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. All rights reserved Manufactured in the United States of America First printing November 1984 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. 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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