines urban more broadly then the definition used for annual statisticalreporting which is what is used here.

Sources: 1983 Statisticalyearbook of China, State StatisticalBureau, Beijing. Table A-7: MEDICALLY VULNERABLE POPULATION (in thousands)

Infants Older working age Aged (65 +) Total medically vulnerable (below one year) Children (1 - 5) -r- 64) vulnerable Absolute % of 1980 Absolute X of 1980 Absolute Z of 1980 Absolute Z of 1980 Absolute Z of 1980 Proportion of Total Years size value size value size value size value size value total population Population

1980 16,155 100 91,574 100 102,285 100 51,240 100 261,254 100 27 979,552

1985 19,548 121 85,552 93 116,128 114 63,463 124 284,691 109 27 1,045,031

1990 15,283 95 86,818 95 129,290 126 75,909 148 307,300 118 28 1,100,576

1995 14,358 89 75,038 82 137,519 134 89,930 176 316,845 121 28 1,143,787

2000 20,427 126 82,781 90 157,031 154 104,314 204 364,553 140 30 1,197,662

2005 20,450 127 100,018 109 195,468 191 117,956 230 433,892 166 34 1,258,379 C-. 2010 17,131 106 96,150 105 235,139 230 128,325 250 476,745 182 36 1,307,060

2015 16,888 105 85,878 94 264,945 259 149,150 291 516,861 198 38 1,343,663

2020 16,380 101 82,658 90 301,152 294 185,826 363 586,016 224 43 1,371,617

2025 17,777 110 84,034 92 317,268 310 219,507 428 638,586 244 46 1,397,011

2030 18,447 114 89,465 98 304,607 298 249,835 488 662,354 254 47 1,418,433

Source: These medically vulnerable population data are drawn from the "interim model" (see Table A-2) age distributions prepared as part of "Demographic Trends in China, 1950-81," by Kenneth Hill, Supplementary Paper Number 1 to this Report. Table B-1: PRINCIPAL CAUSES OF DEATH, RURAL AND URBANAREAS, a/ 1980

17 Cities 38 Counties Diseases Death Rate % of Total Diseases Death Rate % of Total (1/100,000) Deaths (1/100,000) Deaths

Cerebrovascular Diseases 135.35 23.4 Heart Diseases 170.57 25.8

Heart Diseases 132.51 22.9 Cerebrovascular Diseases 113.06 17.1

Malignant Tumors 114.55 19.6 Malignant Tumors 96.89 14.7

Respiratory Disorders 51.97 9.0 Respiratory Disorders 79.14 12.0

Digestive Disorders 22.68 3.9 Digestive Disorders 34.82 5.3

Trauma 18.75 3.2 Pulmonary Tuberculosis 21.36 3.2

Pulmonary Tuberculosis 12.15 2.1 Trauma 18.40 2.8

Toxicosis 10.46 1.8 Infectious Diseases 18.24 2.8 %

Others * 14.1 Others - 16.3

Total 100.0 100.0

a/ Routine reporting of causes of deaths from selected cities and counties began in 1973 and gradually expanded to cover about 40 million population from 14 cities and 32 counties in 1979. The number of surveillance points continues to increase; the data for 1980 stem from 17 cities and 38 counties.

Source: "Statistics of Population and Health Care in China," prepared for the course on State Health Administration and Management conducted by the World Health Organization in China in October, 1981, p. 8. These data are not from representative urban and rural locations but rather from relatively well off ones. - 120 -

Table B-2: PRINCIPAL CAUSES OF DEATH IN URBAN AND RURAL AREAS, SELECTED YEARS

(per 100,000 population)

Urban Area a/ Rural Area a/

Causes of death 1954-59 1960-63 1974-78 1974-78

Diseases of the respitatory system 99.19-132.60 64.57-101.77 54.14- 66.49 77.55- 88.39

Pulmonary tuberculosis 48.26- 73.71 36.32- 48.81 15.72- 21.29 24.91- 32.61

Diseases of the digestive system 48.12- 74.02 31.35- 52.29 24.74- 28.78 39.75- 46.30

Acute infectious diseases 29.48- 89.90 21.24- 41.99 9.43- 11.64 18.42- 23.31

Heart Diseases 44.65- 68.58 36.05- 52.00 113.13-130.67 111.14-151.79

Cerebrovascular diseases 38.56- 57.28 36.87- 41.18 125.02-144.52 88.06-109.44

Malignant neoplasms 36.90- 45.65 35.31- 46.12 111.49-118.01 107.86-119.57

a/ The numbers given represent a range within the given years.

Source: "A Brief Account of 30 Year's Mortality of Chinese Population." World Health Quarterly. World Health Organization, Volume 34, No. 2, 1981. These data appear to have been collected from the same surveillance points referred to in footnote a, Table B-1. - 121 -

Table B-3: MAJOR CAUSES OF DEATH, 1973-75

Disorder Males Females Total Rate a/ % Rate a! % Rate a/ %

Respiratory diseases 117.5 15.3 118.2 16.1 117.9 15.7

Malignant tumors 87.8 11.5 66.0 9.0 77.1 10.3

Other circulatory diseases 94.3 12.3 114.6 15.6 104.2 13.9

Trauma, toxicosis & accidents 82.0 10.7 65.6 8.9 70.6 9.4

Digestive system diseases 72.6 9.5 63.4 8.6 66.8 8.9

Infectious diseases 64.1 8.4 60.6 8.3 63.8 8.5

Thoracic circulatory diseases 59.7 7.8 58.6 8.0 62.6 8.3

Newborn infant diseases 51.0 6.7 41.5 5.7 46.4 6.2

Tuberculosis 46.0 6.0 40.4 5.5 43.3 5.8

Arteriosclerotic heart disease 23.4 3.1 25.5 3.6 24.9 3.3

Others - 8.7 - 10.7 - 9.7

Total 100.0 100.0

a/ Rates are per 100,000 population per year.

Source: "Analysis of Life Expectancy in China," by Yung Shou-De, et. al., Journal of Population and Economics (Beijing), 1981, Table 5, p. 28. These data come from the 1973-75 national cancer mortality survey. - 122 -

Table B-4: AGE-SPECIFICMORTALITY RATES IN URBAN AND RURAL AREAS, BY AGE GROUP AND BY SEX, 1957 AND 1975 (%)

Urban area Rural area

1957 1975 1957 1975

Age group Male Female Male Female Male Female Male Female

- 1 35.01 35.73 10.23 9.72 75.71 76.62 20.53 19.79

1 - 2 21.42 24.32 5.80 5.62 34.55 37.94 9.20 9.36

3 - 6 5.25 6.44 1.39 1.31 10.65 12.49 3.02 3.27

7 - 9 1.77 1.87 0.84 0.57 3.74 3.68 1.34 1.19

10 - 14 1.31 1.33 0.64 0.40 2.32 2.53 0.85 0.70

15 - 24 1.08 1.66 0.98 0.75 2.37 2.91 1.06 0.91

25 - 29 1.34 2.37 1.14 1.10 2.91 3.69 1.47 1.48

30 - 34 1.85 3.00 1.44 1.38 3.77 4.70 1.82 1.74

35 - 39 2.84 4.19 1.94 1.75 5.12 5.18 2.56 2.39

40 - 49 5.67 6.27 3.76 3.19 8.38 7.04 4.52 4.09

50 - 59 14.65 12.40 10.92 8.88 15.96 12.33 11.79 9.55

60 - 69 34.93 25.73 32.38 23.61 35.85 27.52 31.55 25.14

70 & + 83.77 71.66 99.77 83.24 84.44 73.60 96.89 86.20

Total 8.03 9.21 5.70 5.40 13.28 13.56 7.08 6.63

Source: "A Brief Account of 30 Years Mortality of Chinese Population." World Health Quarterly. World Health Organization,Volume 34, No. 2, 1981. Table B-5: MRFAfIlY DM BYDLSEASE CkTX, NLM O lEAI!, PRIE ARAD1ERNT FAC 28 WRALC28VR&SUVE POIlAS,MI NIS N7ADUE R S OFIE1 (IA1MJIAR' 1981

Rural Surveillance Points, 'brth of Qvg Jiarg Pwal Suvnei1 1 Points, South of ChiR Jiarq (Catchment Population = 2,162,927) (Catchment Population - 1,656,468) Total Survellaice Point Population - 3,819,395

ND. of No. of No. of DIseae Category Deatls Rate/100,000 % Park Order Deaths Pate/100,000 % Park Order Deaths Rete/100,000 % Rark Order

Her- Illsease 3,770 174.30 29.1 1 1,575 95.08 16.2 3 5,345 139.94 23.6 1 Cancer 2,361 109.16 18.2 3 1,958 118.20 20.2 1 4,319 113.08 19.1 2 Stnke 2,542 117.53 19.6 2 1,631 98.46 16.8 2 4,173 109.26 18.4 3 BespirRtory DIsem 667 30.84 5.2 4 975 58.86 10.1 4 1,642 42.99 7.3 4 Accidents (includiLrg suicide) 587 27.14 4.5 5 612 36.95 6.3 5 1,199 31.39 5.3 5 Gastrointestiral DLsesee 421 19.46 3.2 7 567 34.23 5.9 6 988 25.87 4.4 6 Infectious Usee 433 20.02 3.3 6 472 28.49 4.9 7 905 23.69 4.0 7 Sugical W*id 214 9.89 1.7 8 247 14.91 2.6 8 461 12.07 2.1 8 Genittoudinay ULie 201 9.29 1.5 9 121 7.30 1.2 11 322 8.43 1.4 9 Intdcatim (poisouirg) 136 6.29 1.1 12 156 9.42 1.6 10 292 7.65 1.3 10 Lasase of the 1iborn 79 3.65 0.6 13 160 9.66 1.6 9 239 6.26 1.1 11 Nuoklcgical M lease 169 7.81 1.3 10 41 2.48 0.4 14 210 5.50 0.9 12 Endocrine Dlsease 136 6.29 1.1 11 63 3.80 0.7 12 199 5.21 0.9 13 PaydhLatric 1aese 35 1.62 0.3 16 63 3.80 0.7 13 98 2.57 0.4 14 Qxgenital HlIforations 45 2.08 0.4 14 32 1.93 0.3 15 77 2.02 0.3 15 Blood Disease 45 2.08 0.4 15 28 1.69 0.3 16 73 1.91 0.3 16 Pgnax-y & Post-partt Maes 17 0.79 0.1 17 11 0.66 0.1 17 28 0.73 0.1 17 Panmstic Dsea se 1 0.05 n.a. 18 3 0.18 n.a. 18 4 0.10 n.a. 18 Other Mseases 494 22.84 3.8 - 624 37.67 6.4 - 1,118 29.27 4.9 - lTkn 596 27.56 4.6 - 361 21.79 3.7 - 957 25.06 4.2 -

TDfAL 12,949 598.68 100.0 9,700 585.58 100.0 22,649 593.00 100.0

Source: This table a adapted from unpublished data from the Institute for Epdedolcgy and M1crobiolgy, Ciraes AcadeM of Ma&cal Sciences. Table B-6: MORTALITY DATA BY DISEASE CATEGORY, NUMBER, RANK ORDER AND MORTALITY RATE, SHEJINSAN DISTRICT, BEIJING, 1956-1959 AND 1974-1978

Total Population for 4 Years (1956-59) Total Population for 5 Years (1974-78) 491,558 980,148 1/ Mortality Mortality Rank Disease Number of Rate/ Rank Disease Number of Rate/ Order Category Deaths Percent 100,000 Order Category Deaths Percent 100,000

1 Respiratory 1136 27.9 231.10 1 Heart Disease 1160 28.2 118.35 Disease (Pneumonia) (651) (16.0) (132.44) 2 Stroke 954 23.2 97.33 (Tuberculosis) (189) (4.6) (38.45) 3 Cancer 663 16.2 67.64 2 Communicable 555 13.6 112.91 Disease 4 Trauma and 329 8.0 33.57 Intoxication 3 Heart Disease 363 8.9 73.85 5 Respiratory 235 5.7 23.98 4 Disease of 340 8.4 69.17 Disease Newborn (Pneumonia) (119) (2.9) (12.14) (Tuberculosis) (85) (2.1) (8.67) 5 Gastrointesti- 295 7.3 60.01 nal Disease 6 Gastrointesti- 30 0.7 3.06 nal Disease 6 Stroke 212 5.2 43.13 7 Communicable 171 4.2 17.45 7 Nutritional 152 3.7 30.92 Disease Deficiency 8 Disease of 58 1.4 5.92 8 Trauma and 133 3.3 27.06 Newborn Intoxication 9 Nutritional 37 0.9 3.77 9 Cancer 126 3.1 25.63 Deficiency

10 Others 322 7.9 65.51 10 Others 362 8.8 36.93

11 Unknown 436 10.7 88.70 11 Unknown 109 2.7 11.12

TOTAL 4070 100.0 827.98 TOTAL 4108 100.0 429.22

1/ The implied growth rate (19.5 year interval: Dec. 31, 1957 to June 30 1976) equals 2.4%.

Source: Wu, Y.K. et al.: Community control of cardiovascular diseases in Beijing, Acta Academiae medicinae sinicae 1982, 4, 105-109. - 125 -

Table B-7: MAJOR CAUSES OF DEATH, BEIJING (EAST CITY DISTRICT), 1979

Disease No. of Mortality 5 Rank Category Deaths x Rate/10

1 Stroke 952 27.5 156.77

2 Heart Disease 828 23.9 136.35

3 Cancer 628 18.1 103.41

4 RespiratoryDisease 220 6.3 36.22

5 GastrointestinalDisease 163 4.7 26.84

6 Infectious Disease 101 2.9 16.63

7 GenitourinaryDisease 89 2.6 14.66

8 NeurologicalDisease 86 2.5 14.15

9 Diseases of the Newborn 73 2.1 12.02

10 Endocrine Disease 50 1.4 8.23

11 UndeterminedDisease 30 0.9 4.94

12 Others 246 7.1 40.51

TOTAL 3,466 100.0 570.76

Source: These data are from the Chinese Journal of PreventiveMedicine, Vol. 15, No. 1, 1981. - 126 -

Table B-8: MORTALITY RATES AND RELATIVE FREQUENCY OF SELECTED MALIGNANT NEOPLASMS, 1973-1975

Females Males

Rank Order Mortality Rank Order Mortality Site a/ per 100,000b/ % Site a/ per 100,000 b/ %

TOTAL 54.27 100.0 TOTAL 80.17 100.0

1. Stomach 10.16 18.7 1. Stomach 20.93 26.1

2. Cervix uteri 9.98 18.4

3. Esophagus 9.85 18.2 2. Esophagus 19.68 24.5

4. Liver 5.61 10.3 3. Liver 14.52 18.1

5. Lung 3.20 5.9 4. Lung 6.82 8.5

6. Colon & Rectum 3.03 5.6 5. Colon & Rectum 4.08 5.1

7. Breast 2.61 4.8

Subtotal 44.44 81.9 Subtotal 66.03 82.3

Others 12.89 18.1 Others 14.14 17.7

a/ Site-specificcancers were selected by rank in order of decreasing frequency to account (in the aggregegate)for greater than 80% of the total cancer mortality; thus all other sites combined account for less than 20% of the total cancer mortality. b/ These data were age-adjustedto the 1964 census populationof China.

Source: National Cancer Mortality Survey, 1973-1975,in the Atlas of Cancer Mortality in the People's Republic of China, Beijing: China Map Press, 1979. Table H-9: REPORTED CASES, DEATHS AND INCIDENCE FROI CGOMINICADLE DISEASES, NATIONWIDE, 1974-1981

1974 1975 1976 1977 1978 1979 1980 1981

Reported Incidence Deported Inoldenc Reported Incidence Reported Iscide-ce5 Reported Incidence Reported IT-idence Reported Incidence Reported Inidence 5 Disease Cases D-eaths p-t 1 Cases Deathe per 105 Cases Deaths pee 105 Cases Seethe pee D55 Cases Deaths per 0 Cases Dahs IS Crs Deaths pee ID Ca.e. DSethe per 105

Dtphtherts 23,858 2,147 2.6 38,189 3,009 4.1 23,882 2,112 2.6 30,767 2,380 3.2 20,084 1,697 2.! 16,921 1,292 1.7 9,767 916 1.0 8,481 838 0.9

E.o phalitle 98,445 2,899 10.8 72,030 422 7.8 115,964 4,380 12.4 90,149 5,113 9.5 107,337 4,313 11.2 109,304 4,903 11.3 108,774 4,590 11.1 67,373 197 6.8 (J=psasee 5)

Me.-ales 1,09,966 5,321 110.9 1,380,962 10,709 149.5 1,113,673 6,861 119.0 1,021,363 6,748 107.9 1,112,600 6,162 116.1 900,075 5,931 92.9 2,937,931 556 299.9 2,043,289 363 206.1

P rtusss... 666,997 938 73.3 765,504 1,399 82.8 624,764 853 66.7 665,681 S01 70.3 595,174 982 62.1 401,372 715 41.4 316,206 356 32.3 269,871 478 27.2 (=bwplag coagh)

Poiteweloeie 10,519 223 1.2 7,619 163 0.82 4,625 121 0.5 7,450 213 0.8 10,408 259 1.1 5,472 144 n.6 7,442 172 0.8 4,634 192 0.5

Chslera-/ NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 85 2 0.009 88 NA 0.009 78 NA 0.008

Ily.e.tery 2,597,814 6,545 285.3 3,159,696 14,551 342.0 2,388,653 6,683 255.2 2,479,484 6,124 261.8 2,640,313 6,242 275.6 2,907,828 6,330 300.1 2,874,255 4,231 293.4 3,454,741 4,385 348.5

Epfdemic PiningitiR 30,914 4,996 3.4 22,126 3,308 2.4 14,861 1,964 1.6 13,865 2,027 1.5 18,082 2,578 1.9 17,437 2,031 1.8 14,192 1,793 1.4 14,572 1,983 1.5

Forest narebritla 36 5 0,004 107 16 0.01 56 3 0.006 24 4 0.003 178 14 0.02 576 57 0.06 140 16 0.01 193 13 0.02

H-nrrhsgi fe.er 14,288 1,303 1.6 18,161 1,468 2.0 15,599 1,290 1.7 17,015 1,380 1.8 15,029 996 1,6 21,227 1,459 2.2 30,464 1,960 3.1 20,748 1,117 2.1

Issiiseass 6,296,609 1,836 691.6 8,075,633 3,666 874.0 3,430,002 2,343 366.5 7,103,704 1,039 750.1 2,658,877 468 277.6 2,654,566 364 274.0 570,037 3,862 58.2 485,934 1,274 49.0

Lets.i.h-1-s 1,169 8 0.13 1,108 6 0.12 489 1 0.05 231 1 0.02 99 1 5.51 48 NA 0.005 38 NA ,D004 56 NA 0.006

L.ptropi-is.s 58,121 900 6.4 162,613 1,140 17.6 31,177 681 3.3 42,864 787 4.5 20,384 545 2.1 27,462 805 2.8 35,891 843 3.7 43,168 1,018 4.4

W-larl 9,931,071 226 1,090.8 6,715,009 170 726.7 4,240,864 98 453.1 4,193,763 103 442.8 3,096,240 132 323.2 2,384,543 104 246.1 3,300,349 64 336.9 3,059,635 70 308.6

Settlet feer 141,353 232 15.5 82,592 122 8.9 69,135 106 7.4 89,559 91 9.5 139,783 106 14.6 148,080 97 15.3 106,938 62 10.9 86,201 45 8.7

Tuteasg hl 1,219 1 0.13 963 NA 0.1 787 NA 0.08 559 NA 0.06 999 3 0.! 661 NA 0.07 704 1 0.07 856 2 0.09

Typbhid d pas- typhisd fe-er 3,756 122 0.41 45,737 209 4.9 38,090 175 4.1 71,530 260 7.6 80,986 365 8.5 61,200 277 6.3 74,038 279 7.6 75,455 343 7.6

Vital b pstitt 241,597 1,276 26.5 311,547 1,187 33.7 258,960 1,113 27.7 264,413 1,121 27.9 411,312 1,068 42.9 471,580 1,103 48.8 474,601 1,153 48.4 431,016 1,164 43.5

Rote: lntid NA-s nalnaleted esi.g the mid-year popolatios tRtals given lo Table A-2.

e/ Th ce reported bees are s11 Vibrel chalers, biotype El Tee, shnsh Is Chios Is nffiEoilly reif-red to as pa-anheleea.

Source: These date re providd to the Ontobse, 1982, World b.no Rsr.l Health sod Medical Edoc-tion m bsonhy the Ministry of Pb1ic Hsslth. - 128 -

Table B-10: PROGRESS ON SELECTED COMMUNICABLE DISEASES

Disease Progress

Parasitic Diseases

Intestinalparasites Ancylostomiasis(hookworm), and Ascariasis (round- worm), both due to intestinal infestationwith parasite worms, are still prevalent in China. Estimates of the 1945-1959 period suggest that up to 100 million people may be affected. Ancylostomiasisremains prevalent in 14 southern provinces, whereas ascariasis remains widespread in most of China. Blood loss from hookworm can create anemia in children, and even adults, when the number of worms is sufficientlyhigh (more than 5,000 eggs per gram of feces). Ascariasis is generally harmless although it may have adverse nutritional consequencesand affect child growth. Improved environmentalsanitation and night soil management have probably reduced the prevalence of both parasites. However, the scattered information available indicates that both remain a public health concern.

Leishmaniasis This is a chronic systemic parasitic infection, (kala azar) characterizedby fever, enlargementof liver and spleen, progressiveemaciation, and death, if untreated. Man and dogs are the only known reservoirs. A 1951 survey 1/ showed the leishmaniasisarea to be entirely north of the Chang Jiang (Yangtze River), covering 1.2 million km2. Prevalence was 1-5 per thousand with an estimated 530,000 cases. Most cases were in children. In Gansu 95.4 percent of the cases were less than 10 years of age; in Sichuan 93.6 percent were less than 10. Destruction of dogs and treatment of human cases with a specially produced antimony drug played a major role in decreasing transmission. Reduction in incidence may also have something to do with the sandfly vector of leishmaniasisbeing affected by insecticide spraying against malarial mosquitoes, in addition to the sandfly insecticidingcarried out as a specific campaign in some areas. Since 1958, kala azar outbreaks have become sporadic,with less than 100 cases reported every year in China, mostly in minority areas.

Schisto,OnM-asIs Schistosomiasiswas a very large prohlem at the time of liberation,with an estimated 10-12

Lern Ai Review of kala-azar in China from 1949 to 1959", Transactions of the Royal Society of Tropical Medicine and Hygiene, Vol. 76, No. 4, 1982, pp. 531-537. - 129 -

Disease Progress

million cases prevalent a decade later in 1959. All of the schistosomiasis is due to S. japonicum, which is the type having the most adverse health consequences.2 / Control of schistosomiasis was made a major priority from the very beginning because of the high disability and fatality rates from the most serious form of the disease. Between 1949 and 1982, a total number of 11.26 million cases have been identified, out of which 10 million have been cured. Various discrete areas of high transmission (Shanghai County being the foremost) have been collecting annual data for many years. Much of the schistosomiasis was managed via night soil control in Shanghai County, beginning in 1953 with excreta vats being moved away from river banks. In 1953 the prevalence in Shanghai County was 38.5 percent and two years later 26.3 percent. By 1956 small scale centralized management of these excreta vats had started and there was a ban on washing commodes and night soil tools in the river. By 1964 a formal system of fermentation-settling tanks had been established that further reduced the risk of transmission. Then began the most vigorous effort at controlling schistosomiasis ever mounted, a massive and labor-intensive effort to find and destroy the oncomelania snails that serve as an intermediate host for the schistosome worm. The Chinese medical literature reports stories of moving whole waterways to bury these snails, followed by persistent and meticulous efforts to search out any remaining snails. Schistosomiasis transmission has not been eliminated, but the areas of transmission have been cut to a fraction of their former size. Although the actual prevalence of schistosomiasis is unknown, the total number of existing cases is estimated at more than two million.

Malaria A majority of China's pre-liberation population was at risk of malarial infection. In 1932, 60% of the population along the lower Chang Jiang river was infected with malaria as a result of major floods, with a subsequent 300,000 deaths caused by the disease. China can be divided into four broad malarial zones: a) the first is the area south of the latitude 250N, which covers the

2/ S. japonicum lives primarily in the intestinal and liver veins. The pathologic effects are derived from the eggs that are constantly being deposited and the body's strong reaction to this foreign protein. Scarring and fibrosis, leading to liver failure and death, are the natural consequences of repeated and long-term infection. - 130 -

Disease Progress

tropical and subtropical parts of China. In this area, malaria transmission occurs trhoughout the year as a result of the presence of all three malaria parasites P. falciparum, P. vivax, and P. malariae. In 1953, 11% of China's population lived in this hyperendemic area. b) The second is the area between latitudes 25°N and 33°N where malaria transmission is due to P. vivax (and exceptionally to other species) and occurs for six months out of the year. This area, which in 1953 contained 50% of the population in China, is at high risk of malaria. c) The third is the area north of latitude 33°N where malaria is unstable, with vivax infections alone prevalent, and short transmission periods. Unusual climatic conditions in this area may cause significant outbreaks although the endemicity is moderate. This area had 31.5% of China's 1953 population and infection rates were then below 5%; and d) The fourth area is a malaria free zone which includes all high altitude and desert areas of Central China with all of Tibet, Oinghai, Gansu, Ningxia, Nei Mongol, and part of other provinces. This area had 8% of the 1953 population. Malaria control acLivities started in 1950 and included insecticide indoor spraying, treatment of clinical cases, intermittent irrigation, pisciculture for larva control, use of mosquito nets, shrub clearance, and in the southern tropical region, mass drug administration twice a year and mass chemoprophylaxis. Between 1950 and 1980, the total number of malaria cases decreased from an estimated 30 million cases to a reported 3 million cases. The number of counties endemic for malaria decreased from 70% of the total number to 28%. Today only 5.6% of counties are in high risk areas. In 1979, 30% of the population of China lived in malaria free areas, and another 35% in areas where malaria is sporadic (fewer than 5 annual cases per 10,000 population). In that year, 28% of the population lived in areas of moderate risk (between 5 and 100 cases per 10,000 Population every year), and only 7% lived in high malaria risk areas (above 100 cases per 10,000).

Non-parasitic Diseases

Dengue and dengue These are acute febrile diseases caused by a virus haemorrhagic fever endemic in most of tropical Asia. Dengue epidemics are explosive and have low fatality rates. Dengue haemorrhagic fever is a serious illness, principally affecting children, with a case fatality rate between 10 and 50%. The first recognized dengue epidemic since liberation - 131 -

Disease Progress

occurredin Foshan County, GuangdongProvince, between June and September1978, with an estimated 20,000 cases affectingpersons between the ages of 4 months and 80 years. Approximately25% had haemorrhagicmanifestations.. Since the usual vector, the Aedes aegyptimosquito, is assumed absent from this area of China, the prime suspect is Aedes albopictus. Epidemiologistswho investigatedthis epidemicassumed that refugees from Vietnam (estimatedto exceed 200,000) imported the virus. Dengue has been added to the list of officiallynotifiable diseases.

Influenza Influenzais the most frequentlyreported disease in China. Surveillancehas been underway since 1968, yielding an epidemic patternin South China that peaks in the summer and early fall, and an epidemic patternin North China that peaks in the winter (similarto North America and Europe). Most outbreaksbegin in the late summer or autumn, often before school begins in the first week of September. One exceptionwas in 1969-70,when an epidemic occurredover the winter; it was the largest epidemic since surveillance began. As China's population ages and grows more vulnerable to influenza because of other serious chronic diseases,influenza will become more importantas an immediatecause of death. An extensiveimmunization campaign has been carried out in recent years. The difficultyof assessing the accuracy of influenzadiagnosis make difficult any comment on the reductionof cases (see Table B-9), from 8 million cases in 1975 to 500,000in 1980 and 1981. As all countriesexperience cyclic outbreaksof the disease, it may be this cycle which is responsiblefor the temporarydecline observedin China.

Japanese B Encephalitis This mosquito-transmittedviral diseaseis seen throughoutmuch of East Asia. The case fatality rate in 1949 was describedby Huang in the Chinese Journalof Pediatrics,(Vol. 15, pp. 117-119, Feb. 1966) as about 30%. Large epidemicswere frequentlyseen near ShanghaiCity until 1965 with the incidenceapproximately 52 per 100,000. Since 1965 the incidencein the Shanghaiarea has been around 2 to 3 per 100,000. Mosquito vector control and vaccinationof childrenhave been priorities. Japaneseencephalitis is thoughtto be presentin all of China except Tibet and Xinjiang. Human cases peak at 4-5 years of age. An inactivatedvaccine is widely used in children less than 10 years of age. About 70 million doses - 132 -

Disease Progress

are produced annually in China. The target population is children between the ages of 5 and 12, with the vaccination schedule being 2 initial doses, 2-3 weeks apart, and a single booster a month later. Since 1979, boosters every four years have been recommended. About 100,000 cases are reported in China every year.

Korean Haemorrhagic This is a serious acute infectious disease that is Fever prevalent from Korea in the east, all across Asia to Europe (Scandinavia) in the west, with the case fatality rate diminishing from east to west (fatality about 6% in Korea and about 0.5% in Scandinavia). The Chinese pattern is similar to Korea's. In the eight years between 1974 and 1981, China officially reported a mean of 19,000 cases per year. The mean case fatality rate for that interval is 7.4%, but the case fatality rate is falling and now is 5.4% (1981). The disease is especially important in China because it requires long hospitalization and is one of the most expensive infectious di.seasesin its treatment.

Measles Measles is a well known childhood disease throughout the world. In China, the fatality rate for measles was 6.5% in 1950, declining to 1.7% in 1956 with improved nutrition. Mass vaccination began in 1969 when the incidence was about 3,000 per 100,000, and has now dropped to below 20 per 100,000 for most big cities. Nationally, the incidence is about 200 per 100,000 and has remained constant during the last seven years despite systematic immunization of children.

Smallpox Smallpox was a major endemic disease at liberation, one of the first that China attacked. Annual case loads of several million are not improbable. In October 1950, a national program was begun to vaccinate all newborns and to revaccinate children at six year intervals. Considerable autonomy and flexibility in approach was demonstrated, with some provinces using the regular health infrastructure and others using unpaid volunteers, such as teachers and cadres. Vaccinators were taught to read vaccination takes and to revaccinate any non-takes. Liquid vaccine was used, with its attendant cold-chain requirements dealt with by keeping the vaccine in streams or wells, by scheduling vaccination campaigns for the cold months and by transporting vaccine on ice in vacuum flasks. By 1953, 307 million doses of smallpox vaccine had been administered. Smallpox incidence declined markedly in a few years. Shandong Province - 133 -

Disease Progress

eliminated smallpox by the middle 1950s. Sichuan reported its last case in 1958. The last reported case in China was from Yunnan Province in March, 1960.

Trachoma Trachoma, an infectious eye disease that can lead to blindness, was an extreme public health problem in China. Half of the population was estimated to have been affected in the mid-1950s and, depending on locality, it could have been as high as 90_.3/ Trachoma was estimated to have caused 45% of the visual impairment and between 25-40% of the blindness in China. While no data are available on current prevalence it is clear that the disease is no longer a public health problem. Education against towel sharing ("one person one towel, running water for washing face") is given great importance as a control mechanism.

Tuberculosis Tuberculosis was the leading cause of death in pre-1949 China, with an estimated mortality rate of 2004/ - 2305/ per 100,000 population per year. By 1979, TB had became the 9th cause of death and the mortality rate had dropped to 43 per 100,000 per year.6 / Presumably, this was accomplished largely through improvement of economic conditions, housing and nutrition and by provision of preventive and curative services. In 1979, a national TB sample survey was performed (see Table B-18). The total number of persons with evidence of TB morbidity was extrapolated to 7 million, but this probably underestimates the problem by at least 1 million cases. Additionally, sputum smears were done to estimate the proportion of infectious cases. The smear positivity rate was 187 per 100,000 population, a figure that translates into a massive national pool of almost 2 million potentially infectious cases. Except for municipalities, public health authorities have only a very limited ability or

31 T'ang F.F. et al. "Studies on the Morphology, Growth Characteristics and Biology of Trachoma Agent," Chinese Journal of Ophthalmology, Vol. 8, Jan. 1958, pp. 7-19.

4/ "TuberculosisControl in New China," by Peking Tuberculosis Research Institute, Chinese Medical Journal, 3(4): July, 1977, pp. 218-223.

5/ "Medicine and Public Health in the People's Republic of China," edited by Joseph R. Ouinn, Ph.D.,U.S. Department of Health, Education and Welfare, Public Health Service, National Institutes of Health publication (NIH 73-67).

6/ "Analysis of Life Expectancy in China," by Yung Shou-De, et al., Journal of Population and Economics (Beijing), 1981, Table 5, p.2 8. - 134 -

Disease Progress

have yet to try to discover these cases and to render them non-infectiousthrough an effective treatmentprogram. BCG vaccinationis a high priority in China, though the efficacy of the locally produced vaccine is questionable. More than 32% of the 1,295,000persons surveyed in the national TB sample survey had never had BCG.

Venereal Disease Venereal disease programs,especially for syphilis and gonorrhea, were also establishedearly on. Despite the absence of reliable official information,it now seems clear that there were several million cases of latent syphilis, largely in the National Minority areas where prevalence rates of 10 percent were reported,and in urban areas, where transmissionwas aided by widespread and uncontrolledprostitution. The social situation changed quickly after 1949 with the outlawing of prostitution. In 1951 a campaign was started against several diseases,including venereal diseases, in National Minority regions. Three years later, a national body -- the Central Research Institute of Dermatologyand Venereology -- began to coordinatethe field work and related training and research programs. By the 1960s, sufficient experience had been gained in the use of penicillinby non-medicallyqualified volunteers, and incidence and prevalence of both syphilis and gonorrhea fell dramatically.7 / Chinese official documents state that venereal diseases have been wiped out.

7/ Although quantitativedocumentation in a systematicway is not possible, the reader is referred to the moving, if anecdotal, account of China's anti-venerealdisease struggle in Away With all Pests by J.S. Horn. - 135 -

Table B-11: LEADING CAUSES OF MORBIDITY IN PATIENTS DISCHARGEDFROM SELECTED CITY HOSPITALS

% of Total Diseases Discharged Patients

1. RespiratoryDisorders 19.2

2. Digestive Disorders 18.4

3. Infectious Diseases 8.8 (excludingpulmonary tuberculosis)

4. Trauma 8.0

5. Gestation, Parturition, 7.0 Puerperal Disorders

6. Heart Diseases 3.8

7. Urologic Disorders 3.7

8. Malignant Tumors 3.4

9. Eye Diseases 2.9

Source: These data were presented in "Statisticson Population and Health Care in China," prepared for the course on State Health Administrationand Managementconducted by the World Health Organizationin China, October 1981, p. 9. Table B-12: TIWIENF AN) DEAM RAT-S PER 100,000 PMUTAI(VJ OF WEN (QIMTNICAB1FJDTSFASFS 1N FASTrEN DISWRIt, IEIJt , 1958-1979

lVhoid & Measles Polimiyelitis Diphtheria Pertussis T>5rsenterv 1iepatitis Parntvpluid fever

Year Inddence tDath Rate Tncidence lRath Rate Incidence 1tath Rate Incidence TDath Rate Tncidence Death Rate Incidence TPath Rate incLdence Tpath Rate

1958 2,680.0 16.6 33.4 1.7 2.1 0 540.0 1.7 2,911.n 20.6 - 7.Q 0 1959 2,152.0 16.6 25.6 1.8 2.1 0.2 249.6 n.8 4,721.0 21.5 287.9 0.5 7.8 0 1960 1,582.9 2.6 19.8 1.2 11.8 0.5 28.6 0 2,913.1 16.7 316.1 0.6 4.9 0 1961 1,939.4 9.9 14.6 0.3 23.6 0.5 66.2 n 2,524.3 6.3 82.8 0.9 6.5 0 1962 2,143.8 9.1 1.2 0.2 14.1 0.2 495.7 0.8 2,138.2 2.3 420.9 n.2 12.2 0 1963 1,763.0 5.6 2.2 0.3 5.4 0 272.7 0.5 3,583.0 3.8 447.2 0.2 10.6 0.2 1964 2,040.6 4.8 9.7 0.2 2.6 0 38.5 0 3,970.9 2.7 30.1 0.3 6.9 0 1965 1,570.0 1.9 0.8 0 2.9 n 59.2 0.2 3,883.0 1.3 507.7 0.2 7.6 0.2 1%6 18.5 0 0.6 0 - 0 85.4 0 4,538.4 2.6 475.6 n 3.2 0 1967 26.0 0.2 0.3 n 0.2 n 11.2 0 3,586.7 0.3 451.3 n 3.1 0 1968 24.6 0 0.2 0 - 0 62.5 0 2,154.6 0.2 138.4 0.5 1.5 0 1969 565.7 0.8 0.7 0 0.5 n 20.3 n 1,927.0 0 104.8 0.3 0.7 0 1970 109.3 0.2 0.2 0 0.2 0 9.2 0 2,235.6 0 167.8 n 1.8 0 1971 41.1 0 - 0 0.2 n 20.n n 2,132.1 0.2 323.0 0 3.3 0.2 1972 130.6 0 0.2 0 0.2 0 15.4 0 2,783.6 0 499.3 0.2 8.0 0 1973 76.5 0 - 0 - 0 49.2 0 2,586.7 1.4 374.6 2.1 2.8 0 1974 102.5 0 0.4 0 - 0 7.2 0 3,340.7 2.1 244.1 1.1 7.1 0 1975 12.4 0 0 0 0 0 In.2 0 3,313.9 I.Q 4(*.7 1.2 7.5 0 1976 53.7 0 0 0 0 0 11.3 0 2,212.3 1.9 292.8 1.4 4.4 0 1977 28.4 0 0 0 0 0 3.5 0 1,659.9 1.1 171.9 1.2 2.4 0 1978 37.7 0 0 n 0 0 2.1 0 1,305.2 0.5 169.5 2.4 3.6 0 1979 22.0 0 0 0 0 0 4.1 0 1,147.5 0.8 158.5 1.5 1.8 0

Source: Primary report of disease surveillance in DFclhw district, R9eijiTr, by the District Fpidemic-prevention Station rbi the Institute of Fpi&emolony amnl Mtcrobiolcsv, (Clrese academy of nedical sciences. Chinese kournal of Preventive Medicine, 1981, 15 (1), q. - 137 -

Table B-13: LIFE EXPECTANCY BY PROVINCE, 1973-75

Province Male Female Total a/

NATIONAL TOTAL 63.62 66.31 64.93

North Region Beijing 68.34 70.77 69.53 Tianjin 69.93 71.96 70.92 Hebei 67.11 70.17 68.60 Shanxi 65.33 68.00 66.63 Nei Mongol 65.25 67.31 66.25

Northeast Region Liaoning 68.64 70.78 69.68 Jilin 65.00 66.73 65.84 Heilongjiang 69.25 71.53 70.36

East Region Shanghai 69.24 74.84 71.97 Ji angsu 65.10 69.34 67.17 Zhejiang 66.44 70.52 68.43 Anhui 64.50 66.88 65.66 Fujian 65.23 69.37 67.25 Jiangxi 62.08 64.34 63.18 Shandong n.a. n.a. n.a.

Central South Region Henan 65.06 68.82 66.89 Hubei n.a. n.a. n.a. Hunan 61.39 63.63 62.48 Guangdong n.a. n.a. n.a. Guangxi n.a. n.a. n.a.

Southwest Region Sichuan 59.16 61.08 60.10 Guizhou 59.03 59.48 59.25 Yunnan 59.80 61.35 60.56 Tibet 59.47 63.22 61.30

Northwest Region Shaanxi 63.96 65.18 64.56 Gansu n.a. n.a. n.a. Oinghai 60.55 62.04 61.28 Ningxia 61.86 62.66 62.25 Xinjiang 61.77 63.29 62.51

Note: Estimates of life expectancy presented here do not attempt to adjust for probable under-reporting of deaths and are hence probably biased upward. a/ Total life expectancy was calculated to equal:

Male life expectancy (1.05) + female life expectancy 2.05

Source: Yung Shou-De, et. al., "Analysis of Life Expectancy in China, 1973-75," Journal of Population and Economics (Beijing), 1981-1, Tables 3 and 4. - 138 -

Table B-14: HYPERTENSION MORBIDITY: CONFIRMED, MARGINAL, AND TOTAL CASES; NUMBER OF CASES AND PERCENT; BY PROVINCE, 1979-1980

Confirmed Cases a/ Marginal Cases b/ Total No. of Cases No. of People No.of Morbid- "Standardized" No.of Morbidity No.of Province Sampled Cases ity x Morbidity c/ Cases % Cases % Relative to National Rate

NATIONAL TOTAL 4,012,128 194,751 4.85 4.67 1.0 115,451 2.88 310,202 7.73

North Region Beijing 33,217 3,494 10.52 9.53 2.04 1,043 3.14 4,537 13.66 Tianjin 21,295 1,841 8.65 8.04 1.72 447 2.10 2,288 10.74 Hebei 134,437 7,486 5.57 5.00 1.07 5,127 3.81 12,613 9.38 Shanxi 206,659 8,825 4.27 4.13 0.88 4,702 2.28 13,527 6.55 Nei Mongol 78,427 4,461 5.69 7.16 1.53 1,870 2.38 6,331 8.07

Northeast Region Liaoning 204,974 13,611 6.64 6.70 1.43 8,488 4.14 22,099 10.78 Jilin 101,386 6,160 6.08 6.71 1.44 4,774 4.71 10,934 10.78 Heilongjiang 141,253 8,019 5.68 6.03 1.29 5,510 3.90 13,529 9.58

East Region Shanghai 26,321 1,570 5.96 4.86 1.04 509 1.93 2,079 7.89 Jiangsu 248,825 16,039 6.45 5.53 1.18 8,339 3.35 24,378 9.80 Zhejiang 189,536 7,510 3.96 3.39 0.73 5,628 2.97 13,138 6.93 Anhui 118,051 6,519 5.52 5.37 1.15 3,492 2.96 10,011 8.48 Fujian 144,580 5,418 3.75 3.47 0.74 3,968 2.74 9,386 6.49 Jiangxi 160,111 7,722 4.82 4.05 0.87 4,459 2.78 12,181 7.61 Shandong 97,481 4,992 5.12 4.80 1.03 2,159 2.21 7,151 7.34

Central South Region Henan 383,214 22,496 5.87 5.48 1.17 9,599 2.50 32,095 8.38 Hubei 210,312 11,436 5.44 5.16 1.10 5,979 2.84 17,415 8.28 Hunan 244,387 11,648 4.77 4.38 0.94 6,784 2.78 18,432 7.54 Guangdong 182,323 4,929 2.70 2.44 0.52 4,836 2.65 9,765 5.36 Guangxi 177,182 6,261 3.53 3.16 0.68 5,886 3.32 12,147 6.86

Southwest Region Sichuan 79,834 4,013 5.03 4.85 1.04 2,948 3.69 6,961 8.72 Guizhou 136,066 3,732 2.74 2.54 0.54 2,981 2.19 6,713 4.93 Yunnan 138,649 5,365 3.87 4.34 0.93 3,492 2.52 8,857 6.39 Tibet (Lhasa) 9,672 1,850 19.13 17.76 3.80 310 3.21 2,160 22.33

Northwest Region Shaanxi 183,464 7,240 3.95 3.48 0.75 3,853 2.10 11,093 6.05 Gansu 70,544 2,689 3.81 4.38 0.94 2,105 2.98 4,794 6.80 Qinghai 28,588 1,085 3.80 4.41 0.94 272 0.95 1,357 4.75 Ningxia 48,020 1,642 3.42 4.12 0.88 979 2.04 2,621 5.46 Xinjiang 213,350 6,698 3.14 3.54 0.76 4,912 2.30 11,610 5.44 a/ A confirmed case is defined as blood pressure standing at or above 160/95 mm Hg, with the same result obtained in more than two tests". b/ A marginal case is defined as "when blood pressure is between 160/95 and 140/90 mm Hg".

C/ "Standardized Morbidity Rate" is defined as a rate obtained by adjusting the number of cases according to the age distribution for the whole population for 1964.

Source: This table was adapted from National Hypertension Sample Survey data, 1979-1980 in press in October, 1982. Survey results were provided by the National Institute of Cardiovascular Disease, Chinese Academy of Medical Sciences. - 139 - Table B-15: CANCERMORTALITY BY PROVINCE,1973-1975

MALES FEMALES Mortality per Relative Mortalityper Relative Province 100,000a/ Mortalityb! 100,OOOa/ Mortalityb/

NATIONALTOTAL 119.64 1.0 80.69 1.0 ProvincialDistribution

North Region

Beijing 116.43 0.97 82.89 1.03 Tianjin 110.67 0.93 84.82 1.05 Hebel 136.34 1.14 88.62 1.10 Shanxi 144.43 1.21 115.76 1.43 Nei Mongol 103.70 0.87 89.94 1.11

NortheastRegion

Liaoning 120.20 1.00 79.73 0.99 Jilin 122.44 1.02 80.70 1.00 Heilongjiang 95.99 0.80 61.73 0.77

East Region

Shanghai 212.44 1.78 111.30 1.38 Jiangsu 195.04 1.63 119.81 1.48 Zhejiang 156.22 1.31 93.83 1.16 Anhui 130.87 1.09 85.61 1.06 Fujian 168.04 1.40 96.11 1.19 Jiangxi 83.18 0.70 65.62 0.81 Shandong 103.12 0.86 72.22 0.90

Central South Region

Henan 150.31 1.26 99.43 1.23 Hubei 106.45 0.89 81.53 1.01 Ilunan 70.41 0.59 67.31 0.83 Guangdong 84.94 0.71 47.47 0.59 Guangxi 70.59 0.59 36.05 0.45

SouthwestRegion

Sichuan 92.98 0.78 67.85 0.84 Guizhou 46.02 0.38 38.27 0.47 Yunnan 45.37 0.38 37.79 0.47 Tibet 95.36 0.80 75.44 0.93

NorthwestRegion

Shaanxi 127.88 1.07 94.70 1.17 Gansu 101.46 0.85 74.98 0.93 Qinghai 136.43 1.14 85.39 1.06 Ningxia 163.69 1.37 100.58 1.25 Xinjiang 93.53 0.78 79.29 0.98

a! These data were age-adjustedto the 1960 world's standard population. b/ This column is derived by dividing the mortalityper 100,000 for each provinceby the sex-specificmortality for the whole country.

Source: NationalCancer Mortality Survey, 1973-75,in the Atlas of Cancer Mortalityin the People'sRepublic of China. Beijing:China Map Press, 1979. - 140 - Table B-16: TUBERCULOSIS PREVALkNCE BY PROVINCE, 1979

Standardized TBa/ Standardized Smear Morbidity Rate Positivity Rate Morbidity Relative to Rank Province (1/100,000) National Rate (1/100,000)

National 717 1.0 187

North Region

25 Beijing 409 0.57 101 28 Tianjin 300 0.42 99 24 Hebei 411 0.57 113 21 Shanxi 472 0.66 138 26 Nei Mongol 404 0.56 60

Northeast Region

16 Liaoning 608 0.85 178 14 Jilin 662 0.92 159 3 Heilongjiang 1051 1.47 189

East Region

29 Shanghai 255 0.36 60 7 Jiangsu 891 1.24 239 17 Zhejiang 593 0.83 156 5 Anhui 970 1.35 244 6 Fujian 914 1.27 318 8 Jiangxi 840 1.17 294 22 Shandong 455 0.63 134

Central South Region

12 Henan 773 1.08 180 13 Hubei 666 0.93 238 11 Hunan 776 1.08 202 9 Guangdong 829 1.16 259 19 Guangxi 555 0.77 180

Southwest Region

10 Sichuan 813 1.13 201 23 Guizhou 413 0.58 87 27 Yunnan 364 0.51 63 2 Tibet 1202 1.68 310

Northwest Region

18 Shaanxi 563 0.79 75 20 Gansu 524 0.73 119 15 Qinghai 647 0.90 108 4 Ningxia 1003 1.40 135 1 Xinjiang 1608 2.24 177 a/ These data were age-adjusted to the 1964 census population of China.

Source: A summarized report on the National Tuberculosis Epidemiology Sample Survey, 1979, was published in the Chinese Journal of Tuberculosis and Respiratory System Diseases, Vol. 5, No. 2, 1982. Table B-17: INCIDENCE AND CASE FATALITY RATES OF WATER-RELATED DISEASES, BY PROVINCE, 198R

Paracholera a/ Dysentery Typhoid and Paratvnhoid Viral HepatitIs

Province Reported Ineidence b/ Case Fatality Rate Reported Incidence bh Case Fatality Rate Reported Incidence h/ Case Fatality Rate Reported Incidence b/ Case Fatality Rate Cases per 100,000 per 100,000 Cases per 100,000 per 10o,on0 Cases per 100,00n per loo1 onn Cases per 100,000 per 100,000

NATIONAL TOTAL 78 - NA 3,454,741 349 127 75,455 8 455 431,n16 44 270

North Region Beijing 67,884 753 199 249 3 803 13,269 147 1,0lo Tianjin 45,547 602 182 219 3 - 6,059 80 4,348 Nehei 209,268 401 25 5,007 10 60 48,741 93 41 Sharxi 50,708 203 209 2,179 9 321 5,452 22 11o Nei Mongol 51,637 272 128 2,R79 15 486 4,n77 22 147

Northeast Region Liaoning 220,183 626 47 861 2 465 31,380 89 163 Jilin 58,036 261 28 584 - 342 4,857 22 412 Heilongjiang 111,119 344 33 1,525 5 852 12,342 38 130

East Region Shanghai 61,945 532 131 693 6 433 11,587 100 1,053 Jiangsu 29 - NA 80,053 134 19 8,693 15 23 40,081 67 95 Zhejiang 10 - NA 121,319 315 35 876 2 114 25,430 66 208 Anhui 287,183 586 17 1,245 3 241 21,555 44 1255 Fujian 9 - NA 16,360 64 275 245 - _ 7,726 30 246 Jiangxi 56,552 172 285 1,227 4 407 8,039 24 535 Shandong 219,682 299 22 5,345 7 37 34,650 47 118

Central South Region Henan 461,740 629 7 4,437 6 135 12,035 16 199 hubei 101,402 215 120 2,360 5 169 13,208 28 840 Hunan 74,185 139 233 1,205 2 498 11,365 21 378 Guangdong 30 - NA 76,784 132 175 2,444 4 450 12 ,233 21 335 Guangxi 58,927 165 168 1,460 4 2,466 36,244 101 185

Southwest Region Sichuan 170,442 172 202 1,07c 1 2,687 35,214 36 406 Guizhou 324,641 1,157 314 6,340 23 1,483 3,199 11 1,594 Yunnan 167,216 522 185 11,267 35 444 6,354 20 283 Tibet 16,164 864 377 38 2 - 466 25 1,502

Northwest Region Shanxi 76,560 268 110 597 2 - 8,275 29 133 Gansu 97,590 505 350 2,337 12 513 2,158 11 325 Oinghai 30,943 808 737 119 3 - 1,504 39 133 Ningxia 12,639 333 554 284 7 1,056 1,234 33 Xinjiang 128,027 995 252 9,841 76 31S 17,284 95 163 a/ The cases reported here are all vibrio cholera, biotype El Tor, which in China is officially referred to as paracholera. b/ The 1981 provincial population totals used to determine incidence per 100,000 population are given in Table A-5.

Source: These data were provided to the World Bank by the Ministrv of Public Health. Table C-1: NUMBER OF HOSPITALS, HOSPITAL REnS AND STAFF, NATIONWIDE, 1981

Number of Number of Total Number of Number of Number of units beds staff technical beds per technical personnel personnel b/ unit per bed

Hospitals under entreprises and other ministries 4,722 399,931 555,741 422,500 84.7 1.1

Hospitals under Ministry of Public Health and Collectives 61,189 1,617,157 2,221,742 1,784,964 28.4 1.1

Total 65,911 2,017,088 2,777,483 2,207,464 30.6 1.1 of which

urban hospitals 6,160 802,880 1,187,116 874,911 130.3 1.1 rural hospitals (total) 59,751 1,214,208 1,590,367 1,332,553 20.3 1.1 of which

county hospitals 2,367 333,964 388,474 301,264 141.1 0.9 commune hospitals a/ 55,500 763 ,114 1,064,070 925 ,354 13.7 1.2 other rural hospitals 1,884 117 130 137 823 105 ,935 62.2 0.9 Hospitals in minority autonomous regionsc/ 10,735 246,922 -- -- 23.0 -- Technical categories

Commune health centers A/ 55,500 763,114 1,064,070 925,354 13.7 1.2

General hospitals 8,044 968,041 1,326,747 1,005,894 120.3 1.1

Traditional medicine hospitals 781 57,944 88,558 68,653 74.2 1.2

Hospitals affiliated to medical schools 151 65,686 114,333 78,876 435.0 1.2

Infectious diseases hospitals 119 19,573 22,325 14,803 164.5 0,8

Psychiatric hospitals 269 52,689 41,936 27,359 195.9 0.5

Tuberculosis hospitals 110 26,055 24,649 15,681 236.9 0.6

Maternal and child care hospitals 159 13,049 22,776 16,480 82.1 1.3

Pediatric hospitals 24 5,659 10,750 7,737 235.8 1.4

Other hospitals 754 45,278 61,339 46,627 60.1 1.0

a/ These totals include major commune health centers. b/ The categories included under technical personnel are found in Table C-12. c/ This category includes hospitals in regions that are designated autonomous at All levels -- provincial, orefect,irsl and county -- of government.

Source: These data were provided to the October, 1982, World Bank Rural Health and Medical Education mission by the Ministry of Public Health. - 143 - Table C-2: NUMBER AND TYPE OF HEALTH PERSONNEL, 1980 AND 1981

(unit - 1,000)

X increase Category 1980 1981 1982 1980 to 1982

NATIONAL TOTAL 3,535 3,796 3,958 12.0

of which: technical personnel of all types, including doctors 2,798 3,011 3,143 12.3

Doctors and assistant doctors of traditionalmedicine 262 290 303 15.6

Pharmacistsof traditional medicine 107 133 140 30.8

Senior Doctors of western medicine 447 516 557 24.6

Doctors with both traditional Chinese and western medicine training NA 2 2 NA

Pharmacists 25 30 33 32.0

Laboratory technicians 15 21 23 53.3

Other technicians 15 19 19 26.7

Assistant doctors of western medicine 444 436 445 0.2

Nurses and assistantnurses 466 525 564 21.0

Midwives 71 71 73 2.8

Assistant pharmacists 84 82 85 1.2

Assistant laboratory technicians 60 63 66 10.0

Other assistant technicians 49 54 56 14.3

Primary health technicians 753 769 777 3.2

Number of health technicians per 1,000 persons 28 30 31.1 11.1

Number of doctors per 1,000 persons 12 12 12.9 7.5

Source: These data were taken from the 1981 and 1983 China - Statistical Yearbook, State StatisticalBureau, Beijing. - 144 -

Table C-3: GRADUATES OF SECONDARY MEDICAL SCHOOLS, BY SPECIALITY, 1979-1981

Graduates Number of Graduates in

1979 1980 1981

Asst. Western Doctors 6,676 11,217 6,332

Asst. Doctors of Traditional Chinese Medicine 3,486 6,981 5,571

Nurses 19,632 37,047 38,484

Asst. Doctors of Public Health 904 2,792 3,273

Asst. Pharmacists 1,400 3,234 1,820

Asst. Dentists 41 384 418

Others 5,187 12,074 12,189

TOTAL 37,326 73,729 68,087

Source: These data were provided to the October, 1982, World Bank Rural Health and Medical Education mission by the Ministry of Public Health. Table C-4: DISTRIBUTION OF HEALTH RESOURCES BY OWNERSHIP, 1981

(units = 1,000)

Total Gov't. Enterprises Collectives Individual

Hospital beds 2,017 1200 400 417

of which: general hospitals 968 576 380 12

commune health centers 763 390 - 373

Salaried health manpower 3796 1935 1141 702 18

of which: technical health personnel a/ 3011 1457 924 612 18 n

of which: doctors of traditional Chinese medicine 102 55 20 26 1

western doctors 516 293 186 37

doctors with both traditional and western medical training 02 01

assistant doctors of traditional Chinese medicine 132 57 18 55 2

assistant western doctors 436 182 168 86

a/ This category excludes administrative and general purpose workers (e.g., cleaners).

Source: Data provided to the October, 1982, World Bank Rural Health and Medical Education mission by the Ministry of Public Health. - 146 -

Table C-5: MEDICAL COLLEGES, 1977-1981: INSTITUTIONS, STUDENTS, ENROLLMENTSAND GRADUATES

1977 1978 1979 1980 1981 1982

Number of Colleges 89 98 107 109 112 a/ 112 a/

Number of students 93,822 112,990 127,400 139,569 158,986 164,038

New Enrollees 34,932 47,320 31,569 31,277 29,241 29,486

Graduates 34,860 27,459 13,483 17,656 9,512 25,963

of which traditional medicine 5,332 4,674 2,622 3,069 1,071 b/ 4,268

a/ In addition to these 112 medical colleges, there are four facultiesof medicine in general universities. b/ This reduction in number of graduates is the result of lengtheningthe program from three to five or six years.

Source: These data were provided to the October, 1982, Rural Health and Medical Education mission of the World Bank by the Ministry of Public Health. - 147 -

Table C-6: MEDICAL COLLEGES: PROJECTIONS OF MANPOWER SUPPLY

Graduates Graduates Graduates expected expected expected Medical Colleges in 1982 in 1985 in 1990

TOTAL 29,963 a/ 28,165 Increase by 10%

Medicine 21,098 18,351

Public Health 1,183 1,345 Increase by 50%

Pharmacy 1,385 1,290

Pediatrics 266 440

Stomatology 462 677 Increase by 100%

Traditional Medicine 4,388 3,944

Traditional Pharmacology 917 740

Others 264 1,378

a/ These numbers are unusually high due to temporarilyexpanded enrollment in 1977/78.

Source: These data were provided to the October, 1982, World Bank Rural Health and Medical Education mission by the Ministry of Public Health. - 148 -

Table C-7: SECONDARY MEDICAL SCHOOLS: PROJECTIONS OF MANPOWER SUPPLY, 1982-1990

Graduates Graduates Graduates expected expected expected in 1982 a/ in 1985 b/ in 1990 C/

TOTAL 71,148 55,683 56,539

Asst. Western Doctors 5,559 4,132 4,118

Asst. Doctors of Traditional 6,464 1,760 1,830 Chinese Medicine

Nurses 40,742 28,060 27,085

Asst. Doctors of 3,085 2,187 2,720 Public Health

Asst. Dentists 428 931 1,130

Others 14,870 i8,613 19,656 a/ All figures for graduates in 1982 are considerably higher than normal due to large enrollment of students in 1979. b/ Expected graduates for 1985 are lower than normal reflecting provincial decisions on enrollment in 1982 influenced by the unusually large output of graduates in 1982. c/ Figures for 1990 indicate expected outputs if current MOPH policies are implemented by the provinces.

Source: These data were provided to the October, 1982, World Bank Rural Health and Medical Education mission by the Ministry of Public Health. - 149 - Table C-8: SELECTED TYPES OF HEALTH FACILITIES ANT) MANPOWER, VARIOUS YEARS, 1949-19A1

Type of Facility 1949 1952 1962 1965 1981

HOSPITALS

All Hospitals

Under MOPH 2,450 3,173 - 40,963 61,189 Under entreprises and other ministries 150 367 - 1,748 4,722

Total number 2,600 3,540 34,379 42,711 65,911

Beds

In MOPH hospitals 41,000 122,027 - 536,246 1,199,944 In collective ownership 30,000 10,408 - 71,463 417,213 In other enterprises and ministries 9,000 27,865 - 157,849 399,931

Total number of hospital beds 80,000 160,300 690,000 765,558 2,017,088

County Hospitals

Number NA 2,123 - 2,276 2,367 Number of beds NA 37,467 - 175,409 333,964 Total staff NA 45,791 - 169,281 388,474

of which Technical staff NA 31,662 - 131,n33 3nl,264

of which Doctors NA 7,454 - 52,033 105,348

Commune Health Centers

Number NA NA 28,656 36,965 55,500 Number of beds NA NA 100,027 132,487 763,114 Total staff NA NA 217,213 245,361 1,064,070

of which Technical staff NA NA 188,647 214,427 925,354

of which Doctors and assistant doctors a/ NA NA 96,431 109,555 395,175

OTHER FACILITIES

MCHI centers: number 9 2,379 2,636 2,795 2,630

Prevention stations: number 0 147 2,30s 2,499 3,202

Other Health Units with Outpatient Department Only

Under MOPH and collective ownership 693 23,884 - 129,049 2,799 Under enterprises and other ministries 76 5,166 - 41,381 108,390

Total 769 29,050 - 170,430 111,189

Other Units b/ 292 3,871 - 5,831 7,194

Total Number of Health Units in China 3,670 38,987 - 224,266 190,126

a/ In this category, most will be either assistant doctors of western medicine or assistant doctors of traditional Chinese medicine, and a few will be senior doctors. b/ This category includes a variety of health institutions such as research institutions, drug control institutes, convalescent centers, "specialized preventive and curative centers" (the functions of which are not clear), and other nonspecified institutions.

Source: 1981 Report, Ministry of Public Health Table C-9: NUMBER OF HOSPITAL BEDS BY TYPE OF HOSPITAL - 1979, 1980 AND 1981

Number of Beds Increase Type of Hospital 1979 1980 1981 1982 from 1979 to 1982 (%)

NATIONAL TOTAL 1,932,083 1,982,176 2,017,088 2,053,838 6.3

Comprehensive(General) 907,998 941,143 968,041 998,315 9.9

Chinese (Traditional) 42,861 49,977 57,944 62,964 46.9 0 Hospitals Affiliatedwith Medical Schools 59,775 62,375 65,686 69,087 15.6

Hospitalsfor Mental Diseases 46,918 49,096 52,689 54,615 16.4

Tuberculosis 25,744 25,088 26,055 26,023 1.0

Rural Commune Hospitals 771,231 775,413 763,114 753,232 - 2.3

Other Hospitals a/ 77,556 79,084 83,559 89,602 15.5

a/ This heading includes hospitals for infectiousdiseases, hospitals for maternal and child health care, children'shospitals, and "other" hospitals.

Source: Data for 1979 and 1980 were provided by the Ministry of Public Health.

Data for 1981 and 1982 are from the 1981 and 1983 China StatisticalYearbook, State StatisticalBureau, Beijing. Table C-10: NUMBER OF HOSPITAL BEDS AND HEALTH PERSONNEL, BY TYPE AND LEVEL, 1949 - 1981

(unit - 1,000)

Beds Health Personnel

Hospitals Technical Personnel Other Year Total Total of which county Nursing Other Health Doctors Health level and above Homes Centers Organizations Totala/ Sub-total Nurses Personnel _ ~~Sub-totalb/Dra. of Trad. Ors, of western Asst. Doctors Chinese Ked. medicine of west. medicine

1949 85 80 80 4 1 541 505 363 276 38 49 33 109 1950 119 100 100 6 13 611 555 380 286 41 53 38 137 1951 159 124 124 9 26 685 606 397 296 45 56 46 163 1952 231 160 160 20 51 819 690 425 306 52 67 61 204 1953 273 181 181 34 58 943 778 449 316 56 77 79 250 1954 329 205 205 45 79 1,038 854 476 327 63 86 94 284 1955 363 221 221 58 84 1,053 874 500 332 70 98 107 267 1956 414 262 262 66 86 1,201 988 525 332 72 121 118 345 1957 462 295 295 69 98 1,254 1,039 547 337 74 136 128 364 1958 672 426 426 72 174 1,529 1,329 544 338 75 131 138 647 1959 810 552 521 89 169 1,638 1,390 594 361 80 153 160 636 1960 977 655 600 107 215 1,769 1,505 596 346 82 168 170 739 1961 916 663 636 113 140 1,784 1,492 652 352 99 201 190 650 1962 933 690 577 105 138 1,685 1,414 688 344 120 224 200 526 1963 934 686 574 100 148 1,730 1,453 721 339 143 239 213 519 1964 972 713 591 101 158 1,767 1,479 739 330 161 248 225 515 ~ 1965 1,033 766 621 98 169 1,872 1,532 763 321 189 253 235 534 @ 1966 1,118 855 666 96 167 1,827 1,484 707 276 187 244 244 533 1967 1,130 913 672 86 131 1,854 1,507 710 270 190 250 260 531 1968 1,123 944 665 62 117 1,834 1,491 701 243 204 254 283 507 1969 1,154 998 678 48 108 1,812 1,471 697 229 212 256 293 481 1970 1,262 1,105 712 48 109 1,793 1,453 702 225 221 256 295 456 1971 1,331 1,208 756 27 96 1,944 1,551 712 206 241 265 318 521 1972 1,472 1,337 828 27 108 2,168 1,708 739 206 256 277 331 638 1973 1,564 1,421 868 31 112 2,306 1,822 781 216 269 296 335 706 1974 1,662 1,508 905 34 120 2,439 1,932 831 224 280 327 357 744 1975 1,764 1,598 948 37 129 2,594 2,057 878 229 293 356 380 799 1976 1,862 1,687 986 40 135 2,780 2,206 930 236 308 386 413 863 1977 1,954 1,777 1,050 45 132 2,942 2,341 978 240 329 409 405 958 1978 2,042 1,856 1,093 51 135 3,106 2,464 1,033 251 359 423 407 1,024 1979 2,128 1,932 1,148 60 136 3,344 2,642 1,088 258 395 435 421 1,133 1980 2,184 1,982 1,192 68 134 3,535 2,798 1,153 262 447 444 466 1,179 1981 2,234 2,017 1,239 81 136 3,796 3,011 1,244 290 516 436 525 1,242 1982 2,280 2,054 1,285 88 138 3,958 3,143 1,307 303 557 445 564 - a/ Total excludes urban and rural part-time health workers (in narticular, barefoot doctors). b/ This number includes Z,000 senior doctors who completed both traditional Chinese and western medical training.

Source: Statistical Yearbook of China, 1983, State Statistical Bureau, Beijing. Table C-1l: SALAPIRI) TECHNICAL HEALTH STAFF, VARIDUS YEARS, 1952-1981

Doctors of Doctors and Assistant western medicine Doctors of Traditional of which: Assistant Doctors Asststant Year Total Medicine Total Public Health of western mpdlcine PharmacIsts Pharmacists Ntirses Midwives

1952 690,437 306,000 st,736 532 66,500 900 7,071 60,900 22,400

1957 1,039,208 337,022 73,573 2,132 135,701 2,388 1R,407 128,174 35,774

1963 1,452,84n 339,291 142,640 6,428 239,412 6,219 31,327 212,842 43,971

1965 1,531,595 321,430 188,661 NA 252,713 8,265 37,201 234,546 45,639

1976 2,205,682 236,046 307,716 NA 386,181 13,717 61,31R 413,082 70,925

1977 2.340,879 240,047 328,611 NA 40Q,444 14,535 6s,092 405.223 70,418

1978 2,463,931 251,088 358,520 in,895 423,410 16,749 67,633 406,649 70,552

1979 2,641,558 257,811 395,062 NA 435,316 20,020 76,684 421,406 70,703

1980 2,798,241 262,185 447,288 NA 443,761 25,241 83,90l 465,79P 70,843

1981 3,011,038 289,50?) 516,498 NA 436,196 29,948 81,863 525,311 70,004

Source: These data were provided to the October, 1982, World Bank Rtiral Health and Y'edical F.ducatfon mission hv the Ministry of Public Health. Table C-12: SALARIED HEALTH STAFF, ALL LEVELS PER POPULATION, VARIOUS YEARS - 1950, 1952, 1965 AND 1980

Number of Persons

1950 1952 1965 1980

Categories No. Population per: a/ No. Population per: a/ No. Population per: No. Population per: a/

NATIONAL TOTAL 611,240 943 818,937 730 1,872,335 393 3,534,707 277 of these:

Health and Technical Personnel Subtotal 555,040 1,038 690,437 866 1,531,595 480 2,722,936 360 Doctors and assistant doctors of traditional medicine 286,000 2,015 306,000 1,955 321,430 2,289 262,185 3,736 Pharmacists of traditional medicine NA NA 6,536 91,524 71,848 10,240 106,963 9,158

Doctors of western medicine 41,400 13,920 51,736 11,563 188,661 3,890 447,288 2,190 Pharmacists NA NA 900 664,667 8,265 89,014 25,241 38,810 Other technicians NA NA 860 695,581 6,476 113,604 14,717 66,562 Assistant doctors of western medicine NA NA 66,500 8,995 252,713 2,911 443,761 2,207 Nurses 37,800 15,246 60,900 9,823 234,546 3,137 465,798 2,103 Midwives NA NA 22,400 26,705 45,639 16,120 70,843 13,828 Assistant Pharmacists NA NA 7,071 84,599 37,201 19,776 83,901 11,676 Other Technical Assistants NA NA 11,316 52,863 49,771 14,782 49,603 19,749 Primary-level health/ technical personnel NA NA 156,218 3,82Q 315,045 2,335 752,636 1,302

a/ These numbers are derived from the mid-year population interim model" given in Table A-2.

Source: Ministry of Health, Beijing, 1983. - 154 -

Table C-13: HEALTH FACILITIES AND PERSONNEL UNDER OTHER MINISTRIES, VARIOUS YEARS - 1949, 1952, 1965 and 1981

Facilities 1949 1952 1965 1981

Hospitals 150 367 1,748 4,722

Outpatient facilities 76 5,166 41,381 108,390

Number of beds 9,000 27,865 157,849 399,931

Personnel 25,880 71,331 294,301 923,878

Doctors and assistant doctors 9,941 20,426 128,797 395,625

of which: Doctors of traditional medicine and of western medicine 4,408 10,700 61,864 227,676

Source: 1981 Report, Ministry of Public Health. - 155 - Table C-14: HEALTH SERVICES IN PRODUCTIONBRIGADES, 1970, 1975, 1980 and 1981

1970 1975 1980 1981

Total Number of Brigades 650,720 675,445 702,910 714,700

Brigades with rural cooperative insurance systems - Number 498,451 571,427 483,601 415,957

- % of total 76.6 84.6 68.8 58.2

Number of barefoot doctors (BFD) 1,218,266 1,559,214 1,463,406 1,396,452

- of which female BFD n.a. 502,225 489,422 443,275

- Proportionof female BFD n.a. 0.32 0.33 0.32

Average number of BFD per brigade 1.9 2.3 2.1 2.0

Number of rural midwives n.a. 615,184 634,858 584,565

Number of brigade health aides 3,561,014 3,282,481 2,357,370 2,006,560

Total number of part-time health staff in brigades 4,779,280 5,456,879 4,455,634 3,987,577

Source: These data were provided to the October, 1982, World Bank Rural Health and Medical Education mission by Ministry of Public Health. - 156 -

Table C-15: NUMBER OF BRIGADES HAVING COOPERATIVEMEDICAL SERVICES (CMS) AND PART-TIMEHEALTH PERSONNEL, SELECTED YEARS, 1970-1981

Years

Brigade Facilities 1970 1975 1980 1981

Brigades with CMS 498,451 571,427 483,601 415,957

Barefoot doctors (BFD) 1,218,266 1,559,214 1,463,406 1,396,452

Female BFD NA 502,225 489,422 443,275

Average # BFD per brigade 1.9 2.3 2.1 2.0

Brigade health aides 3,561,014 3,282,481 2,357,370 2,006,560

Rural midwives NA 615,184 634,858 584,565

% brigades with CMS to total number of brigades 76.6 84.6 68.8 58.2

Source: 1981 Report, Ministry of Public Health. - 157 -

Table C-16: DISTRIBUTIONOF HEALTH PERSONNEL BY TECHNICAL CATEGORY, VARIOUS YEARS, 1949-1981

(excludingbarefoot doctors and part-time brigade health workers)

1949 1952 1965 1981

TOTAL 541,240 818,937 1,872,335 3,796,121

of which technical staff 505,040 690,437 1,531,595 3,011,038

Senior Staff: Total 314,875 366,032 596,680 1,010,114

Western doctors 38,000 51,736 188,661 516,498 Traditional doctors 276,000 306,000 321,430 289,502 "Integrateddoctors" a/ - - - 1,591 Traditionalpharmacists - 6,536 71,848 132,805 Western pharmacists 484 900 8,265 29,948 Laboratory personnelb/ n.a. n.a. n.a. 20,987 Other technicians 391 860 6,476 18,783

Middle Level Staff: Total 103,277 168,187 619,870 1,231,407

Assistant doctors 49,400 66,500 252,713 436,196 Nurses 32,800 60,900 234,546 525,311 Midwives 13,900 22,400 45,639 70,904 Assistant pharmacists 2,873 7,071 37,201 81,863 Laboratory techniciansb/ n.a. n.a. n.a. 63,242 Other assistant technicians 4,304 11,316 49,771 53,891

Primary Level Staff: Total 86,888 156,218 315,045 769,517

Nurse aides - - - 245,774 Pharmacy aides - - - 79,170 Laboratory aides - - - 39,423 Others (technical) - - - 405,150

a/ "Integrateddoctors" represents the number of doctors with both degrees in western and traditionalmedicine. b/ Laboratory staff is included among "others" in 1949, 1952 and 1965.

Source: 1981 Report, Ministry of Health Table C-17: NUMBERS OF SALARIED HEALTH WORKERS BY LEVEL, URBAN AND RURAL, VARIOUS YEARS, 1952-19AI

Level 1952 1965 1977 1979 1981

Total Total Total Ulrban Rural Total Urban Rural Total Ulthan Rnra1

Total 690,437 1,531,595 2,340,879 1,062,610 1,278,269 2,641,558 1,232,875 1,40R,683 3,011,038 1,434,324 1,576,214

Doctors and assistant doctors of Traditional Medicine 306,000 321,430 240,047 49,665 190,382 257,811 60,484 197,327 289,502 78,171 211,331

Pharmacists of Traditional Medicine 6,536 71,848 89,531 26,749 62,782 101,766 31,578 70,188 132,805 40,509 q2,29e

Senior Staff 53,496 203,402 357,692 219,340 138,352 436,029 280,720 155,309 658,549 417,339 221,210

Middle Level Staff 168,187 619,870 1,041,740 511,217 530,523 1,If),4 6 570,174 538,312 1,150,665 610,302 569,863

Lower Level Staff 156,218 315,045 611,869 255,639 356,230 737,466 289,919 447,547 769,517 288,003 481,514

Total per 1,000 population (western and traditional medicine) 0.62 0.70 0.60 1.74 0.40 0.67 1.97 0.42 0.81 2.39 0.49

Note: Inclided are also those workers paid onlv in part bv government or bv collectives. Countv hospitals are constdered "uirban".

Source: These data were provided to the October, 1982, World Rank Rural Health and eeAical Education mission hy the Ministry of Philic Health. Table C-18: HOSPITAL BEDS BY PROVINCE, INCLUDING TOTAL NUMBER OF BEDS, COMPREHENSIVE HOSPITAL BEDS AND COMMUNE HEALTH CENTER BEDS, 1979, 1980 AND 1981

a/ b/ c/ Province Hospital Beds Couprehensive (General) Hospital Beds Commune Clinic Beds 1979 1980 1981 2 increase 1979 1980 1981 2 increase 1979 1980 1981 X increase (1979-1981) (1979-1981) (1979-1981)

NATIONAL TOTAL 1,932,083 1,982,176 2,017,088 4.4 907,998 941,143 968,041 6.6 771,231 775,413 763,114 - 1.1

North Region

BeiJing 26,788 28,495 29,783 11.2 13,523 14,331 15,732 16.3 2,696 2,725 2,849 5.7 Tianjin 17,929 18,753 20,301 13.2 10,100 10,342 10,490 3.9 2,086 2,152 2,139 2.5 Bebei 86,990 87,584 88,426 1.6 44,816 46 023 46,968 4.8 34,606 33,564 31,712 - 8.4 Shanxi 66,519 69,141 70,669 6.2 35,366 36,596 37,918 7.2 25, 830 26,489 26,331 1.9 Nei Mongol 46,495 47,271 47,942 3.1 23,712 24,163 24,589 3.7 17,862 17,387 17,238 - 3.5

Northeast Region

Liaoning 107,696 109,252 112,629 4.6 54,598 55,709 58,193 6.6 28,698 28,517 27,772 - 3.2 Jilin 59,687 60,682 61,921 3.7 29,095 30, 272 30,964 6.4 18,868 18,729 18,701 - 0.9 Heilongjiang 91,899 93,325 92,592 0.7 56,937 58,040 57,252 0.6 18,894 19,073 18,645 - 1.3

East Region

Shanghai 47,774 49,363 49,913 4.5 24,071 24,582 24,787 3.0 7,454 7,538 7,303 - 2.0 Jiangsu 114,004 116,228 119,555 4.9 36,496 37,063 38,923 6.7 60,515 60,684 60,680 0.3 Zhejiang 59,892 63,195 64,297 7.4 25,083 27 ,107 28,238 12.6 25 ,927 27,007 26 272 1.3 Anhui 72,786 76,283 77,126 6.0 29,907 31,936 32, 671 9.2 37,693 38 ,762 38,299 1.6 Fujian 45,821 46,172 48,013 4.8 21,629 21,710 22 541 4.2 18,845 18,748 19,070 1.2 Jiangxi 67,398 69,716 70,876 5.2 35,484 37,155 37 ,950 6.9 25 ,414 25,292 24,946 - 1.8 Shandong 115,501 117,134 117,970 2.1 48,357 49,559 50,520 4.5 54,001 54,065 52,689 - 2.4

Central South Region

Henan 106,293 111,720 116,482 9.6 46,950 49,188 52,121 11.0 49 771 52,301 53,564 7.6 Hubei 108,859 112,216 114,875 5.5 43,936 45,269 46,707 6.3 55,018 56,396 56,650 3.0 Hunan 115,565 115,753 112,643 - 2.5 44,518 46,131 45,901 3.1 55,400 54,396 50,678 - 8.5 Guangdong 103,793 103,697 105,414 1.6 46,214 46,905 48,933 5.9 42,009 41,395 40,038 - 4.7 Guangxi 45,358 47,608 49,140 8.3 22,030 23,159 23,965 8.8 16,908 17,327 17,427 3.1

Southwest Region

Sichuan 175,577 179,426 181,309 3.3 71,458 74,905 76,636 7.2 90,264 89,344 87,114 - 3.5 Guizhou 40,001 40,835 41,314 3.3 19,642 20,344 20,730 5.5 16,918 16,884 16,756 - 1.0 Tunnan 58,505 60,249 61,800 5.6 33,557 34,138 35,405 5.5 21,026 21,622 21,551 2.5 Tibet 4,125 4,261 4,507 9.3 3,332 3,421 3,565 7.0 403 470 595 47.6

Northwest Region

Shaanxi 53,220 55,161 57,238 7.5 29,457 30,395 31,538 7.1 17,698 18,120 18,258 3.2 Gansu 33,531 33,776 33 876 1.0 21,143 21 ,329 21,937 3.8 8,917 9,044 8,663 - 2.8 Qinghai 10,666 10,460 11,429 7,2 7,691 7,480 8,390 9.1 1,307 1 ,325 1,101 -15.8 Ningxia 7,110 7,184 7,427 4.5 4,553 4,707 4,962 9.0 1,845 1 765 1,716 - 7.0 Xinjiang 42,301 47,236 47,621 12.6 24,343 29,184 29,515 21.2 14,358 14 ,292 14,357 0

a/ This category includes the total number of beds in hospitals of all types, including commune clinic beds. b/ This category excludes the following: hospitals of traditional medicine, hospitals affiliated with medical schools, hospitals for mental diseases, tuberculosis hospitals, commune clinics and the category of 'other hospitals." c/ Beds in comsune clinics are typically 'for observation' of patients and are not as fully equipped as regular hospital beds.

Source: These data were provided to the October, 1982, World Bank Rural Health and Medical Education mission by the Ministry of Public Health. Table C-19: HOSPITALS BEDS BY PROVINCF, ALL CATEGORIES OF HOSPTTAL, 1980

Total Gen-ral Tr-ditlon-l Hoep. Affil. Inf-oti-oo Mootol T. B. 'dter-al & Children-' Rral Other Nneber Beda per HoopitEt. Hospit.l. to Med. CoIl. Dis. Ho-p. Hosplta.l 8oep1tale Child. Beep. Hoepit.l. Commuoc Beep. Bo-pitale 1,000 - Re.goi Boap. Reds Populatlon H.op. Beda Boep. Beda Roep. Beda Boep. Bode HRop. Beda Hdop. Bede Ho.P. Bode Hoep. Bode Hoop. Bede FoCp. Bede

NATIONAL TOTAL 65,450 1,982,176 2.0 7,859 941,143 678 49,977 143 62,375 118 18,580 255 49,096 108 25,088 135 11,013 24 5,407 55,413 775,413 717 44,084

North RegioO

beijirg 393 28,495 3.2 84 14,331 6 1,373 8 3,487 3 746 3 2,680 2 834 3 412 3 771 264 2,725 17 1,136 Tin jin 332 18,753 2.5 53 10,342 2 180 4 1,733 3 330 1 785 2 750 3 167 1 434 214 2,112 49 1,880 Hebei 4,336 87,584 1.7 415 46,023 8 902 6 2,988 7 784 9 1,410 4 642 8 437 1 40 3,870 33,564 8 794 Shanxi 2,346 69,141 2.8 366 36,596 13 960 2 1,026 3 420 8 1,250 1 150 - - 1 300 1,907 26.489 45 1,950 Net Iloogol 1,760 47,271 2.5 258 24,163 28 1,484 3 1.086 5 365 8 850 6 1,170 2 60 - - 1,422 17,387 28 706

No-the-st Region

Li-oning 1,688 109,252 3.1 357 55,709 31 3,035 6 3,034 15 3,625 24 5,502 18 6,190 11 1,163 1 200 1,186 28,517 39 2,277 Jilin 1,259 60,682 2.7 240 30,272 29 1,675 7 2,871 5 740 10 2,310 9 1,862 4 637 2 325 933 18,729 20 1,261 HeiloqgjI.og 1,766 93,325 2.9 531 58,040 45 2,894 6 3,361 10 1,611 13 3,289 16 3,509 4 250 1 300 1,105 19,073 35 998 East RgiOD

Shanghai 399 49,363 4.3 109 24,582 3 172 14 6,818 8 1,599 14 3,340 6 1,560 8 1,195 1 300 200 7,538 36 2,259 Jiang.s 2,457 116,228 2.0 243 37,063 43 3,889 7 2,869 17 2,372 32 3,991 5 940 4 710 2 415 2,054 60,684 50 3,295 Zhejing 3,554 63,195 1.7 161 27,107 26 1,995 5 1,940 4 575 11 1.794 1 103 3 390 - - 3,317 27,007 26 2,284- Aholi 3,083 76,283 1.6 220 31,936 14 925 4 2,005 3 506 7 1,486 - - 4 353 - - 2,827 38.762 4 310 Fujisn 1,130 46,172 1.8 149 21,710 19 1,978 2 710 2 250 6 1,180 1 500 1 200 - - 922 18,748 28 896 Jiasgxi 2,189 69,716 2.1 406 37,155 44 1,859 4 1,538 3 470 7 1.581 - - 4 609 1 360 1,705 25,292 15 852 Shandotg 2.552 117,134 1.6 395 49,559 22 2,296 6 2,089 5 790 21 3,266 16 2,445 3 360 1 80 2,063 54,065 20 2,184

Ceeotrsl Regio

Hen.n 2,530 111,720 1.5 347 49,188 29 2,354 5 1,716 4 490 11 2.131 1 320 18 976 2 202 2,071 52,301 42 2,042 H.beS 1,827 112,216 2.4 320 45,269 29 2,085 7 3,323 4 480 9 1,650 2 514 2 90 1 370 1,379 56.396 74 2,039 Hu -n 4,402 115,753 2.2 384 46,131 98 8,144 5 2,263 3 480 14 2,247 3 590 1 135 - - 3,845 54,396 49 1,367 Gu ngdong 2,447 103,697 1.8 393 46,905 34 2,758 11 3,538 2 310 14 2,840 3 775 36 1,407 2 420 1,931 41,395 21 3,349 G-ugai 1,231 47,608 1.3 159 23,159 19 1,008 5 1,479 2 265 6 710 1 266 4 309 - - 1,019 17,327 16 3,085

SoothWest Region

Sichuna 10,388 179,426 1.8 684 74,905 72 4,043 10 3,851 3 540 14 2,720 2 300 4 415 1 40 9,552 89,344 46 3,268 Gd ho.. 4,529 40,835 1.5 209 20,344 7 425 3 1,527 1 120 1 260 1 300 2 230 - - 4,296 16,884 9 745 Yunnes 1,864 60,249 1.9 350 34,138 9 528 3 1,100 2 252 5 777 1 200 2 302 1 150 1,478 21,622 13 1,180 Tibet 528 4,261 2.3 92 3,421 1 20 ------434 470 1 350

Nosiehest REgile

Sbsei 3,095 55,161 1.9 291 30,395 33 1,505 3 1,813 2 300 2 350 2 650 2 60 1 400 2,748 18,120 11 1,568 Gan&u 1,665 33,776 1.8 231 21,329 7 342 2 1,200 - - 1 217 2 148 2 146 - - 1,411 9,044 9 1,350 Oisgh.i 511 10,460 2.8 100 7,480 2 276 1 720 - - I - - - - - 1 300 401 1.325 5 359 Sieg.i. 305 7,184 1.9 57 4,707 1 152 1 430 - - 1 130 ------245 1.765 - - Binjiang 884 47,236 3.7 255 29,184 4 720 3 1,860 2 160 2 350 3 370 - - - - 614 14,292 1 300

Ssrce: The dat. in this table wre provided in the October, 1982, World Back Rural Health and Medical Ed-cation udiYYOn by the Mioiotry of Public He-1th. - 161 -

Table C-20: DISTRIBUTION OF MEDICAL PERSONNEL, BY PROVINCE, 1981

Doctors Doctors and assistant Assistant Health Care of western doctors of traditional Doctors Barefoot Personnel Medicine a/ medicine of western medicine Doctors (per 1,000 population) Total per 1,000 Total per 1,000 Total per 1,000 Total per 1,000 rural x increase population population population population b/ 1979 1981 79 - 81

NATIONAL TOTAL 518,089 0.52 289,502 0.29 436,196 0.44 1,396,452 1.40 2.74 c/ 3.04 11.4

Provincial distribution

North Region

Beijing 22,801 2.53 4,763 0.53 10,322 1.14 11,466 2.85 8.28 9.00 9 Tianjin 11,866 1.57 4,008 0.53 7,067 0.93 8,197 2.24 6.22 7.30 17 Nebei 24,651 0.47 14,072 0.27 25,434 0.49 100,828 2.13 2.33 2.57 10 Shanxi 18,009 0.72 10,426 0.42 15,354 0.62 56,816 2.64 3.35 3.85 15 Nei M'ongol 11,948 0.63 9,013 0.48 11,283 0.60 22,279 1.53 3.54 4.11 16

Northeast Region

Liaoning 28,874 0.82 10,077 0.29 20,254 0.58 34,527 1.48 4.17 4.77 14 Jilin 17,219 0.77 6,179 0.28 12,569 0.56 24,164 1.54 3.75 4.22 13 Heilongjiang 24,449 0.76 10,145 0.31 18,560 0.58 29,485 1.34 3.99 4.34 9

East Region

Shanghai 17,913 1.54 6,820 0.59 18,967 1.63 9,347 1.90 7.84 8.25 5 Jiangsu 28,423 0.47 14,816 0.25 21,934 0.37 79.669 1.52 2.47 2.71 10 Zhejiang 14,723 0.38 8,847 0.23 13,284 0.35 54,795 1.60 2.24 2.55 14 Anhui 19,295 0.39 10,226 0.21 13,729 0.28 54.089 1.22 2.13 2.27 7 Fujian 10,025 0.39 6,647 0.26 5,891 0.23 32,179 1.44 2.29 2.43 6 Jiangxi 15,833 0.48 8,835 0.27 12,353 0.38 40,701 1.41 2.29 2.77 21 Shandong 31,717 0.43 12,336 0.17 24,429 0.33 154,788 2.28 2.22 2.42 9

Central South Region

Henan 24,547 0.33 19,410 0.26 24,114 0.33 145,026 2.14 1.79 2.22 24 Hubei 26,652 0.56 19,977 0.42 18,604 0.39 75,811 1.85 3.20 3.54 11 Hunan 18,162 0.34 18,961 0.36 24,887 0.47 70,007 1.45 2.40 2.63 10 Guangdong 30,327 0.52 16,950 0.29 16,774 0.29 51.286 0.96 2.77 3.02 9 Cuangxi 15,291 0.43 6.937 0.19 13,029 0.36 32,072 1.03 1.81 2.07 14

Southwest Regio:

Sichuan 34,457 0.35 39,864 0.40 37,184 0.38 134,402 1.50 2.37 2.62 11 Guizhou 13,140 0.47 4,385 0.16 9,273 0.33 14,353 0.56 2.22 2.46 11 Yunnan 11,781 0.37 6,269 0.20 19,287 0.60 29,158 0.99 2.18 2.40 10 Tibet 1,214 0.65 534 0.29 2,172 1.16 4,750 2.77 3.61 3.74 4

Northwest Region

Shaanai 18,056 0.63 9,789 0.34 12,862 0.45 69,879 2.80 2.70 3.08 14 Gansu 10,627 0.55 5,409 0.28 9,913 0.51 32,560 1.90 2.48 2.80 13 Qinghai 3,707 0.97 980 0.26 2,689 0.70 6,925 2.18 3.74 4.44 19 Ningxia 2,870 0.76 1,049 0.28 1,940 0.51 5,086 1.58 3.12 3.43 10 Xinjiang 9,512 0.74 1,778 0.14 12,038 0.94 11,807 1.18 4.28 4.90 14

aI These figures include 1,591 doctors who are trained in Chinese as well as western medicine.

b/ rnese data were derived from the percent urban population given in Table 1.4 of China: Recent Economic Trends and Policy Developments, World Bank Report No. 4072-CNA, and the mid-1981 population totals given in Table A-5.

c/ The Health of China (see Sources) uses the figure of 2.37 for the national total, but recalculation of the weighted average indicates that this should read 2.74.

Sources: The data on doctors was provided to the October, 1982, World Bank Rural Health and Medical Education mission by the Ministry of Public Health. Data on health care personnel (excluding barefoot doctors) per 1,000 in 1979 is from the Statistics Section, Statistics and Finance Bureau, Ministry of Public Health (China Encyclopedia Yearbook, 1980), as quoted in The Health of China, by Ruth and Victor Sidel, Boston: Beacon Press, 1981. Data on health care personnel by category were calculated using the mid-1981 population figures in Table A-5.

Data on health care personnel per 1,000 population in 1981 was calculated using the medical personnel column on page 481 of China - 1981 Statistical Yearbook and the 1981 mid-year populations from Table A-5. Table D-1: PER CAPITA AVAILABILITY OF GRAINS AND OTHER CROPS, 1950-1982 (Figures are kg per year)

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) Soy- Vege- Total Sorg- beans Other table Vege- Year Grains a/ Rice Wheat Corn hum Millet Tubers b/ (food) Pulses Grains c/ Oil8 d/ Sugar Fruit tables

1950 142.32 59.95 17.92 NA NA NA 13.56 NA NA 50.90 1.89 .49 3.40 90.27 1951 151.45 64.45 20.94 NA NA NA 15.04 NA NA 51.02 2.17 .74 3.53 92.13 1952 168.63 71.30 21.60 16.76 10.69 10.43 17.22 7.31 6.12 7.21 2.40 .72 3.66 93.75 1953 168.84 72.56 21.36 NA NA NA 17.11 NA NA 57.81 2.19 1.05 4.36 94.97 1954 167.86 70.53 26.66 NA NA NA 17.14 NA NA 53.53 2.40 1.42 4.25 96.19 1955 178.26 75.82 25.62 NA NA NA 18.66 NA NA 58.15 2.54 1.46 4.23 98.15 1956 182.30 77.96 27.08 NA NA NA 21.10 NA NA 56.16 2.64 1.54 4.06 99.76 1957 181.91 81.11 25.35 19.24 6.63 6.94 20.75 5.65 10.31 5.93 2.38 1.27 4.18 101.23 1958 180.18 72.87 23.90 NA NA NA NA NA NA 83.42 2.46 2.19 4.04 98.60 1959 149.94 61.19 22.92 NA NA NA NA NA NA 65.82 2.12 1.55 4.11 97.08 1960 127.25 53.10 22.94 NA NA NA NA NA NA 51.21 1.30 1.91 4.19 96.71 1961 137.40 48.81 18.38 NA NA NA NA NA NA 70.21 1.33 2.66 4.29 96.53 1962 149.89 56.65 22.67 NA NA NA NA NA NA 70.56 1.35 1.40 4.28 95.06 1963 154.57 65.18 23.70 NA NA NA NA NA NA 65.69 1.52 1.40 4.20 92.64 1964 168.35 71.44 26.82 NA NA NA NA NA NA 70.08 1.77 1.66 4.06 89.60 1965 172.07 73.78 30.16 19.01 5.56 4.55 16.99 3.14 13.28 5.60 1.84 1.86 3.91 86.86 1966 181.60 77.58 30.62 NA NA NA NA NA NA 73.40 1.72 1.77 3.81 84.05 1967 177.47 74.32 29.66 NA NA NA NA NA NA 73.49 1.75 1.93 3.74 81.61 ' 1968 167.77 73.34 29.82 NA NA NA NA NA NA 64.61 1.75 1.60 3.67 78.79 1969 162.74 71.93 26.92 NA NA NA NA NA NA 63.90 1.80 1.73 3.59 76.22 1970 181.04 79.97 29.54 23.49 6.04 6.28 20.04 4.37 6.05 5.25 1.83 1.99 3.66 73.83 1971 180.96 82.94 29.86 NA NA NA NA NA NA 68.16 1.88 1.92 3.86 75.52 1972 172.49 79.89 33.12 NA NA NA NA NA NA 59.48 1.88 2.50 4.08 77.61 1973 186.91 82.85 33.40 NA NA NA NA NA NA 70.66 1.89 2.33 4.33 79.82 1974 190.78 83.08 36.70 NA NA NA NA NA NA 71.00 1.81 2.15 4.59 82.22 1975 192.54 83.58 37.86 NA NA NA NA NA NA 71.10 1.80 1.96 4.88 84.86 1976 194.17 83.35 40.02 30.58 5.35 3.20 17.93 3.15 5.69 4.91 1.57 2.40 4.82 87.97 1977 192.75 83.91 36.69 31.05 4.69 3.51 19.72 3.78 5.02 4.38 1.70 3.23 5.01 93.21 1978 204.56 88.02 46.74 NA NA NA NA NA NA 69.80 2.01 3.37 5.73 94.84 1979 221.98 91.93 53.00 36.93 4.36 3.28 17.61 3.86 5.87 5.14 2.36 3.36 6.00 92.77 1980 212.49 88.11 48.93 35.81 4.34 3.37 17.05 4.30 5.81 4.78 2.58 3.25 5.69 91.56 1981 215.13 89.95 52.27 33.85 4.45 3.33 15.09 4.19 6.80 5.19 2.99 3.80 5.66 92.29 1982 229.59 99.89 58.89 34.43 3.56 2.81 15.88 4.34 4.37 5.32 4.16 5.17 5.65 92.10

Note: The term "availability" refers to food available for human consumption net of trade, milling, seed use, feed grains, manufacturing uses and waste. a/ Total grains includes columns 3 through 11. b/ Tubers expressed as one-fifth the wet weight (one fourth prior to 1963). c/ Other grains is a composite of barley, oats, other minor grains, and all other coarse grains in that year for which data is not available. The value for other grains in 1950, for examp½e, includes 1950 per capita corn, sorghum, millet, soybeans (food), pulses, barley, oats, and other minor grains. d/ Vegetable oils include soy, peanut, cottonseed, rapeseed, sesameseed, sunfloverseed, and other minor edible vegetable oils.

Sources: For 1980 to 81, Trends in Food and Nutrient Availability in China, 1950-81", by Alan Piazza, Supplementary Paper Number 7 to this Report; for 1982, World Bank preliminary estimates. - 163 - Table D-2: PER CAPITA AVAILABILITYOF MEATS AND OTHER ANIMAL PRODUCTS, 1950-1982 (figures in kg per year)

Pork Other Beef & Poultry Red Animal year Mutton Meats a/ Meats Fish Eggs a/ Milk a/ Fats

1950 4.11 .88 .15 1.50 1.48 .92 .38 1951 4.44 .88 .15 2.15 1.43 .92 .41 1952 5.45 .88 .16 2.65 1.43 .92 .46 1953 5.97 .88 .16 2.95 1.43 .92 .54 1954 6.27 .88 .16 3.48 1.43 .92 .56 1955 5.45 .88 .17 3.75 1.43 .92 .58 1956 4.98 .88 .16 3.87 1.40 .92 .51 1957 5.66 .88 .16 4.46 1.38 .91 .48 1958 6.60 .88 .15 3.94 1.36 .91 .76 1959 5.17 .89 .15 4.29 1.44 .92 .71 1960 3.02 .91 .14 4.23 1.48 .94 .52 1961 2.57 .93 .14 3.23 1.53 .97 .38 1962 2.66 .94 .13 3.16 1.53 .98 .36 1963 5.06 .94 .13 3.54 1.52 .98 .43 1964 6.31 .93 .13 3.71 1.50 .97 .55 1965 6.88 .93 .13 3.85 1.49 .97 .59 1966 7.29 .92 .13 3.90 1.47 .96 .63 1967 7.30 .92 .14 3.74 1.48 .96 .69 1968 7.00 .91 .14 3.24 1.47 .95 .66 1969 6.62 .91 .11 3.54 1.46 .94 .61 1970 6.72 .89 .09 3.61 1.45 .94 .49 1971 8.01 .89 .09 3.87 1.44 .93 .51 1972 8.70 .88 .08 4.16 1.45 .93 .65 1973 8.59 .88 .09 4.17 1.45 .93 .64 1974 8.29 .88 .11 4.47 1.45 .94 .64 1975 8.16 .88 .10 4.53 1.46 .94 .65 1976 7.90 .89 .10 4.46 1.47 .96 .70 1977 7.84 .90 .10 4.62 1.48 .96 .72 1978 8.50 .89 .10 4.53 1.49 .98 .76 1979 10.46 .89 .09 4.13 1.68 1.31 .93 1980 11.64 .89 .08 4.26 1.98 1.34 1.05 1981 12.11 .90 .07 4.32 2.16 1.49 .95 1982 12.78 .95 .13 4.85 2.15 1.76 .90

Note: The term "availability"refers to food available for human consumptionnet of trade, manufacturinguses and waste. a/ The limited fluctuationin poultry meats, eggs and milk availabilityrepresents recent year base period data extrapolatedusing a constant growth rate assumption of 2%.

Sources: For 1980 to 81, "Trends in Food and Nutrient Availabilityin China, 1950-81," by Alan Piazza, SupplementaryPaper Number 7 to this Report; for 1982, World Bank preliminaryestimates. - 164 - Table D-3: DAILY PER CAPITA NUTRIENT AVAILABILITY, 1950-1982

Per capita Total Total Total Total Year Unprocessed Energy Protein Fat Grain (KCal) (g) (g) (Kg.)

1950 238 1,543 (1,844) 41 19 1951 252 1,659 44 20 1952 274 1,861 51 24 1953 279 1,879 50 23 1954 283 1,895 50 24 1955 296 2,005 53 25 1956 301 2,051 53 24 1957 303 2,045 55 24 1958 301 2,053 54 26 1959 268 1,722 46 22 1960 242 1,453 (1,875) 39 16 1961 251 1,558 43 16 1962 260 1,660 45 17 1963 264 1,776 46 19 1964 276 1,934 50 22 1965 278 1,967 53 22 1966 286 2,078 53 23 1967 280 2,042 52 23 1968 266 1,931 49 22 1969 259 1,881 48 22 1970 275 2,076 (2,131) 52 23 1971 279 2,082 51 23 1972 274 2,006 49 24 1973 291 2,160 53 25 1974 297 2,194 54 24 1975 302 2,210 55 24 1976 306 2,220 56 24 1977 312 2,236 56 25 1978 327 2,360 58 25 1979 346 2,562 65 31 1980 337 2,487 (2,611) 64 32 1981 342 2,517 (2,650) 65 33 1982 364 2,729 68 38

Source: These data were calculated using the "final estimate" model in Table A-2, and were prepared for "Trends in Food and Nutrient Availability in China,1950-81," by Alan Piazza, Supplementary Paper Number 7 to this Report.

Note: Figures in parenthesis show, for selected years, estimates of energy availability based on these production figures but assuming only a 20% wastage rate of grain. This assumption about wastage is used by the Chinese Government. (The World Bank estimates, on the other hand, have been calculated using commodity specific coefficients for food disappearance for seed, feed, and manufacturing requirements in addition to waste.) - 165 -

Table D-4: FOOD AVAILABILITY BY PROVINCE, 1979

(figures are kg per capita per year)

Processed Edible Pork, Mid-1979 Total Vegetable Beef & Aquatic Province Population Grains a/ Peanuts Oils Sugar Fruit Mutton Products Milk

NATIONAL AVERAGE 964.45 203.34 1.26 2.20 2.45 6.55 10.57 4.24 1.293

North Region

Beijing 8.60 122.17 1.10 .62 .00 15.93 12.61 .30 6.60 Tianjin 7.31 113.21 .38 .53 .00 3.29 6.98 4.26 2.55 Hebei 50.81 206.38 1.95 1.94 .10 14.06 6.50 1.77 .60 Shanxi 24.35 184.40 .03 1.06 .39 10.11 5.53 .02 .84 Nei Mongol 18.40 159.00 .00 2.20 2.94 1.44 10.86 .60 6.06

Northeast Region

Liaoning 34.23 186.11 1.10 1.14 .20 26.92 9.60 12.21 1.21 Jilin 21.69 222.69 .08 1.06 2.94 1.86 9.02 .35 1.22 Heilongjiang 31.51 259.59 .01 .53 5.29 .98 11.06 .52 4.57

East Region

Shanghai 11.15 136.52 .01 4.49 .00 2.78 16.59 18.14 5.94 Jiangsu 58.63 255.38 .84 3.34 .10 3.19 15.52 5.19 .39 Zhejiang 37.71 249.22 .14 2.55 1.18 5.36 14.55 20.44 .98 Anhui 47.58 205.62 1.19 3.08 .00 1.97 10.28 1.11 .09 Fujian 24.69 182.96 2.04 1.50 14.60 4.52 8.15 17.43 .49 Jiangxi 32.06 241.90 .81 3.26 2.06 1.69 9.02 1.99 .22 Shandong 71.96 203.91 6.33 3.78 .10 22.08 10.77 8.28 1.01

Central South Region

Henan 71.27 182.33 .81 2.02 .00 6.61 7.18 .31 .27 Hubei 46.04 243.25 .62 3.87 .00 2.48 11.15 .00 .45 Hunan 51.94 254.76 .36 2.73 .78 2.04 14.55 2.38 .12 Guangdong 56.37 183.55 3.27 1.76 14.21 4.56 10.67 1.61 .34 Guangxi 34.36 202.93 1.81 1.41 11.27 4.09 10.48 17.48 .07

Southwest Region

Sichuan 97.40 194.85 .52 2.11 1.86 2.59 14.84 .46 1.26 Guizhou 27.08 134.05 .23 1.14 .29 1.55 8.05 .13 .19 Yunnan 31.13 149.95 .23 .44 5.10 2.82 7.95 .43 .54 Tibet 1.81 154.45 .00 1.23 .00 1.27 27.06 .00 63.71

Northwest Region

Shaanxi 27.93 197.22 .11 1.58 .00 7.65 6.79 .09 2.05 Gansu 18.84 153.21 .00 1.23 .10 3.51 6.60 .01 1.09 Qinghai 3.68 147.04 .00 4.58 .00 1.01 19.59 .86 25.51 Ningxia 3.66 181.13 .00 2.02 .39 5.10 4.07 .11 1.04 Xinjiang 12.44 197.45 .02 3.17 2.94 10.29 8.24 .47 5.33

Note: The term "availability" refers to food available for human consumption net of trade, milling, seed use, feed grains, manufacturing uses and waste.

Note: Figures exclude all interprovincial and internationsl trade in food crops.

Note: Provincial breakdowns for vegetables, poultry meat, other meats, eggs and animal fats are not available. Energy from these five commodities represents less than 5% of the total energy available in the average diet of the Chinese. The figures for energy, protein and fat contributed by these five commodities to the national average diet have been added directly to the nutrient availabilities supplied by the other 16 commodities for which provincial production data is available.

a/ Total grains includes rice, wheat, corn, sorghum, millet, tubers, soybeans, pulses and other minor grains: see also Table D-1.

Source: - Trends in Food and Nutrient Availability in China, 1950-81," by Alan Piazza, Supplementary Paper Number 7 to this Report. - 166 -

Table D-5: PROVINCIAL PER CAPITA NUTRIENT AVAILABILITY, 1979-1980, AND RURAL FOOD EXPENDITURES, 1981

Annual Rural Food Energy Protein Fat Expenditure (KCal) (g) (g) per capita/in yuan a/

Province 1979 1980 1979 1980 1979 1980 Total On Staples (% total)

NATIONALAVERAGE 2,372 2,296 60 58 38 40 114 54

Beijing 1,461 1,502 46 45 46 47 163 47 Tianjin 1,307 1,277 40 37 23 27 126 51 Hebei 2,313 1,998 68 56 48 50 86 61 Shanxi 2,041 1,764 59 51 38 38 86 66 Nei Mongol 1,882 1,577 58 47 32 35 111 52

Northeast Region

Liaoning 2,139 2,226 60 61 69 68 139 45. Jilin 2,476 2,495 72 69 38 49 152 49 Heilongjiang 2,888 3,084 98 101 44 61 102 60

East Region

Shanghai 1,742 1,336 48 41 39 33 198 34 Jiangsu 2,888 2,794 76 77 40 40 128 52 Zhejiang 2,863 2,679 66 63 38 41 147 42 Anhui 2,394 2,190 58 53 33 33 118 58 Fujian 2,318 2,384 47 49 28 28 124 50 Jiangxi 2,735 2,578 53 51 29 26 118 56 Shandong 2,549 2,482 70 67 70 71 90 59

Central South Region

Henan 2,106 2,115 61 60 36 38 89 65 Hubei 2,758 2,299 62 53 36 30 115 57 Hunan 2,906 2,763 58 56 33 31 136 48 Guangdong 2,313 2,387 44 48 30 32 158 39 Guangxi 2,434 2,381 54 50 30 30 116 50

Southwest Region

Sichuan 2,364 2,389 54 56 33 38 121 51 Guizhou 1,577 1,631 37 38 22 26 105 52 Yunnan 1,758 1,895 43 47 23 27 92 54 Tibet 1,926 2,061 77 81 43 39 NA NA

Northwest Region

Shaanxi 2,190 1,832 64 53 36 38 92 67 Gansu 1,722 1,815 54 58 26 30 93 71 Qinghai 1,865 2,079 63 69 42 47 103 61 Ningxia 1,995 2,226 60 65 28 27 89 69 Xinjiang 2,228 2,191 65 63 45 48 99 56

Note: Figures exclude all interprovincial and international trade in food crops. Consequently, the nutrient availability figures for China's three municipalities (Beijing, Tianjin, and Shanghai) and perhaps other regions are gross underestimates of true nutrient availability.

Sources: Data on energy, protein and fat is taken from, "Trends in Food and Nutrient Availability in China, 1950-1981," by Alan Piazza, Supplementary Paper Number 7 to this Report.

4 4 5 Data on expenditures come from the Statistical Yearbook of China 1981, p. . a/ These data are presumed to represent expenditures for the entire year 1981, but the source failed to specify the exact time period covered. - 167 -

Table D-6: FOODPRICES, SELECTED LOCALES, 1981

(retail, in yuan per jin) a/

Price Price information in Beijing in Chengdu, in Yexian City National source Sichuan Shandong average

Ration shops

wheat flour 0.19 0.17 NA noodles 0.28 0.17 - 0.30 NA glutinous rice 0.21 0.15 - 0.18 0.17 regular rice 0.16 0.14 0.12 corn neal 0.12 NA NA vegetable oil 0.84 0.78 - 1.15 NA peanut oil 0.85 NA 0.80 sesame oil 2.30 NA 0.95 rice flour NA 0.11 NA soybeans NA 0.16 0.14 wheat (4 types) NA NA 0.16 - 0.25 peanuts NA NA 0.48 sesame seeds NA NA 0.58 beans (many types) NA NA 0.16 - 0.3

State Stores

sausage (pork 5 beef) 1.0 - 2.3 2.24 - 3.40 NA fish 0.87 NA NA chicken (frozen) 1.10 NA NA duck (fresh) 1.50 NA NA beef and mutton 1.00 0.62 - 0.80 NA eggs (9 per jin) 1.20 1.21 NA pork (lean) 1.46 1.20 NA pork (fatty) 1.24 1.40 NA potatoes 0.12 NA NA pears 0.28 NA NA apples 0.41 NA NA grapes 0.80 NA NA pork fat NA 1.53 NA green beans NA NA 0.14 fresh cabbage NA NA 0.03 egg plant NA NA 0.03 taro root NA NA 0.16 hot pepper NA NA 0.09 seaweed NA NA 0.51 bean noodles NA NA 0.72 soy sauce NA NA 0.12 vinegar NA NA 0.08 salt (bulk) NA NA 0.13 salt (packaged) NA NA 0.37 sugar NA NA 0.88

Free Markets

sweet potatoes 0.10 - 0.11 0.10 NA rice 0.34 NA NA millet 0.33 NA NA peanuts 0.30 - 0.33 NA NA grapes 0.85 NA NA pears 0.25 - 0.33 0.20 - 0.29 NA crab apples 0.80 NA NA rooster NA 1.00 - 1.20 NA chicken NA 1.10 NA 10 chicken eggs NA 1.35 - 1.55 NA 10 duck eggs NA 1.45 - 1.60 NA fish i 1 NA 1.80 - 2.20 NA fish t 2 NA 1.40 - 1.80 NA fish t 3 NA 0.95 - 1.20 NA duck NA 0.85 - 1.00 NA spring onions NA 0.06 - 0.10 NA winter melon NA 0.06 - 0.09 NA red radishes NA 0.06 - 0.08 NA potatoes NA 0.10 NA apples NA 0.20 - 0.35 NA green beans NA 0.20 NA persimmons NA 0.30 NA Mixed Average Retail Prices of Principal Commodies

pork 1.10 beef 0.94 autton 0.90 domestic fowl a/ 2.62 fresh vegetables 0.67

a/ This category presumably refers to purchases of entire fowls, and the price represents the average yuan per fowl cost.

Sources: Food prices for Beijing, Chengdu (Sichuan), and Yexian City (Shandong) were collected by members of the October, 1982, World Bank Rural Health and Medical Education Miasion.

National average prices are given in Statistical Yearbook of China 1981, page 426. - 168 -

Table D-7: FOOD RATIONS, 1982

Ration Locale Rationed item Category jin a/ per month (age or occupation) Beijing Chengdu, Yexian, Sichuan Shandong

grain below 1 year 8

grain 1 year 11

grain 2 years 13

grain 3 years 15

grain 4 years 17

grain 5 years 18

grain 6 years 20

grain 7 years 21

grain 8 years 22

grain 9 years 24

grain 10 years 25

grain senior middle school students 32 32.0

grain university students 34.5 35.0

grain ordinary person 27

grain office worker (male) 34 28 30.0

grain office worker (female) 30 28

grain manual laborer 40-60 45-50 56.0

oil all ages 0.5 0.5 0.5

sugar all ages 0.5 0.5 0.5

peanuts 1.0

meat] not fish] rationed

a/ One jin is equal to 500 grams.

Source: These data were collected by World Bank staff during the October, 1982, Rural Health and Medical Education mission of the World Bank. - 169 -

Table D-8: PER CAPITA FOOD ENERGY REQUIREMENTS, 1953

(1) (2) (3) (4) (5) (6) Requirement Requirement per per capita Total Average kg body weight adjusted for daily energy body at moderate activity level Mid-year requirement Age group weight activity levels (Kcal) c/ Population (109 Kcal) (years) (kg) a (Kcal) b/ (Col. 2 x 3) (millions)d/ (Col. 4 x 5)

NATIONAL TOTAL ENERGY REQUIREMENT 567.5 1,148.6

Children

0-1 900 19.0 17.1 1-3 1,360 55.8 75.9 4-6 1,830 42.2 77.2 7-9 2,190 35.1 76.9

Male

10-12 2,600 17.9 46.5 13-15 37.9 44.65 1,836 16.7 30.7 16-19 49.6 46.92 2,525 21.6 54.5 20-39 52.3 46.00 2,611 83.8 218.8 40-49 49.8 43.70 2,361 31.1 73.4 50-59 49.8 41.40 2,237 22.8 51.0 60-69 47.0 36.80 1,877 13.4 25.2 70+ 47.0 32.20 1,642 5.3 8.7

Female

10-12 - 2,350 15.3 36.0 13-15 38.4 45.20 1,884 14.0 26.4 16-19 46.2 42.00 2,105 20.1 42.3 20-39 47.8 40.00 2,075 79.2 164.3 40-49 45.1 38.00 1,860 29.3 54.5 50-59 45.1 36.00 1,762 22.1 38.9 60-69 43.2 32.00 1,382 14.9 20.6 70+ 43.2 28.00 1,210 8.0 9.7

Total daily average per capita energy requirement:

9 Total daily energy requirement (109 KCal) = 1,148.6 x 10 = 2,024 KCal d/ Mid-1964 Population (millions) 567.5 x I0

a/ Data on average body weights for individuals aged 19 and younger come from a 1979 survey of 16 provinces; see Research on Physical Shapes, Functions and Qualities of Chinese Children and Youth, by the Research Group in the Study of the Physique of Chinese Children and Youth (Beijing, 1982). Weights for older individuals were estimated by the mission. Estimates of 1980 weights use the 1979 figures; estimates of 1953 weights assume an increase of .25% p.a. in age specific weights of the population, i.e., that 1953 weights were 94% of 1979 ones.

b/ These are computed according to WHO/FAO recommendations for moderate activity levels. Recommended per capita requirements for children and adolescents aged 0-12 are not adjusted for weights as are requirements for other ages but are instead set equal to the requirements for children of standard weight. The rationale for this is that children who weigh less than standard can use the extra nutrients for catch-up growth given that they are likely to be growing below the genetic potential rate.

c/ Half of the population aged 13 to 59 is assumed to be "very active," and half "moderately active." Very active members of the population require 17% more energy than do moderately active members. Moderate activity levels are assumed for those aged 60 and up; requirements for ages 0-12 are explained in footnote b/.

d/ The 1953 population total and age distribution are from the 1953 census.

Source: Rural Health and Medical Education Mission calculations. - 170 -

Table D-9: PER CAPITA FOOD ENERGY REQUIREMENTS, 1979

(1) (2) (3) (4) (5) (6) Requirement Requirement per per capita Total Average kg body weight adjusted for daily energy body at moderate activity level Mid-year requirement Age group weight activity levels (Kcal) cl Population (109 Kcal) (years) (kg) a/ (Kcal) b/ (Col. 2 x 3) (millions)d/ (Col. 4 x 5)

NATIONAL TOTAL ENERGY REQUIREMENT 979.6 2,140.6

Children

0-1 - 1,090 16.2 17.7 1-3 - 1,360 52.5 71.4 4-6 - 1,830 60.1 110.0 7-9 - 2,190 70.0 153.3

Male 10-12 - 2,600 40.6 105.6 13-15 40.3 44.65 1,952 37.3 72.8 16-19 52.8 46.92 2,688 40.1 107.8 20-39 55.7 46.00 2,780 158.9 441.7 40-49 53 43.70 2,513 50.9 127.9 50-59 53 41.40 2,380 37.9 90.2 60-69 50 36.80 1,840 24.0 44.2 70+ 50 32.20 1,610 12.4 20.0

Female 10-12 - 2,350 37.9 89.1 13-15 40.9 45.20 2,006 34.9 70.0 16-19 49.2 42.00 2,242 37.4 83.9 20-39 50.8 40.00 2,205 144.1 317.7 40-49 48 38.00 1,979 45.0 89.1 50-59 48 36.00 1,875 36.3 68.1 60-69 46 32.00 1,472 26.0 38.3 70+ 46 28.00 1,288 16.9 21.8

Total daily per capita energy requirement: 2,_85.2 Kcal d/ a/ Data on average body weights for individuals aged 19 and younger come from a 1979 survey of 16 provinces; see Research on Physical Shapes Functions and Qualities of Chinese Children and Youth, by the Research Group in the Study of the Physique of Chinese Children and Youth (Beijing, 1982). Weights for older individuals were estimated by the mission. Estimates of 1980 weights use the 1979 figures; estimates of 1953 weights assume an increase of .25% p.a. in age specific weights of the population, i.e., that 1953 weights were 94% of 1979 ones. b/ These are computed according to WHO/FAO recommendations for moderate activity levels. Recommended per capita requirements for children and adolescents aged 0-12 are not adjusted for weights as are requirements for other ages hut are instead set equal to the requirements for children of standard weight. The rationale for this is that children who weigh less than standard can use the extra nutrients for catch-up growth given that they are likely to be growing below the genetic potential rate. c/ Half of the population aged 13 to 59 is assumed to be "very active, and half "moderately active." Very active members of the population require 17% more energy than do moderately active members. Moderate activity levels are assumed for those aged 60 and up; requirements for ages 0-12 are explained in footnote b/. d/ The 1980 population total and age distribution are based on the World Bank model summarized in Annex Table A-2. e/ The 1977 FAO estimate of per capita energy requirements is 2,360 kilocalories per day.

Source: Rural Health and Medical EduicationMission calculations - 171 -

Table D-10: SAFE LEVELS OF PER CAPITA PROTEIN INTAKE, 1953

(1) (2) (3) (4) (5) (6) Total safe level of Average Safe level daily pro- body Safe level per per capita tein intake Age group weight kg body weight per day (g) Population f/ (103 kg) (years) (kg) a/ per day (g) bl (Column 2x3) (millions) (Column 4x5)

Children

0-1 7.5 19.0 C/ 1-3 10.3 1.19 12.3 55.8 686.3 4-6 15 1.01 15.15 42.2 639.3 7-9 19.7 0.88 17.3 35.1 607.2

Male adolescents

10-12 26.3 0.81 21.3 17.9 381.3 13-15 37.9 0.72 27.3 16.7 455.9 16-19 49.6 0.60 29.8 21.6 643.7

Female adolescents

10-12 26.3 0.76 20.0 15.3 306.0 13-15 38.4 0.63 24.2 14.0 338.8 16-19 46.2 0.55 25.4 20.1 510.5

Adults: men 49.8 0.57 28.4 156.4 4,441.8 women 45.1 0.52 23.5 153.4 3,604.9

Allowance for pregnancy 5.5 20.9 d/ 115.0 Allowance for lactation 17.0 c/ 19.0 c/ 323.0

Total 567.5 13,053.7

Total safe level of daily per capita protein intake in milk or egg equivalents:

Total safe level of daily protein intake - 13,053.7 = 23.0 gm/day Mid-1964 population 567.5

Expressed at 70% protein quality 32.9 gm/day e/

a/ Weights here are 94% of those in the same column of Annex Table D-11; see footnote a/ of Annex Table D-9. b/ See p. 87 of FAO/WHO Energy and Protein Requirements (FAO, 1973). c/ The FAO/WHO expert committee suggests that in the absence of information on number of lactating women and duration of lactation, the allowance for all infants whether breastfed or not can be approximated by the requirement for lactation (17.0 grams) multiplied by the total number of infants. See FAO (1973), footnote b/ above, p. 85. d/ The number of pregnant women is estimated to be 10% more than the number of infants below 12 months of age. e/ The 1977 FAO estimate of requirements is 38.4 grams per capita per day. f/ The 1953 population total and age distribution are from 1953 census.

Source: Rural Health and Medical Education Mission calculations. - 172 -

Table D-11: SAFE LEVELS OF PER CAPITA PROTEIN INTAKE,1979

(1) (2) (3) (4) (5) (6) Total safe level of Average Safe level daily pro- body Safe level per per capita tein intake Age group weight kg body weight per day (g) Population (103 kg) (years) (kg) a/ per day (g) b/ (Column2x3) (millions) (Column 4x5)

Children

0-1 8 16.2 c/ 1-3 11 1.19 13.09 52.5 687.2 4-6 16 1.01 16.16 60.1 971.2 7-9 21 0.88 18.48 70.0 1,293.6

Male adolescents 10-12 28 0.81 22.68 40.6 920.8 13-15 40.3 0.72 29.02 37.3 1,082.4 16-19 52.8 0.60 31.68 40.1 1,270.4

Female adolescents 10-12 28 0.76 21.28 37.9 806.5 13-15 40.9 0.63 25.77 34.9 899.4 16-19 49.2 0.55 27.06 37.4 1,012.0

Adults: men 53 0.57 30.21 284.3 8,588.7 women 48 0.52 24.96 268.3 6,696.8

Allowance for pregnancy 5.5 (17.8) d/ 97.9 Allowance for lactation 17.0 c/ (16.2) c/ 275.4

Total 979.6 24,602.3

Total safe level of daily per capita protein intake in milk or egg equivalents: 25.1 gm

Total safe level of daily per capita protein intake in a diet of protein quality 35.9 gm e/ 70% relative to milk or eggs: a/ See footnote a/, Table D-9 for an explanationof average body weight estimatesfor China for individualsaged 13 and above. Estimates for younger children come from a 1975 9-city survey (Annex Table D-12). bl See p. 87 of FAO/WHO Energy and Protein Requirements(FAO, 1973). c/ The FAO/WHO expert committeesuggests that in the absence of informationon number of lactatingwomen and duration of lactation,the allowance for all infantswhether breastfed or not can be approximatedby the requirementfor lactation (17.0 grams) multipliedby the total number of infants. See FAO (1973), footnote b/ above, p. 85. d/ The number of pregnant women is estimatedto be 10% more than the number of infants below 12 months of age. e/ The 1977 FAO estimate of requirementsis 38.4 grams per capita per day.

Source: Rural Health and Medical Education Mission calculations. 4 4'0OI .40)' 4 ~. .0) .' . .1. . - 174 - Table D-13: MALNUTRITION: PERCENTAGE OF CHILDREN STUNTED, VARIOUS AGES, 1975

Males Females Age Group Urban National National Urban National National (Years) Beijing urban suburban Beijing urban suburban

3-3.5 1.7 4.4 21.8 0.3 4.4 24.2

5-5.5 1.3 5.9 21.5 1.4 3.8 24.5

7-8 1.1 4.4 26.1 1.9 5.8 26.8

9-10 1.2 4.5 23.0 4.8 6.9 33.0

11-12 8.4 10.6 37.1 6.2 13.1 43.6

13-14 16.1 22.7 50.0 4.8 11.1 34.8

15-16 10.6 14.9 39.0 3.0 4.0 10.0

17-18 4.1 7.6 23.6 2.0 2.7 7.5

Notes: (i) "Stunting" is defined in terms of a child having low height for his age; specifically a child is defined as stunted if his height is less than 90% of the median height for children of that age according to the NCHS standard. Nutritionists regard stunting as the appropriate measure for chronic (but not necessarily severe) malnutrition.

(ii) The national urban areas for which data are reported in this table are from a survey of nine cities - three in northern China, three in central China, and three in the south. The suburban areas are ones located just outside these nine cities; they are, therefore, probably somewhat better off than typical rural areas. The data from urban Beijing are from the same survey.

Source: "The Nutritional Status of Children in China: A Review of the Anthropometric Evidence", by D. Jamison and F. R. Trowbridge, Supplementary Paper No. 8 to this Report. - 175 -

Table D-14: HEIGHTS AND WEIGHTS OF YOUNG ADULTS IN URBAN AREAS OF SIXTEEN PROVINCES, 1979

Males Females

Height Weight Height Weight

Percentile Percentile Percentile Percentile position in position in position in position in Provinces cm. NCHS kg. NCHS cm. NCHS cm. NCHS

NATIONAL AVERAGE 170.3 17 58.9 12 159.0 29 51.5 24 (unweighted)

North Region

Beijing 172.7 26 67.1 31 161.2 42 53.5 30 Tianjin 171.5 21 60.1 14 159.8 33 52.4 26 Hebei NA NA NA NA NA NA NA NA Shanxi 170.8 19 59.7 13 160.0 34 52.9 28 Nei Mongol NA NA NA NA NA NA NA NA

Northeast Region

Liaoning 171.6 22 59.2 13 159.1 29 51.8 24 Jilin NA NA NA NA NA NA NA NA Heilongjiang 171.6 22 59.6 13 159.1 29 51.8 24

East Region

Shanghai 171.3 21 58.0 10 158.9 28 50.9 20 Jiangsu NA NA NA NA NA NA NA NA Zhejiang NA NA NA NA NA NA NA NA Anhui 169.7 15 57.8 10 158.6 26 50.7 19 Fujian 170.0 16 58.5 11 158.1 23 50.7 19 Jiangxi NA NA NA NA NA NA NA NA Shandong 171.8 22 60.8 14 160.3 36 53.0 28

Central South Region

Henan NA NA NA NA NA NA NA NA Hubei 170.3 17 59.3 12 159.6 32 52.4 26 Hunan 167.9 9 56.3 8 157.6 22 50.6 19 Guangdong 168.9 12 55.8 8 157.1 20 49.1 12 Guangxi NA NA NA NA NA NA NA NA

Southwest Region

Sichuan 168.5 11 56.9 9 157.2 20 50.0 16 Guizhou NA NA NA NA NA NA NA NA Yunnan 168.1 19 55.6 8 157.3 20 50.3 17 Tibet NA NA NA NA NA NA NA NA

Northwest Region

Shaanxi 170.8 19 59.3 12 160.0 34 52.5 26 Gansu 170.0 16 57.7 10 159.5 32 52.0 24 Qinghai NA NA NA NA NA NA NA NA Ningxia NA NA NA NA NA NA NA NA Xinjiang NA NA NA NA NA NA NA NA

Note: The Chinese young adults ranged in age from 18 to 25 years; in comparing their heights and weights to the NCHS growth curves, the age 21-22 years was used.

Source: Cm. and kg.: "A General Description of the Physical Shapes, Functions and Qualities of Chinese Children and Youth," Research Group for the Study of the Physique of Chinese Children and Youth Of the National Research Institute of Sports Science, 1979.

Percentiles: NCHS Growth Curves for Children, Birth - 18 Years, United States. National Center for Health Statistics, Public Health Service, U.S. Department of Health and Human Services, November 1977. - 17, -

Table D-15: HEIGHTS AND WEIGHTS OF 7-YEAR OLD CHILDREN IN URBAN AND RURAL AREAS OF SIXTEEN PROVINCES, 1979 (PHYSICAI MEASURES)

Boys Girls Height (cm) Weight (kg) Height (cr) Weight (kg) Provinces Urban Rural Urban Rural Urban Rural Urban Rural

NATIONAL TOTAL 121.2 117.3 21.3 20.3 120.4 116.3 20.63 19.6 (4.97) (4.92) (2.40) 2.13) (5.03) (4.81) (2.44) (2.14)

North Region

Beijing 123.2 118.3 22.3 20.7 123.0 117.7 21.8 20.2 (4.77) (4.80) (2.52) (2.21) (5.06) (4.87) (2.60) (2.27) Tianjin 123.8 120.0 22.8 21.5 121.9 1181.0 21.6 20.5 (4.75) (4.75) (2.65) (2.13) (5.21) (4.64) (2.74) (2.20) Hebei NA NA NA NA NA NA NA NA

Shanxi 121.5 117.3 21.4 20.4 119.7 115.7 20.4 19.3 (4.41) (4.75) (2.04) (2.03) (4.90) (3.89) (2.20) (1.84) Nei Mongol NA NA NA NA NA NA NA NA

Northeast Region

Liaoning 121.6 118.8 21.1 21.1 121.0 117.3 20.5 20.3 (4.95) (4,47) (2.26) (2.17) (4.81) (4.99) (2.54) (2.39) Jilin NA NA NA NA NA NA NA NA

H1eilongjiang 122.3 115.8 21.6 19.9 121.7 115.8 20.7 19.4 (4.87) (4.68) (2.41) (1.99) (4.52) (4.98) (2.05) (2.10) East Region

Shanghai 112.6 118.0 22.0 70.4 122.2 117.3 21.5 19.6 (4.99) (4.71) (2.67) (2.22) (4.61) (4.45) (2.73) (1.98) Jiangsu NA NA NA NA NA NA NA NA

Zhejiang NA NA NA NA NA NA NA NA

Anhui 121.3 118.5 21.3 20.9 120.3 117.8 20.2 20.1 (4.85) (4.26) (2.35) (2.09) (4.39) (4.46) (2.02) (2.03) Fujian 119.4 117.0 20.8 19.9 118.5 116.8 20.1 19.6 (5.10) (4.76) (2.32) (2.10) (4.63) (4.47) (2.22) (1.97) Jlangxi NA NA NA NA NA NA NA NA

Shandong 121.8 117.8 21.7 20.5 120.5 115.9 20.7 19.5 (5.07) (5.20) (2.51) (2.16) (5.14) (4.90) (2.34) (2.21)

Central South Region

Henan NA NA NA NA NA NA NA NA

Hubei 121.2 116.9 21.3 20.0 120.6 115.7 21.0 19.3 (4.31) (4.59) (2.14) (1.90) (4.74) (4.21) (2.30) (1.83) Hunan 120.1 116.4 20.6 19.7 119.4 115.51 20.2 19.2 (4.95) (4.14) (2.22) (1.90) (4.95) (4.90) (2.23) (2.07) Guangdong 121.7 115.8 21.1 19.3 121.2 115.1 20.4 18.6 (4.54) (4,64) (2.12) (1.83) (5.27) (4.54) (2.53) (1.37) Guangxi NA NA NA NA NA NA NA NA

Southwest Region

Sichuan 118.7 113.5 20.5 19.2 1181.1 112.9 19.6 18.5 (4.97) (4.93) (2.13) (1.98) (5.16) (4.93) (2.10) (2.0) Guizhou NA NA NA NA NA NA NA NA

Yunnan 118.8 117.3 20.1 20.0 119.2 116.3 20.0 19.2 (4.57) (4.44) (2.17) (1.79) (4.59) (4.23) (2.17) (1.81) Tibet NA NA NA NA NA NA NA NA

Northwest Region

Shaanxi 120.7 116.2 21.2 20.1 119.4 115.0 20.6 19.5 (4.47) (5.23) (2.18) (2.20) (5.03) (4.77) (2.57) (2.11) Gansu 120.3 117.6 20.8 20.1 119.4 115.0 20.6 19.5 (4.63) (4.83) (2.16) (2.05) (4.71) (5.06) (2.36) (2.31) Qinghai NA NA NA NA NA NA NA NA

Ningxia NA NA NA NA NA NA NA NA

Xinjiang NA NA NA NA NA NA NA NA

Note: The standard deviations of the distribution of heights and weights are shown in parenthesis below the mean values. The figures reported are for children between the ages of 7 and 8 years of age.

Source: Research on Physical Shapes, Functions and Qualities of Chinese Children and Youth, by the Research Group in the Study of the Physique of Chinese Children and Youth. Beijing, 1982. (Various tables from section 5.) - 177 -

Table D-16: HEIGHTS-FOR-AGE OF 7-YEAR OLD BOYS, RURAL AND UIRBANAREAS OF 16 PROVINCES, 1979

(measured as percent of NCHS median and in Z-Score UJnits)

Province Height for Age

As % of NCHS median a/ In Z-Score unitsb/ Urban Rural Urban Rural

NATIONAL TOTAL 97.5 94.3 -0.6 -1.4

North Region

Beijing 99.1 95.1 -0.2 -1.2 Tianjin 99.6 96.5 -0.1 -0.8 Hebei NA NA NA NA Shanxi 97.7 94.3 -0.5 -1.4 Nei Mongol NA NA NA

Northeast Region

Liaoning 97.8 95.5 -0.5 -1.1 Jilin NA NA NA NA Heilongjiang 98.3 93.1 -0.4 -1.6

East Region

Shanghai 98.6 94.9 -0.3 -1.2 Jiangsu NA NA NA NA Zhejiang NA NA NA NA Anhui 97.5 95.3 -0.6 -1.1 Fujian 96.0 94.1 -1.0 -1.4 Jiangxi NA NA NA NA Shandong 97.9 94.7 -0.5 -1.3

Central South Region

Henan Hubei 97.5 94.0 -0.6 -1.4 Hunan 96.6 93.6 -0.8 -1.5 Guangdong 97.9 93.1 -0.5 -1.6 Guangxi NA

Southwest Region

Sichuan 95.5 91.3 -1.1 -2.1 Guizhou NA NA NA NA Yunnan 95.5 94.3 -1.1 -1.4 Tibet NA

Northwest Region

Shaanxi 97.1 93.4 -0.7 -1.6 Gansu 96.7 94.6 -0.8 -1.3 Qinghai NA NA NA NA Ningxia NA NA NA NA Xinjiang NA NA NA NA

a/ The NCHS standards are based on a U.S. National Center for Health Statistics sample of U.S. children.

b/ Z-scores represent the number of standard deviations above (+) or below (-) the NCHS median that an entry is.

Source: "The Nutritional Status of Children in China: A Review of the Anthropometric Evidence," by D. T. Jamison and F. R. Trowbridge, Supplementary Paper Number 8 to this Report. 178 - Table D-17: MAJOR MICRONUTRIENTDEFICIENCY DISEASES

Deficiency Current status

Rickets (Vita- Either insufficientexposure to sunlight or insufficient min D defi- dietary intake of vitamin D can lead to rickets, the ciency) consequenceof which is inadequate bone development. This has historicallybeen a major problem in North China and, although there have undoubtedlybeen improvements,it remains so; a 1979 10-provincesurvey of over 70,000 children 3 years old and younger found a prevalence of rickets of 29 percent. There was virtually no difference between rural and urban areas. The role of large monthly doses of vitamin D in prevention is now being studied.

Anemia (iron Anemia, which leads to low energy levels, can result from deficiency) iron-deficientdiets or from losing the blood's iron because of parasiticinfection or menstruation. As with many developing countries, anemia is widespread in China; a 1979 survey of children 1 month to 7 years of age in Beijing and Shanxi found 47 percent moderately anemic (hematocritof 9-12 g/mm) and 2.4 percent severely anemic (hematocritless than 9 g/mm).

Keshan disease Keshan disease, named for a county in China where it was (Selenium severely endemic, is found in many of the hilly and deficiency) mountainousregions of China; prevalence in those regions reaches 1 percent of children under ten years old. In the recent past the case fatality rate was close to 80 percent; improvementin treatmentmethods has reduced this to 13 percent. Selenium supplementationof food appears to be an effectivepreventive measure. Recent research is suggesting that selenium deficiency is also a risk factor for Kaschin-Beckdisease, which afflicts joints and limbs. Far more people are affected by Kaschin-Beckdisease, than by Keshan disease; in HeilongjiangProvince, for example, almost 2% of the population suffers from Kaschin-Beck disease.

Goiter (iodine Iodine is an essential ingredient in the hormones produced deficiency) by the thyroid gland in the throat, and its absence in the diet causes the thyroid to swell with the visible symptoms of goiter. High prevalence of goiter is associatedwith cretinism,and there is some evidence that moderate iodine deficiency is also harmful. A 5-year goiter control program (providingiodized salt and, sometimes, injections of iodized oil) has recently been judged successfulin 607 counties of North China. Over 10 million individualshave been cured and 130 million are being protected;information on remainingand new cases was not, however, provided, and it appears likely that there are pockets where goiter remains a problem. - 179 -

Table E-1: STATE BUDGET EXPENDITUREON HEALTH, 1957-1981

(Billion Yuan)

Recurrent Capital Total

Central Local Total Hlealtha/ Government Total Government Government Insurance

1957 0.482 N.A. N.A. 0.069 N.A. N.A. 0.551

1965 0.929 N.A. N.A. 0.087 N.A. N.A. 1.016

1970 1.047 N.A. N.A. N.A. N.A. N.A. N.A.

1975 1.992 N.A. N.A. 0.178 N.A. N.A. 2.170

1976 2.095 N.A. N.A. 0.186 N.A. N.A. 2.281

1977 2.232 1.809 0<423 0.273 0.158 0.115 2.505

1978 2.726 2.242 0.484 0.321 0.195 0.126 3.047

1979 3.172 2.602 0.570 0.421 0.236 0.185 3.593

1980 3.684 3.016 0.660 0.571 0.263 0.308 4.255

1981 4.054 3.274 0.780 0.607 0.280 0.327 4.661 a/ This category includes recurrentexpenditure on health by the Central Ministry of Public Health and local Bureaus of Health.

Sources: 1957-1976: China: SocialistEconomic Development,World Bank Report No. 4072-CHA, June, 1981, StatisticalAppendix, Table 5.7.

1977-1981:These data were provided to the World Bank October, 1982, Rural Health and Medical Education Mission by the Ministry of Public Health. - 180 -

Table E-2: ALLOCATION OF RECURRENT STATE BUDGET EXPENDITURE ON HEALTH, 1981

Yuan Percent (Millions) of Total

Hospitals 1,193.99 36.47

Hospitals of Traditional 103.59 3.16 Chinese Medicine

Subsidy to Commune 721.44 22.04 Health Centers

Anti-Epidemic Activities 475.33 14.52

Drug Control Institutes 35.86 1.10

Maternal and Child Health 68.30 2.09

Middle Level Training 169.68 5.18 Schools

Scientific Health 114.09 3.49

Cooperative Health 23.55 0.72 Servicesa/

Other 368.09 11.24

Total 3,273.92 100.00

a/ This provides a subsidy for the training of barefoot doctors but excludes salary subsidies.

Source: These data were provided to the October 1982 Rural Health and Medical Education World Bank mission by the Ministry of Health. - 181 -

Table E-3: HEALTH SECTOR BUDGETARY RATIOS, 1957-1980

Percent of Total State Budget Expenditure 1/ Year Recurrent Capital Total

1957 2.7 0.6 1.8

1965 3.0 0.6 2.2

1970 3.0 N.A. N.A.

1975 4.0 0.5 2.6

1976 4.2 0.6 2.8

1977 4.1 0.9 3.0

1978 4.1 0.7 2.7

1979 4.2 0.8 2.8

1980 4.8 1.6 3.7

t/ Demominators are recurrent, capital and total state budget expenditures respectively.

Sources: These data are from Table E-1 and China; Socialist Economic Development. World Bank Report No. 4072-CHA, June 1981 Statistical Appendix, Table 5.7. - 182 -

Table E-4: PER CAPITA STATE EXPENDITUREON HEALTH 1957-1981

(Yuan)

Year Recurrent Capital Total a/

1957 0.72 0.10 0.82

1965 1.26 0.12 1.38

1970 1.25 N.A. N.A.

1975 2.16 0.19 2.35

1976 2.24 0.20 2.44

1977 2.36 0.29 2.65

1978 2.85 0.34 3.19

1979 3.27 0.43 3.70

1980 3.76 0.58 4.34

1981 4.09 0.61 4.70 a/ These data were derived from the "interimmodel" population totals in Table A-2 and the health expendituredata in Table E-1.

Source: These data were provided to the October, 1982, World Bank Rural Health and Medical Education mission by the Ministry of Public Health. Table E-5: COST AND REVENUES OF MEDICAL COLLEGE AFFILIATE.D HOSPITALS (unit - 10,000)

Operating Income

Current Expenditure Outpatients Inpatients Total Outpatients Inpatients 1980 1981 1980 1981 1980 1981 1980 1981 1980 1981 1980 1981

Beijing Traditional Medical 286.7 400.1 91 130.5 30.4 34.4 121.4 164.9 402,507 433,098 2,656 2,703 College

Guangzhou Traditional Medical 391.7 534.5 209 233.4 64.1 82.5 273.1 315.9 883,165 917,338 5,695 6,195 College

Beijing Medical College 1,639.3 2,233.7 594.8 681.8 404.4 393.1 999.2 1,074.9 2,098,300 2,262,551 31,646 28,553

Shanghai First Medical College 1,863.9 1,898.9 654.9 724.9 584.1 594.4 1,239.0 1,319.4 2,356,978 2,457,357 37,945 38,498

Zhangahan Medical College 1,342.3 1,552.5 584.7 713.8 374.5 462.3 959.2 1,176.1 1,892,160 1,974,607 30,578 29,575

Shandong Medical College 457.4 582.2 188.6 206 131 139.4 319.6 345.4 511,439 579,471 9,379 9,627 o

Hunan Medical College 925.5 1,104.1 265.9 304.5 253.3 307.2 519.3 611.7 971,365 1,004,645 20,336 22,092

Wuhan Medical College 1,208 1,306.3 442.1 494.8 362.2 416 809.3 910.8 1,636,685 1,494,229 27,650 29,202

Sichuan Medical College 803.6 948.4 179.1 203.8 187.9 205.3 367.6 409.1 843,564 901,536 14,795 16,437

Xi'an Medical College 729.6 859.2 188.3 212.5 177.2 218.2 365.5 430.7 1,077,002 1,110,928 20,625 20,998 (Shaanxi Province)

Shenyang Medical 1,327.8 1,430 425.2 479.9 288.4 312 713.6 791.9 1,55Z,105 1,694,233 29,883 30,658 College of China

Bethune Medical College 1,093.9 1,305.2 262.9 300.9 301.2 330 564.1 630.1 1,048,133 1,108,302 30,477 29,742

Total a/ 12,069.7 14,153.1 4,086.5 4,686.8 3,158.7 3,494.9 7,245.2 8,181.7 15,274,412 15,948,295 261,666 264,280 a/ The Capital Medical College Hospital is financed separately and is not included in these totals.

Source: These data were provided to the October, 1982, World Bank Rural Health and MedicAl Education mission by the Ministry of Public Health. Table E-6: EXPENDITURES ON MEDICAL COLLEGES BY THE MINISTRY OF PUBLIC HEALTH, 1980-1982

(in thousands of Yuan)

Medical Education Affiliated Hospital Capital Contribution 1980 1981 1982 1980 1981 1982 1980 1981 1982

Beijing Traditional Medical 2480 3000 3490 1620 2470 3830 3230 2830 2610 College Guangzhou Traditional Medical 2440 2620 3430 2250 2580 2660 1525 875 1580 College Beijing Medical College 5670 6150 7600 7600 13530 16960 7880 8610 7900 Shanghai First Medical College 5570 5800 7600 8950 10950 11200 4060 2500 3110 Zhangshan Medical College 1330 5800 7010 5900 7370 7800 2450 3150 2060 Shandong Medical College 3000 3930 4650 2170 3140 3290 2060 1840 1400 c Hunan Medical College 3320 3710 4300 5200 6440 6840 1760 1895 1510 Wuhan Medical College 4170 4670 5160 4620 5350 5670 2420 2230 2050 Sichuan Medical College 4990 5580 6730 4850 6220 6520 2240 3010 2500 Xian Medical College 3410 3810 4460 4600 5730 6050 2470 2010 1990 (Shaanxi Province) Shenyang Medical College of 3860 4160 5010 6160 7420 7840 3210 3540 3180 China Bethune Medical College 4070 4660 5370 6050 7110 7540 3920 2940 2120 Capital Medical College 1160 1600 2400 ------NA NA NA of China

Total 45,470 55,490 67,210 59,970 78,310 86,200 37,225 35,430 32,010

Source: These data were provided to the October, 1982, World Bank Rural Health and Medical Education mission by the Ministry of Public Health. - 185 -

Table E-7: PROVINCIAL DISTRIBUTION OF STATE HEALTH EXPENDITURES, 1979-81

(in millions of yuan)

Recurrent Government Insurance Capital Construction

Provinces 1979 1980 1981 1979 1980 1981 1979 1980 1981

NATIONAL TOTAL 2,506.17 2,889.31 3,118.21 570.36 668.99 785.30 NA NA 546.29

North Region

Beijing 60.76 64.64 76.11 22.79 27.52 32.26 NA NA 16.21 Tianjin 46.57 57.94 66.40 11.25 13.46 15.66 NA NA 18.21 Hebei 104.37 117.67 124.05 29.00 34.89 40.17 NA NA 25.28 Shanxi 65.57 73.19 74.72 16.94 19.20 22.11 NA NA 11.88 Nei Mongol 72.64 75.81 81.60 17.04 18.14 22.34 NA NA 8.11

Northeast Region

Liaoning 121.33 144.24 150.05 24.79 27.69 32.84 NA NA 45.37 Jilin 80.18 94.33 107.82 13.62 15.61 18.55 NA NA 8.89 Heilongjiang 100.56 120.92 128.08 20.07 22.95 26.47 NA NA 18.49

East Region

Shanghai 71.01 87.54 103.30 17.99 19.73 21.59 NA NA 11.20 Jiangsu 128.29 147.87 162.71 24.06 28.82 32.39 NA NA 28.03 Zhejiang 88.69 109.05 122.19 18.78 22.07 24.62 NA NA 14.68 Anhui 97.64 110.70 110.00 19.07 22.94 24.14 NA NA 13.04 Fujian 66.92 76.30 91.67 14.84 16.57 19.78 NA NA 17.81 Jiangxi 77.89 86.29 92.59 14.15 18.10 22.46 NA NA 12.57 Shandong 174.54 201.75 210.61 30.40 36.92 42.61 NA NA 26.93

Central South Region

Henan 140.25 160.03 173.15 48.18 55.99 62.53 NA NA 24.98 Hubei 127.43 157.76 163.03 33.53 40.53 53.66 NA NA NA Hunan 111.94 134.15 139.20 23.75 28.95 32.58 NA NA 22.39 Guangdong 125.87 150.19 169.68 28.90 35.57 46.74 NA NA 48.81 Guangxi 77.20 81.98 89.46 17.95 21.23 26.14 NA NA 15.69

Southwest Region

Sichuan 182.75 212.63 224.96 47.22 53.31 60.72 NA NA 35.92 Guizhou 61.27 63.11 70.55 13.16 14.50 17.32 NA NA 8.80 Yunnan 70.69 77.90 86.79 16.74 19.12 21.79 NA NA 18.74 Tibet 23.07 26.12 28.67 1.03 0.88 0.94 NA NA 2.93

Northwest Region

Shaanxi 76.22 89.88 97.58 19.34 22.86 28.01 NA NA 16.46 Gansu 52.91 56.27 56.81 11.04 12.66 13.95 NA NA 11.05 Oinghai 25.34 26.67 27.75 3.90 5.06 6.17 NA NA 6.92 Ningxia 20.43 20.32 20.61 2.93 3.47 4.17 NA NA 6.32 Xinjiang 53.95 64.05 68.08 7.89 10.27 12.62 NA NA 11.24

Source: The provincial expenditure data were provided to the October, 1982, Rural Health and Medical Education mission by the Ministry of Public Health. Population data used are from Table A-5. - 186 -

Table E-8: PROVINCIAL DISTRIBUTION OF STATE HEALTH EXPENDITURES PER CAPITA, 1979-1981

(in yuan)

Recurrent Government Insurance Capital Construction

Provinces 1979 1980 1981 1979 1980 1981 1979 1980 1981

'NATIONAL TOTAL 2.60 2.96 3.15 0.59 0.68 0.79 NA NA 0.55

North Region

Beijing 7.05 7.34 8.44 2.65 3.12 3.58 NA NA 1.80 Tianjin 6.47 7.85 8,77 1.56 1.82 2.07 NA NA 2.41 Hebei 2.06 2.29 2.38 0.57 0.68 0.77 NA NA 0.48 Shanxi 2.70 2.97 2.99 0.70 0.78 0.89 NA NA 0.48 Nei Mongol . . .a/ 4.06 4.30 .. .8 / 0.97 1.18 NA NA 0.43

Northeast Region

Liaoning ... a/ 4.16 4.26 .. a/ 0.80 0.93 NA NA 1.29 Jilin .. .a/ 4.29 4.84 .a. ./ 0.71 0.83 NA NA 0.40 Heilongjiang .. .a/ 3.79 3.97 ... a/ 0.72 0.82 NA NA 0.57

East Region

Shanghai 6.33 7.66 8.87 1.60 1.73 1.85 NA NA 0.96 Jiangsu 2.19 2.50 2.72 0.41 0.49 0.54 NA NA 0.47 Zhejiang 2.35 2.86 3.17 0.50 0.58 0.64 NA NA 0.38 Anhui 2.04 2.29 2.24 0.40 0.47 0.49 NA NA 0.27 Fujian 2.72 3.05 3.60 0.60 0.66 0.76 NA NA 0.70 Jiangxi 2.43 2.66 2.82 0.44 0.55 0.68 NA NA 0.38 Shandong 2.43 2.77 2.86 0.42 0.50 0.58 NA NA 0.37

Central South Region

Henan 1.96 2.21 2.36 0.67 0.77 0.85 NA NA 0.34 Hubei 2.77 3.38 3.45 0.73 0.87 1.14 NA NA NA Hunan 2.16 2.55 2.61 0.45 0.55 0.62 NA NA 0.42 Guangdong 2.23 2.62 2.91 0.51 0.62 0.80 NA NA 0.84 Guangxi 2.25 2.34 2.50 0.52 0.61 0.73 NA NA 0.44

Southwest Region

Sichuan 1.88 2.17 2.27 0.49 0.54 0.61 NA NA 0.36 Guizhou 2.26 2.29 2.52 0.49 0.53 0.62 NA NA 0.31 Yunnan 2.27 2.47 2.71 0.54 0.61 0.68 NA NA 0.49 Tibet 12.68 14.20 15.33 0.57 0.48 0.50 NA NA 1.57

Northwest Region

Shaanxi 2.73 3.18 3.42 0.69 0.81 0.98 NA NA 0.58 Gansu 2.81 2.95 2.94 0.59 0.66 0.72 NA NA 0.57 Oinghai 6.87 7.09 7.25 1.06 1.35 1.61 NA NA 1.81 Ningxia 5.69 5.51 5.44 0.82 0.94 1.10 NA NA 1.67 Xinjiang 4.33 5.06 5.29 0.63 0.81 0.98 NA NA 0.87

aB boundary changes in mid-1979 preclude estimation of per capita totals for 1979.

Source: These data were derived from Statistical Annex Tables A-5 and E-7. - 187 -

Table E-9: SALARIES OF COUNTY-LEVELHEALTH PERSONNEL, SHANDONG PROVINCE, 1982

Category Grade range Salary range (Yuan per month)

Public Health

Director 7 - 1 147 - 316 Senior doctor 14 - 6 59 - 168 Assistant doctor 17 - 6 41 - 168 Technician 19 - 15 31 - 54

Clinical

Director 7- 1 147- 316 Visitingdoctor 11 - 6 86 - 168 Senior doctor 14 - 9 59 - 115 Assistant doctor 17 - 11 41 - 86

Pharmacy

Director 7- 1 147- 316 Pharmacist 14 - 6 59 - 168 Assistant pharmacist 17 - 11 41 - 86 Technician 20 - 15 29 - 54

Auxiliary

Head nurse or midwife 14 - 6 59 - 168 Nurse or midwife 17 - 11 47 - 86 Nurse aides and MCH personnel 20 - 15 29 - 54

Source: These data were obtained from the Bureau of Public Health, Shandong Province. - 188 _

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_ I~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

eijing Thnhaianjin inguSichuan YnrnBiigSaga

- Animal Center Matena Medica Hematology Dermatology - Biomedical Engineenig Medical Biology - Acupuncture Traditional Medicine - Antibiotcs (Phanmacology) (in Nanjing) Blood Transfusion Basic Medicine [Capital Parasitology" Padiation Medicine Traditional Medicine Hospial affiliated) Traditional Pharmacology - Cardiovascular Disease Affiliated Hospitals- (Fuwai Hospital Guangonmen Hospital offiliated) and Xiyuan Hospital - Clinical Medicine - Epidemiology and Infectious Disease" - Family Ptanning - Medical Inforrnation - Oncology (Rian Hospital affiliated) Pediatrics Plastic Surgery (Plastic Surgery Hospital affiliated) Public Health" Virology"

'These Institutes are scheduled to become part of the newly created National Center tor Preventive Medicine.

WB 2S356 Chart 3 Organizationand Functionsof TheState Pharmaceutical Administration

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StatePhairnoceutical Administration

National Corp. of Phonceulr China Natinal Heat Care GeneradCOfice TheChina National China National Herbal China National Drug China NatbonalMedical Equip- cal Economic an ehal ProductsImports & Exports

ForeignAfkirs Pharmaceutical Corporation Medicine Corporation Corporation ment ProductionCorporation International Cooperation Corporation 1

Parwnn ResponsibilityProduction ot ResponsibilitvGrowi.ng collect- ResponsibilityDistribution of Responsibility:Producton of ResponsibilityScientdtic, tech- Responsibility:This newly tormned 0

vuaOuolitY CI)heaf chernical (i.e.western) drugs for ing,processing and distributing chemical medicine medical equipment nical & economic cooperation corporationis assuming respon- DrugOlt Cn the entire country. Chineseherbal medicine. with foreign corporations and sibilityfor the irmportand export Construction ~~~~~~~~~~~~~~~~~~~~~~~~~~Size140,000staff woirking in Sze~ f0.000staff employed!in governmentsand with muffl- at pharmiaceuticalstiom the Cor_ucio Size Em'ploys280,000 people in Size Over80.000 people 3,000distribution centers amroud 400 mniddle-andJ large-scale notional OrganizationsThey slate esport-importcorporations Lobor oove700 middle- ond large- employed in 400units (factories, the country (1 per county plus tactories plusnumerous small coordinate patent & license that had previoustyheld these scale factories and numerous formsetc). urban),and t 70.000people tactories. arrangernents trom abroad as responsibilites. Personnei sncillerfactones. working in numerousretail shops. well as joint ventufreseither in Output: 650,000to 700.000mt Valueof Output Approximately China or abroad. Output: Ina tpical recent pear per year Financing: Thee isapproxi- 700million yuan per year MaenridsResearch outputwas aboutl50.000mt matelv a 15%markup between Size 30persons. c duccn withinthe centralplant & up to OutputValue: One billion yuan purchase and salepnce. These Finance ord Pr 20.000mt ouhide the plant. per year rnorkupscoverthe entire cost Policy Variety:Produces 1.100diferent EnterpriseManagement dnrgs that are packaged into Distdbuionof SalesAnyvone can over 3,000fintl products. buy trom retail shops,but 90% ot products sold to health units Output Value 6 billion yuan per such as hospitols;remaining peor 10% purchased directlyby individuals or bv groups like the All-China Federation ot Viarnen,

vVA25355 value of these findings and provides Demographic Aspects of Worid Bank valuable insights into possibilities for Migration in West Africa- P'ublications implementing mass programs for K. C. Zachariah and others needy people in villages throughout of Related the world. Volume I Staff Working Paper No. 414. September Interest 1980, 369 pages (including statistical an- Volume 1: Integrated Nutrition nexes, bibliography). and Health Care Stock N\o. WP 0414. $15. Arnfried A. Kielmann and others This volume provides detailed data Volume 2 suggesting that synergism between Staff Working Paper No. 415. September malnutrition and infection is probably 1980. 391 pages (including statistical an- the greatest cause of mortality, mor- nexes, bibliography). bidity, and retarded growth and devel- Stock No. WP 0415. $15. Me Aftocan Trypano omtases: opment in children. In an experiment (These WorkingPaps are background Methods and Concepts of over a period of four years, viUlagers tdies forMigrapers We aca: Control and Eradication in received nutrition care, general health 5tudiesfor Migration in West Africa: Relation to Development care to control infections, or both. Dra- Demographic Aspects, describedin this C. W. Lee and J. M. Maurice matic improvements, including a 40%- section.) Here is a practical cost-benefit ap- 50%decline in mortality, a 20% reduc- Economic Motivation versus proach to an age-old problemnecting-tion in duration of morbidity, and in- City Lights: Testing pahu ans anlivestokblem eod thaffecting creases in height and weight. In addi- Hpthesesa ntr humnansand livestock alike, the Afri- tion, detailed information on costs is Hypotheses about Inter- can Trypanosomiases. Describes new presented that permits the most com- Changwat Migration in techniques that offer tsetse control plete analysis of cost-effectiveness and Thailand without destroying game animals. progTam relevant costs and benefits Fred Amold and Susan H Also sucnmarotes current research in yet available in this kind of field re- Cochran genetic control, the use of traps and search. The study focuses directly on e screens, attractants, and pheromones. practical program implications and Staff WorkingPaper No. 416. September TechnicalPaper No. 4. 1983. 107 pages. ways in which such integrated services 1980. 41 pages(including footnotes, refer- ISBN 0-8213-0191-8. Stock No. BK 0191. can be applied under field conditions. ences). 55. The JohnsHopkins UniversityPress. 1984. Stock No. WP 0416. 53. A-nlyzngthe Impact of 288pages. Experiments in Family Health Servicesn Project LC82-23915. ISBN 0-8018-3064-8.Stock Planning: Lessons from the Experiences from India, Oeveloping World Ghana, and Thailand Roberto Cuca and Catherine S. Rashid Faruqee Volume II. Integrated Family Pierce StaffeorinStaff Working Paper No. 546. 1982. 44 Planning adHand HealthltCremental Car A comprehensiveeffortsin the review developing of experi- world pagS.N081-179 tc V.W 56 Carl E. Taylor and others to determine more effective ways of ISBN 0-82133117-9. Stock No. WP 0546. To village people, politicians, and in- providing family planning services. ternational health planners, health and The JohnsHopkins UniversityPress, 1978. family planning have always seemed 276 pages (including bibliography, index of NEW to fit naturally together. But in the experiments). early 1960s, when international aware- LC 77-16596.ISBN 0-8018-2013-8,Stock Child and Maternal Health ness of the social and economic conse- No. JH 2013, $19.50 hardcover,ISBN 0- Seices indMarndia: THeah quences of surging population growth 8018-2014-6,Stock No. JH 2014, $8.95 Services in India: The moved family planning into a position paperback. Narangwal Experiment of high prioritv, some international What can primary health care and agencies began to advocate separation Family Planning Programs: An family planning do for women and of famidlyplanning from health serv- Evaluation of Experience children in the poor and deprived ices. In international policy discussions Roberto Cuca areas of the world? Some of the most the question continues to be impor- specific evidence available todav to tant. This volume analyzes this ques- Staff WorkingPaper No. 345. 1979. 146 support the benefits of these services tion and provides arguments and evi- pages(including 2 annexes, references). is contained in these two studies, dence to support integration of health Stock No. WP 0345. 55. which represent the findings of re- care and family planning; it outlines search carried out during 1967-74in the purposes underlying the research Fertility and Education: What twenty-six villages in Punjab, India. in this area; and it proposes policy Do We Really Know? Members of the research staff, which questions regarding the effectiveness, Susan H. Cochrane started with 15 people and grew to efficiency, and equity of such an inte- A model identifying the many chan- about 150 by the end of the project, gration. nels through which education might spent many years working with, and The Johns Hopkins UniversityPress. 1984. sharing the lives of, villagers. The 256 pages. depth of understanding that came LC 83-23915. ISBN 0-8018-2830-9.Stock Prices subject to change without notice from this type of sharing enhances the No. rH 2830. $22.50. and may vary by country. act to determine fertlitv and a review Health Issues and Policies in Kenya: Population and of the evidence ot the relation between the Developing Countries Development education and the intervening vaia- Fredrick Goiladav (See description under Countrv b[es in the model that affect fertility. Staff Working PaperINo. 412, 1980. so Studies listng.) The Johns Hopkins University Press, 1979. a W I88 pages (including bibliography, index), p ges. LC .78-26070.ISBN 0-8018-2140-1.Stock Stock NVo.WP 0412. 3. No. JH 2140, 36.95 paperback. Health, Nutrition, and Family Migration in West Africa: Planning in India: A Survey of Demographic Aspects Experinents and Special K. C. Zachariah and Julien Conde Fertility and Its Regulation in Eperoje ts adSeilThe first study of the large-scale move- Bangladesh Prajcshi h ment of people in nine West African R. Amin and Rashid Faruqee Rashid Faruqee and Ethna Johnson countries. Discusses the volume and Staff Working Paper No, 507. 2982. 108 direction of internal and exteral flows Staff Working Paper No. 383. 1980. 54 pages (including references). and the economic and social character- ages (including references. Stock No. WP 0507. 55. istics of migrants. Stock No. WP' 0383. 3.3. A ioint World Bank-OECD study. Oxford Infant and. Child Mortality as a LiniversityPress, 1981. 166 pages (includ- Determinant of Fertility: The ing 22 maps, bibliography, index). Health Policy Implications LC 80-21352.ISBN 0-19-520186-8,Stock Fredrick Golladay, coordinating Susan Hill Cochrane and K. C. No. OX 520186, 519.95 hardcover;ISBN author Zachariah 0-19-520187-6,Stock No. OX 520187, Draws on experience gained from An illustrative analvsis that suggests 38.95 paperback. health components of seventv World infant mortality mav be an important Bank projects in forty-four countries component of a fertility reduction pro- between 1975 and 1978. Emphasizes gram in countries where mortalitv is o a the disproportionately high expendi- high and few couples are able to have Populahon and Family tures incurred on curative medicine, the number of surviving children they Planning in Bangladesh: A maintenance of expensive hospitals, desire. Study of the Research and sophisticated training of medical World Bank Staff Working PaperNo. 556. Mohammad Alauddin and Rashid personnel at the cost of preventive 193 4pgs aue care for the majoritv of the people. 1983. 44 pages. Faruqee Points out that low-cost health care ISBN 0-8213-0147-0.Stock No. WP 0556. Reviews major studies on family plan- systems are feasible and recommends 53 ning and on tertility trends, profiles, svstemsare feankibleginreguaandr ndit S. .and determinants. Evaluates results of that the Bank begin regular and direct Integrating Family Planning such studies and critiques their meth- lending for health, in addition to having health components as part of pro- with Health Services: Does It odology and application. Underscores jects in other sectors. Help? need for continued study and suggests Sector Policy Paper. 1980. 90 pages (in- Rashid Faruqee directions for future research to improve the Bangladesh population ;uding 8 annexes,4 figures, map). Staff Working PaperNo. 515. 1982. 47 problem. Stock Nos. BK 9066 (Arabic).BK 9067 pages. World Bank Staff Working PaperNo. 557. (English). BK 9068 (French),BK 9069 ISBN 0-8213-0003-2.Stock No. WP 0515. 1983. 176 pages. (Spanish).S5. - $3. ISBN 0-8213-0150-0.Stock No. WP 0557. 35.

l lG \ \ }Visit the WorldBank l llKStet ~ whenyBookstore Population and Poverty in the ______SUWwhen you are in Developing World =I t t Cm Washington,D.C. Nancv Birdsall Staff Working PaperiNlo. 404. 1980. 96 g SbSeetg I } pages(including 2 appendixes,bibliography). 5 - s s No.\ \ WPlStock 0404. 53.

H Street

HStreet < | | - LafayetteSquare Population Policy and Family

!5~* i 1 ______I__I__I Planning Programs: Trends in * Avenue Policy and Administration Kandiah Kanagaratnam and GStreet The WhiteHouse Catherine S. Pierce StaffWorking Paper No. 447. 1981.80 .x I I I pagesI (including bibliography, appendixes). WorldBank Bookstore Stock No. WP 0447. 33. NEW published as World Populatzon Prowec- falling mortalitv, and urbanization- tions: Short- and Long-term Projections by factors that tend to lower fertility else- Short-term Population Age and Sex for All Countries, with Re- where. Calls for a viable population Projection, 1980-2020 and Long- lated Demographzc Statistics policy and programs appropriate to term Projection, 2000 to 1983. 391 pages. the culture. Stationary Stage by Age and ISBN 0-8213-0355-4. S30 paperback. Staff Working Paper No. 559. 1983. 116 Sex for All Countries of the pages. World NEW ISBN 0-8213-0152-7. Stock NVos.WP Mv T. Vu, under the supervision Rapid Population Growth in of K. C. Zachariah Sub-Saharan Africa: Issues and This report gives detailed population SRegional Aspects of Family projections by age and sex for each Olicies Planning and Fertility Behavior country at five-vear intervals from 1980 Rashid Faruqee and Ravi Gulhati in Indonesia to 2020 and at twenty-five vear inter- No other country has higher fertility Day Chernichovsky and Oev Astra vals from 2000 to the year in which than Kenya and its neighboring coun- Meesook population becomes stationary in each tries in Sub-Saharan Africa. This country. The implied fertilitv and rnor- Working Paper examines the reasons Staff Working Paper No. 462. 1981. 62 tality measures are also given. Revised for fertility rates staying high, even pages (including appendix, references). annually. The 1984 edition will be rising in the face of greater education, Stock No. WP 0462. $3. Bangladesh: Current Trends NVJEW NEW and Development Issues Carl A. B. Jayarajah, chief of Bhutan: Development in a Brazil: Country Economic mission, and others Himalayan Kingdom Memorandum Provides an update on current devel- This is a landmark World Bank report Fred Levy, Lorene Yap, and others opment with emphasis on rural and on the Kingdom of Bhutan. Provides Provides a macroeconomic overview of industrial development and domestic an overview of the economy. Analyzes Brazil's economy during the 1970s. resource mobilization and suggests key sectors: agriculture, forestry, in- Looks at the macroeconomics of the that more funds should be channeled dustry, tounsm, energy, transport, hu- federal public sector, labor market de- into agriculture, education, health, and man resources, and communications. velopments and wage policv, and the population control. Examines current stage of develop- changing pattems of povertv and in- 7979. 126 pages (itcluding map, annexes ment. 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ISBN 0-8213-0095-4.Stock No. BK 0095. ductivity outside the modern sector of StockNo. BK 0308. 55. $0. the economy will be crucial to achiev- with special attention paid to unem- BK 9168) for $40 and save $10 over the ing more equitable socioeconomic deployment and mechanisms crucial to cost of volumes ordered separately. velopment; and that accelerating prog- the success of such instruments as the ress in the provision of basic services Caribbean Free Trade Association and Colombia: Economic will require not only increased finan- the Caribbean Common Market. Development and Policy under cial backing but considerable efforts to The Johns Hopkins University Press. 1978. Changing Conditions overcome institutional problems. 536 pages (including appendixes;statistical Jose B. Sokol, chief of mission, Volume II examines important sectors: appendix, index). and others health, nutrition, and education. Pro- LC 77-17246. ISBN 0-8018-2089-8,Stock Provides a survey and analysis of Col- vides information about general health No. IH 2089, $30 hardcover;ISBN 0- ombia's developmental experience and conditions, malnutrition, and emerg- 8018-2090-1, Stock No. IH 2090, $10.95 its principal features. Focuses on de- ing policy issues. paperback. mograpic trends, employment, wages, 1979. 560 pages (including map, 4 an- . price stabilization, financial policies, nexes). Chile: An Economy in public expenditure, agricultural devel- ISBN 0-8213-9119-4.Stock No. BK 9119. Transition opment, and issues and policies in the $20. Fred D. Levy, chief of mission, manufacturing industry. Examines re- and others cent economic developments and out- NEW Traces the development of the Chilean look for the future. economy since the Great Depression of 1984. 320 pages. Brazil: Industrial Policies and the 1930s and emphasizes economic ISBN 0-8213-0329-5.Stock No. BK 0329. 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Describes the basic regulation and development, in- 1980. 601 pages (including map, 2 appen- painful path to self-sufficiency since dustrial technology, and technology dixes, 96 tables, glossary). The Comoros declared their indepen- Stock9124. No. $20.dence BK in 1975. Recovery from revolu- 1983. 308 pages (including 4 annexes). Stock No. BK 9124. $20. tionary changes is underway but the ISBN 0-8213-0156-X.StockNo. BK 0156. China: Socialist Economic worlds pcnrest Fnonrecmainsone of the $10. Development need for outside financial and techni- Brazil: Integrated Development Vol.1. The Economy, Statistical Sys- cal assistance. of the Northwest Frontier tem, and Basic Data (408 pages, ISBN 1983. 180 pages. Dennis J. Mahar, chief of mission, 0-8213-0245-0,Stock No. BK 0245, $20.) ISBN 0-8213-0157-8.Stock No. BK 0157. and others Vol. II. The Economic Sectors: Agricul- $5 ture, Industry, Energy, Transport, and Points out that the Brazilian northwest External Trade and Finance (476 pages, The Comoros: Problems and has the potential to become an impor- ISBN 0-8213-0246-9,Stock No. BK Prospects of a Small, Island tant agricultural and timber-producing 0246, $20.)Ecnm region, as well as a place where rmi- Economy grants from other parts of the country Vol. III The Social Sectors: Population, Pierre Landell-Mills, chief of may be productively and permanently Health, Nutrition, and Education (128 mission, and others settled on small-scale farms. Thus, pages, ISBN 0-8213-0247-7,Stock No. economic development of the region is BK 0247, $10.) economyDescribes andthe principalsummarizes features the main of the currently one of the high priorities of The Bank's first Country Study cover- sectoral and structural constraints to the Brazilian govemment. Outlines de- ing China raises the curtain on development. Notes that, in view of velopment plans for the area; exam- Chinese economic progress since 1949 its extreme povertv, the Comoros will ines population, migration, and social and on its prospects for the next gen- require a substantial inflow of re- indicators; and considers issues and eration. It forecasts a substantial in- sources and technical assistance in the recommendations related to the identi- crease in the living standards of its future. A statistical annex provides a fication and protection of Indian lands, people-if the country's immense comprehensive compilation of social land settlement, and environmental wealth of human talents effort and and economic data not otherwise concerns. discpline are marshaled effectively. available. 1981. 107 pages (including annex). But, the report warns, China is enter- 1Stock1N.107 9140s(including anning a difficult period. A successful 1979. 184 pages (including 5 maps. 3 an- Stock No. BK 9140. $5. transition requires policies that in- nexes). English, French,and Spanish. The Commonwealth crease the efficiency with which all re- Stock Nos. BK 9115 (English), BK 9158 Caribbean: The Integration sources are used. (French),BK 9159 (Spanish). S5. Experiene.Everyone with interests in develop- Experience ment and trade will want a personal Sidney E. Chemick and others set of this three-volume study. Prices subject to change zvithout notice Broad issues of regional integration Order the three-volume set (Stock No. and may vary by country. Ecuador: Development NEW 1979. 178 pages (including map, 3 an- Problems and Prospects nexes, 3 graphs, organization chart). Alexander G. Nowicki, chief of Stock No. BK 9122. $5. mission, and others Ghana: Policies and Program Reviews the country's main socioeco- for Adjustment Indonesia: Employment and nomic sectors and focuses on the tra- Ishrat Husain, chief of mission, Income Distribution in ditional quality of Ecuador's economv and others Indonesia which makes it difficult to bring the Analyzes Ghana's economy since 1970. Mark Leiserson, mission chief and benefits of modern development to a Outlines policies and programs for ad- coordinating author majority of the poor. Discusses the ex- justment. Focuses on growth and effi- Examines demographic, employment, pected shortfall in foreign exchange ciency, the extemal sector, domestic wage, d emorends; analyzent, and fiscal revenues compared to the resources, and human resources and functiow ng of rural and urban labor country's needs, which can be alle- social development. A detailed statisb- markets; and formulates employment viated if aided by a vigorous effort in cal appendix provides background pa- and income policy issues that are im- petroleum exploration and a revision pers that review major sectors, includ- portant in addressing Indonesia's of the domestic price policy for petro- ing agriculture, mining, energy, l leum derivatives. manufacturing, population, and trans- 1979. 660 pages (including 4 technical an- port. 1980. 198 pages (including appendix, 2 nexes, statisticalappendix). Englishand 1984. 224 pages. Spanish. ISBN 0-8213-0358-9. Stock No. BK 0358. Stock No. BK 9232. $5. Stock Nos. BK 9160 (English) and BK $10. Ivory Coast: The Challenge of 9Z61(Spanish). $20. 9161$20.Guatemala:(panish. Economic and Success Egypt: Economic Management Social Position and Prospects BastiaanA. den Tuinder and in a Period of Transition John R. Hansen, chief of ,sion others Khalid Ikram and others and others ,, Investigates the so-called "Ivorian Mir- The most detailed examination of the C dsthat, d ¢ acle" and wavs to maintain growth Egyptian economy to appear since the Concludes t O curren prob- while reducinrg or eliminating gaps in 196/)s and the first to lay heavy em- ems ue o in cofee prces, income levels and opportunities for phasis on economic management and the econc;NS rinancally sound and advancement. policies. h u g . The Johns Hopkins University Press, 1978. The Johns Hopkins University Press, 1980. 1978. pages (including statistcal181 an- 464 pages (including appendixes, statistical 464 pages (including statistical appendix, nex, map annex). appendix, index). index). Stock No. BK 9150. $5. LC 7647395. ISBN 0-8018-1939-3,Stock LC 80-552. ISBN 0-8018-24184, Stock No. JH 1939, $28.50 hardcover; ISBN 0- No. IH 2418, $32.50 hardcover;ISBN 0- NEW 8018-2099-5, Stock No. jH 2099, $12.95 8018-2419-2,Stock No. JH 2419, $11.50 paperback. paperback. Hungary: Economic Kenya: Population and The Gambia: Basic Needs in Developments and Reforms Development The Gambia The World Bank's first analysis of the Rashid Faruqee, chief of mission, Heinz B. Bachmann, mission chief economy of the Hungarian People's and others and coordinating author, Rene Republic. Examines aspects of the eco- Vandendries, and Ann nomic structure of Hungary and the States that fertility in Kenya is high, MacNamara nature and evolution of its economic appears to be increasing, and shows This report outlines a basic needs management system. Reviews princi- considerable variation by region, tribal strategy designed to guide the Gain- pal sectors - agriculture, industry, ogroup, tandsocidoeon tomista wtushRc bian govenment and the World Bank energy. Discusses policv issues and in- ognizes that rapid popufation growth in making policy decisions that will indicates medium-term perspectives for public expenditure for basic needs crease the chances of base survival for the economy. services, such as education, health, that country's people. The Gambia is 1983. 296 pages. water, and housing. Argues that a extremely poor; the rural population is Stock No. BK 0307. $10. rapid decline in fertility will facilitate worse off than those living in urban the implementation of the govem- areas; and women and children, who India: Economic Issues in the ment's commitment to the provision of make up 30 to 40 percent of the popu- Power Sector basic needs, but that the satisfaction of lation, are the most disadvantaged C. Tavior basic needs, such as education, is an group and suffer most from poor im health and malnutrition. A strategy is Reviewing the country's demand for portant instrument for securing proposed that is aimed at improvig electricity, points out that economic lower fertility. Explores the socioeco- the halthandntritonaltatu ofgrowth the health and nutritional status of growth min India depends crthcallycritically on currentnomic determinantsstatus of the ofcountrv's fertility, familv the pregnant women and lactating moth- the development of the power sector ers bv combating endemic disease, im- and suggests that public funds be sup- planning program. the social status of proving the supply and distribution of plemented by increased tariffs to aug- wommendatindfertiiy ancmakeensirec food, improving eating habits, and ment the internal cash generation of popuelations forlacomrhesv g * stSuos * * Of P red * m=d xanf! t aug- ~~~1980.226pages (including bibliography). supplying clean water in rural areas. the State Electricitv Boards, as well as pplto oiy 1981. 253 pages (including 2 annexes). provide for a more efficient use of 19. 2 Stock No. BK 9267. $5. power resources. Stock No. BK 9134. $10. Korea: Policy Issues for Long- The Maldives: An Introductory key sectors such as agriculture, indus- Term Development Economic Report try, tourism, energy, and transporta- Parvez Hasan and D. C. Rao K. Sarwar Lateef, chief of mission, tion, as well as human resource devel- Can Korea's growth rate continue with and others opment. greater considerations of equity, struc- Provides a brief introduction to the 1979. l34 pages (including map, 2 an- tural changes to maintain the compar- Maldives, a nation that is among the nexes, statisticalappendix). ative advantages of Korean exports, twenty poorest countries in the world, Stock No. BK 9123. $5. the new roles for govermment in re- and points out that the fisheries sector Papua New Guinea: Its sponse to changing domestic and ex- accounts for 44 percent of employment E Situat d ternal conditions? and nearly all visible export earnings conomic Station an The Johns Hopkins University Press, 1979. and discusses other important sec- Prospects for Development 558 pages (including map, appendixes, in- tors-agriculture, tourism, cottage in- George B. Baldwin and others dex). dustries, health, and education. Out- Assesses prospects for increasing eco- LC 78-21399.ISBN 0-8018-2228-9,Stock lines the development priorities for the nomic self-reliance and financial credit- No. IH 2228, $35 hardcover;ISBN 0- country in the 1980s and the role of worthiness by developing considerable 8018-2229-7,JH Stock No. 2229. $15 pa- external assistance. natural resources. perback. 1980. 178 pages (including 5 annexes, sta- The Johns Hopkins University Press, 1978. tistical appendix). 38 pages (including appendixes, statistical Madagascar: Recent Economic Stock No. BK 9139. $5. appendix, bibliography). Development and Future LC 77-17242. ISBN 0-8018-2091-X, Stock Prospects Mauritius. Economic No. JH 2091, $6.50 paperback. P.C. Joshi, mission chief, and Memorandum: Recent Papua New Guinea: Selected others Developments and Prospects Development Issues Examines, in the light of recent eco- Michel J. C. Devaux, mission Alice Galenson, chief of mission, nomic developments and the govern- chief, and others and others ment's objectives, the strategy under- Report of a November-December 1981 Thi oth cos Iying both the 1978-80 Development mission to review the economic situa-a con- Plan and those plans to be imple- tion of Mauntius and to assess prog- tinuing dialogue between the World mented subsequently. Points out that ress under the structural adjustment bank and the government of Papua the overall performance of the econ- loan approved by the World Bank in New Guinea on a wide range of eco- omy has been disappointing in recent 1981. nomic and sector issues. It focuses on vears, but that the government has a few specific areas that were agreed been able to focus on certain important 1983. 122 pages. to be among the most important for social objectives; the satisfaction of ISBN 0-8213-0122-5.StockNo. BK 0122. the country's development during the basic needs,. reduction of urban-rural $5. 1980s. Points out that the major goal income disparities, and the protection facing the country in the 1980s will be of living standards of low-income ur- Morocco: Economic and Social to provide rising incomes for its peo- ban groups. Proposes a policy frame- Development Report pie and productive livelihood for its wvorkcharacterized by increased reli- Christian Merat, coordinating growing labor force. Discusses, in par- ance on external assistance, vigorous author, and others ticular, the employment, agriculture, export promotion, and a general relax- forestry, fisheheesnand industrv sec- ation of economic controls, and con- This study examines the growth and tors. siders the feasibility and appropriate- structural changes the Moroccan econ- 280 pages (including 4 annexes). ness of this strategy in relation to the omy has experienced during the ten- resources of the economy and long- year period, 1968-77. It seeks to deter- Stock No. BK 0096. $20. term development goals of the coun- mine the results that can be expected Paraguay: Regional trv. from the annual plans of financial adjustment that dominate the period 1980. 307 pages (including 6 annexes, 4 1978-80 and looks ahead to the overall Paraguay appendixes). Englishand French. prospects for the economy during the Alfredo Gutierrez, chief of Stock Nos. BK 9157 (English) and BK period 1981-90. Considers growth mission, and others 9164 (French).515. problems at the sector level and out- Reviews recent economic develop- lines the general employmertt situation ments and provides a framework for Malaysia: Growth and Equity and the social development strategy policy actions and investment projects in a Multiracial Society the country is pursuing. designed to make maximum use of de- Kevin Young, Willem Bussink, and 1981. 454 pages (including statistzcalap- velopment possibilities, and suggests Parvez Hasan pendix). English and French. the need to coordinate public-sector Rapid growth is essential to achieving Stock Nos. BK 9165 (English) and BK activities in a geographic and sectoral Malavsia's economic and social objec- 9166 (French).$20. dimension to exploit the eastern re- tives; favorable resource prospects are gion's natural resources. conducive to such growth. Nepal: Development 1978. 58 pages (including maps, stattstlwai TlheJohns Hopkins University Press, 1980. Performance and Prospects appendix).Engush. 364 pages (including appendixes, index). Yukon Huang, chief of Stock No. BK 9103 tLtgillsh) aud BK 9252 LC 79-3677. ISBN 0-8018-2384-6,Stock mission, and others (Spanish). 53. No. IH 2384, S25 hardcover:ISBN 0- Reviews Nepal's achievements during 8018-2385-4.Stock No. JH 2385, $12.95 the Fifth Development Plan and its Prices subject to change . itrtout notice paperback. strategy options for the Sixth Plan for and may vary by country. The Philippines: Housing Portugal: Current and 1980.73 pages (including statisticalap- Finance Prospective Economic Trends pendix). Madhusudan Joshi, mission chief, Basil Kavalsky,chief of mission, StockNo. BK 9133.$3. and others and Surendra Agarwal Thailand: Income Growth and Reports the findings of a 1981 study Discusses Portugal's difficult transition Poverty Alleviation requested by the govemment of the after the revolution of 1974175and John Shilling, chief of mission, and Philippines focusing on resource mobi- notes that the country has a sound others lization and its macroeconomic impli- economic base, but will have to come Synthesizes the results of four special cations, the development of appropri- to terms with the serious unemploy- studies on poverty-related issues and ate institutions and instruments, and ment problem, increase investment discusses some of the determinants of access to housing finance. and output in export-oriented manu- poverty, the impact of socioeconomic 1983.137 pages (including appendices). facturing, and improve agricultural and political factors on the poor, and ISBN 0-8213-0108-X.Stock No. BK 0108. productivity. the relationship between basic needs $5. 1978. 58 pages (including statisticalap- and poverty. Formulates guidelines for pendix, map). policies aimed at alleviating poverty Philippines: Industrial Stock No. BK 9106. $3. and promoting equitable growth. Development Strategy and Companion paper to Thailand:Toward a Policies Romania: The Industrialization DevelopmentStrategy of Full Participa- Barend A. de Vries, chief of of an Agrarian Economy under tion, March 1980. mission, and others Socialist Planning 1980. 64 pages (including 2 annexes, Outlines the country's industrial de- Andreas C Tsantis and RoyS velopment strategy, its major objec- Pepper Stork No. BK 9135. $3. tives, and industrial investment priori- The first comprehensive study of the Thailand: Industrial ties and determines that the Romanian economy, the study con- Development Strategy in nontraditional manufactured export tains a data base of the economy and Thailand drive should continue with increased describes the planning and manage- Bela Balassa, chief of mission, and participation by industries, firms, and ment system. others regions and that policies for the home The Johns Hopkins University Press, 1979. Notes that the country had an out- industries should be reoriented toward 742 pages (including maps, appendixes, standing economic record during the better use of capital and domestic re- bibliography). postwar period, especially between sources and more employment crea- LC 79-84315. ISBN 0-8018-2269-6,Stock 1960 and 1973, but points out that tion. No. IH 2269, $35 hardcover;ISBN 0- there is a slowdowr. in the growth of 1980. 310 pages (including statisticalap- 8018-2262-9, Stock No. IH 2262, $15 pa- Thai exports that will have a negative pendix, 9 annexes). rback* effect on the economy. Examines the Stock No. BK 9313. $15. Seychelles: Economic prospects for future exports of processed food and manufactured goods Portugal: Agricultural Sector Memorandum and analyzes the country's compara- Survey Robert Maubouche and Naimeh tive advantage in these products. Con- Jacques Kozub, chief of Hadjitarkhani siders the need for the economic eval- mission, and others Traces the development of Seychelles' uation of large government-sponsored Analyzes the main issues of agricul- economy from its primary dependence projects; examines measures of import tural development and identifies on the export of copra and cinnamon protection and export promotion investor needs for future World Bank to service economy with tourism as its schemes and questions relating to re- consideration. miajor industry. Concludes that the gional development. Provides recoin- country's management capability is mendations for a coherent industrial 1978. 328 pages (including 2 appendixes, impressive and its development strat- development strategy for the country 10 annexes, maps). egy well designed, but that it is likely that is aimed at increasing industrial Stock No. BK 9105. $15. to be confronted with financial con- employment, expanding small and straints in the near future, and its investment program will require increased domestic efforts, as well as substantial levels of external capital aid. medium-sized firms, and improving Turkey: Policies and Prospects NEW the living standards of the poor. for Growth 198() 69 pages Vinod Dubev, mission chief, Yugoslavia: Adjustment Stock No. BK 9155. S3. Shakil Faruqi, deputv mission Policies and Development

NEW chief, and others Perspectives States that overall economic growth Reviewss Yugoslavia's adjustment dur- Thailand: Rural Growth and during the 1960s and most of the 1970s ing the strenuous economic period of was good compared with other devel- 1976-80. Based on the findings of a Employment oping countries. Concludes, however, World Bank economic mission to Yu- Examines the high rate of economic that the sharp increase in oil prices goslavia in 1981, this report is espe- growth in Thailand with respect to ag- had an unfavorable impact on the ciallv useful to economists, country ncultural growth. Concludes that agri- countrv and that resumption of sus- planners, and those interested in eco- cultural growth has a great effect on tamable growth depends on the adop- nomic trends and institutional change. rural development. Supports develop- tion of an export-oriented strategy; on The first section of the report deals ment of programs to alleviate the policies aimed at increasing domestic with issues of adjustment strategy and pockets of rural poverty. Discusses savings and at keeping aggregate de- policv across the economv. The second supply-side factors in rural nonfarm mand for resources in line with aggre- part explores issues in agriculture, in- activities and the effect of industrial gate supply; and on the support for dustry, employment, and regional pol- policies on provincial manufactunng. these policies by various donors and icv. Includes more than 100 tables of 1983. 212 pages (including appendixes). the financial community. statistics from 1965 through estimates ISBN 0-8213-0203-5. Stock No. BK 0203. 1980. 347 pages (including 6 appendixes, for 1985. 510, statistical annex). 1983. 464 pages. Thailand: Toward a Stock No. BK 9151. 515 ISBN 0-8213-0189-6. Stock No. BK Development Strategy of Full Uganda: Country Economic 0189. S20e Participation Memorandum Yugoslavia: Self-Management E.R. Lim, chief of mission, John Mark Baird, mission leader, and Socialism and the Challenges Shilling, deputy chief, and others others of Development Shows that rapid and sustained This is the first economic report pre- Martin Schrenk, Cyrus Ardalan, growth has helped a substantial pro- pared bv the World Bank on Uganda an lawa A. E atawy portion of the population, but that, to since 1969. It reviews events prior to Describes major development issues a large extent, the rural population has the 1978-79 war and developments and the overall performance of the not benefited. Stresses that the coun- since the war, including the govern- economv, showing that the new eco- trv should not follow a tvpe of "trickle ment's new financial program. Out- nomic framework of the 1970s down" development strategy, but lines the priority areas for further ac- strengthens decisionmaking at the should focus on raising the productiv- tion and the implications of the lowest microeconomic level and at the itV and incomes of the poorest farm- balance-of-payments outlook for aid same time allows greater coordination ers. This strategy would be a logical requirements. A more detailed review of economic activity by extending self- continuation of the economic change of the problems and issues in five ma- management principles to the macroe- that began in the middle of the 19th jor sectors-agriculture, industrv, conomic level. centurv, with development based pri- transport, energy, and education-is The Johns Hopkins Universzty Press, 7979 marilv on indigenous capital and skills also discussed. 410 pages (including map, appendix, glos- and the gradual assimilation of foreign 1982. 166 pages (including statistical ap- sarv, -index). technology.I pendix). LC 79-84316. ISBN 0-8018-2263-7,Stock 1980. 246 pages (including statistical ap ISBN 0-8213-0027-X. Stock No. BK 0027. No. JH 2263, $27.50 hardcocer; ISBN 0- ,vendixl. 5. 8018-2278-5, Stock No. JH 2278, $12.95 Stock.No. BK 9125. 510. paperback. Turkey: Industrialization and Yemen Arab Republic: Zaire: Current EconorAic Trade Strategy Development of a Traditional Situation and Constraints Bela Balassa, mission chief and Economy Bension Varon, chief of mission, pnncipal author Otto Maiss, chief of mission, and and others Reports the findings of a special eco- others Presents an integrated analvsis of the nomic mission that visited Turkev in Outlines the far-reaching changes in difficulties experienced by the Zairian %tav-June 1981. Includes production the socioeconomic and political struc- economv between 1975 and the first incentives, financing of economic ac- ture of the Yemen Arab Republic since half of 1979 and suggests that the titvtv, taxation and investment incen- the 1962revolution and discusses ma- countrv needs to revamp its institu- tives, industnal development and ex- jor development issues of the late tions and its svstem of incentives and ports, state economic enterprises in 1970s and the 1980s. adopt policies that will lav the founda- manutactunng agriculture develop- 1979. 333 pages (including 3 mavs, 7 an- tion for a development pattern that ment and exports, and tourism. Con- nexes, statistical appendix, selected bibliog- will render it less vulnerable to eludes with policv recommendations. raphu). changes in the world economv. .983. ai - 435 pages (including append- Stock No. BK 9109.-$15. 1980. 196 pages (including map, annex, ces 11dstatistical tables) statistical appendix). English and French. 'SBN 0-8213-0046-6.Stock No. BK 0046. Prices subject to change without notice Stock Nos. BK 9128 (English) and BK $90 and may vary by country. 9154 (French).35.

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