PHN Technical Notes GEN 18 This paper is for distribution within the World Bank Group only. Public Disclosure Authorized It should not be cited in any external publication. THE WORLD BANK Public Disclosure Authorized HEALTH SECTOR ISSUES IN SHANDONG PROVINCE (Peoples Republic of China) 1983 Public Disclosure Authorized April Population, Health and Nutrition Department Public Disclosure Authorized * This paper is one of a series issued by the Population * * Health and Nutrition Department for the information and * * guidance of Bank staff working in these sectors. The * * views and opinions expressed in this paper do not neces- * * sarily reflect those of the Bank. * GEN 18 ABSTRACT This document provides an update and a review of the health sector in China through a detailed analysis of Shandong Province. Shandong may represent the average in China without distortion associated with extreme per U capita income levels or high urbanization rates. Its agricultural output per capita is slightly above national average; its industrial output per capita is 87.3% of the national average; and its distributed collective income per capita represents 95% of the national average. The medical service organization and utilization, training of health manpower and cost and finance of health expenditure from brigade to province are reviewed and illustrated, in addition, with a case study of Qufu county. It is a county of great historical and cultural significance -- the birthplace of Confucious. This leads to the discussion of emerging health issues as a consequence of improvement of health care delivery, improvement of population coverage together with social-economic changes since liberation. New demands on health service facilities, training and health management are emerging as a result of the "epidemiologic transition," population changes and agricultural reform. Finally, it discusses how the health officials propose to address these issues and whether the cost for implementation of the new policies are feasible. This paper is Supplementary Paper No. 9 to World Bank Report No. 4664-CHA, "The Health Sector in China". Prepared by: Andre Prost, PHN; Jacques van der Gaag, DRD; John Krister, WHO Nicholas Prescott, PHN and Mary Young, CON April 1983 NOTE This case study was prepared on the basis of a visit by the authors to Shandong Province from October 1 to 15, 1982, duriig the course of the World Bank's Rural Health and Medical Education mission to China. TABLE OF CONTENTS - Page INTRODUCTION CHAPTER I. Population and Family Planning....................... 2 CHAPTER II. Medical Services Organization and Utilization........ 4 CHAPTER III. The Outcome of Health Care Services: Disease Situation and Epidemiological Picture.......... *.12 CHAPTER IV. Training of Health Manpower..... ................... 21 CHAPTER V. Case Study on Qufu County*..........................31 CHAPTER VI. Costs and Financing.. ................................ 41 CHAPTER VII. Issues and Health Priorities in a Changing Environment.... 0.... 0 ..... 0..0.0.....................46 - Issues related to population changes - The changing financial environment - The changing epidemiological pattern - Lingering problems - The pressures on the referral system - Issues in training - Issues in health mangement The equity issve and the One-third Countries Program CHAPTER VIII. Government Policies and Planning.....o...............54 REFERENCES TABLES LIST OF TABLES Within text: Page Table A. Population in Shandong Province.......................... 2 Table B. Distribution of X-ray Sets in Shandong Province............. 8 Table C. Enrollment in Shandong Medical College..................... 23 Table D. Qufu County Demographic Indicators for Selected Years...... 31 Table E. Main Agricultural Productions, Qufu, 1957-1981............. 33 Table F. Health Sector Shares of Government Expenditure; Yexian and Qufu Counties................................... 41 Following Text: Table 1 - Health Manpower and Facilities in Shandong as Compared to Nationali Figures in China, 1981 Table 2 - Health Personnel and Facilities in 1981; Distribution-. by Prefectures and Municipalities Table 3 - Utilization of Selected Hospital Facilities Table 4 -.Outputs of Health Services Table 5 - Water Supply Table 6 - Communi.able Diseases: Cases Reported, Mortality, Incidence per 100,000 Population Table 7 - Achievements in Control of Communicable Diseases in Yexian Table 8 - Prevalence and Intensity of Ascariasis in Selected Areas of Shandong Province Table 9 - Immunization Schedule in Rural Areas of China Table 10 - Relative Frequency of Cancer by Site; Comparison of Shandong with China Table 11 - Age-Adjusted Cancer Mortality Rates per 100,000 Population; Comparison of Shandong with China Table 12 - Anthropometric Survey in Qingdao Municipality Primary Schools, 1946 Table 13 - Anthropometric Status of Rural and Urban Children-and Youth, 1979 Table 14 - Anthropometric Status of Female Children and Youth, Shandong Provinze, 1979 Table 15 - Food Prices-and Rations in Yexian City, October 1982 Table 16 - Birth Control Situation of Twelve Communes in Qufu County, 1981 Table 17 - Agricultural Production Situation in Qufu County, 1981 Table 18 - Qufu County Health Facilities and Staff, 1957-1981 Table 19 - Qufu County - Staffing and Utilization of Commune Health Centers, 1981 Table 20 - Qufu County - Incidence of Reported Communicable Diseases Table 21 - Qufu County Hospital - Distribution of Diagnosis in 3,627 Inpatients Admitted during 1981 Table 22 - Qufu County Hospital - Ranking of Death Causes in 133 Deaths during 1981 Table 23 - Immunizations Delivered in Qufu County Tables, continued: Table 24 - Consolidated State Expenditure on Health: 19.75-1982 Table 25 - Distribution of Consolidated State Expenditure on Health per Capita by Municipality and Prefecture, 1981 Table 26 - Functional Shares of Government Expenditure of Health Table 27 - State Expenditure on Health in Yexian and Qufu Counties Table 28 - Sources of Finance for Government Expenditure on Health in Yexian and Qingdao Table 29 - Health Insurance Expenditure in Selected Areas Table 30 - Rural Cooperative Insurance: Brigade Level Data, 1981 Table 31 - Comparison of Revenues and Expenditures in Selected. Hospitals Table 32 - Average Patient Charges in Selected Hospitals Table 33 - The One-third County Program (37 Counties) INTRODUCTION Situated in the east of China, Shandong province covers an area of 153,300 square kilometers. The census on July 1, 1982, was 74,419,054, making it the third most populated province in China. The average population density is 485 inhabitants per square kilometer, with 1,020 inhabitants per square kilometer of arable land. Shandong is one of China's oldest cultural centers and the birth place of Confucius. Shandong province is divided into nine prefectures, four municipalities under provincial authority, five cities under prefectural authority, 106 counties, 2,093 people's communes and 86,143 production brigades. /1 Shandong province is composed of mainland and a peninsula extending into the Yellow Sea. It has hilly and rolling land in its middle south -and the peninsula, and flat land in its western part which belongs to the Great Plain of eastern China. Topographically, Shandong reaches 1,540 meters above sea level, at Mount Tai, and drops to more than 50 meters below.sea level in northwest and southeast. The Yellow River (Huang He) flows 617 kilometers across the northwest Shandong plain and empties into Bohai sea. Winter is long and dry. Rainfall is concentrated during summer time. Severe droughts plagued Shandong province during historical times. Effects of the most recent drought, in 1980, were alleviated by the huge number of dams and reservoirs recently built for water conservation and irrigation. Shandong has 7.4% of mainland China's population; 90.5% of the population live in rural areas. The gross value of agricultural output in .the province was 7.8% of the national total in 1979. The value of agricultural output per capita is just above national average, 101%. From 1952 to 1979, agricultural production grew at an average 3.2%,per year. Wheat and corn represent the main crops, with additional yields of peanuts, vegetables, and apples. The Province does not produce rice. The gross industrial output in Shandong province was 6.5% of the national total in 1979. The value of industrial output per capita-as--a percentage of the national average is only 87.3%. Industrial production increased 11.5% per year between 1952 and 1979. The distributed collective income per capita was 81.5 yuan in 1979. This amount represented 95% of the national average. These indicators adequately reflect the relative position of the province in the country. Shandong ranks as the 18th richest province among the 29 provinces, municipalities, and autonomous regions.of China. Shandong may represent the average in China, or something very close to the average, without distortions associated with extreme capita income levels, or high urbanization rate. This makes Shandong province suitable for a case study aiming at a better understanding of the health sector in China. /1 List of administrative units and official pinyin spelling of names are recorded in "The Administative Divisions of China" 1980.. -2- CHAPTER I: P-, LATION AND FAMILY PLANNING POPULATION The total population of Shandong Province in 1981 was estimated at 73,948,000; there were 37,498,000 males and 36,450,000 females. No age/sex distribution is available. The population per prefecture