China - The health sector

A WORLD BANK COUNTRY STUD' PU B-4664 CHINA The Health Sector 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. Some of the reports are published informally with the least possible delay for the use of govern- ments 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 Research Program: 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 Fertility Levels ......... 4 2.2 Achievements in Reducing Mortality - Levels, Trends and Regional Differences in Life Expectancy and Infant Mortality ....................................... 7 - Trends in Life Expectancy and 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 Improvements in Nutritional Status ........19 - Secular Improvements in Nutritional Status - Micronutrient Deficiency Disorders 2.5 Current Disease Problems .21 - Emerging Problems of Chronic Disease - Lingering Problems of Infectious Disease - Malnutrition and 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 Fertility Rate in China, 1950-81 .................. 6 2.2 Expectation of Life at Birth, 1950-82. ... .................... 9 3.1 Organization of Health and Birth Planning Services .......... 36 3.2 Total Number of Doctors of Western and Chinese Traditional Medicine (per 1000 population) ........................... 53 3.3 Recurrent Expenditure on Health, 1981: Sources of Finance, Resource Inputs and Delivery Systems ............. 63 3.4 Distribution of Population by Insurance Status .............. 65 3.5 Urban-Rural Differentials 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 Population Over 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 Fertility and 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 Distribution of Deaths by Cause, China and Model High- and Low-Income Countries .................. 13 2.4 Principal Causes of Death, Rural and Urban Areas, 1980 ...... 22 2.5 Percentage of 7-Year Old Boys Malnourished, Selected Provinces, 1979 .. 32 3.1 Selected Health Care Workers - Education and Role . . 51 3.2 Availability of Health Care Personnel - China and Other Developing Countries .54 3.3 Medical School, University and Secondary Enrollments - 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-urban differences (and differences among 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 professionals throughout 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 substantial new information available. 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 influences on 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 fertility and 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 expectancy of 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, indirectly derived 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 constructed a 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 improvements in 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-provincial differences. 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 reinforcing the importance of 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 infectious diseases have been substantially replaced 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-aged and 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 'epidemiologic transition'. 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 schistosomiasis remain 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 interpret without 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 substantially reduced and can no longer be considered an important problem. Many children in rural areas, by contrast, continue to suffer moderate-to-serious malnutrition. A 1979 survey of 16 provinces and municipalities provides a basis for assessing urban-rural and inter-provincial differences in child malnutrition. A clear pattern of moderate rural malnutrition can be seen, with an estimated 12.7 percent of seven-year-old rural 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 epidemiological transition 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 emphasized public 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 inexpensive ways 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 industrialized world -- 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 significant expenditures with relatively little 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 revolution by extending the methods that have been successful in 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 international community. 21. Completing the first revolution. Major disparities continue 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 epidemiological considerations, 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 production brigades had cooperative insurance, 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 alternative financing mechanisms are in place. 23. Tasks for a second Chinese health care revolution. Success in the control of communicable disease has transferred the burden of China's health problems to the older age groups, who are particularly vulnerable 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 temptation to emulate high- cost curative approaches that have proved relatively inefficacious and 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 expectancy as the control of communicable and infectious diseases. 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, particularly control 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 exceptionally high 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 productivity and unnecessary medical expenses. Other preventive measures may be less obvious: Prevention of chronic disease is inherently more difficult than prevention of communicable disease. 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 implementation of 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 incapacitated by non-communicable disease; 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 anterioridad a 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 espectacular de la esperanza de vida, con una disminuci6n concomitante de las enfermedades. Las medidas de salud publica, combinadas con la reducci6n de la malnutrici6n, el mejor abastecimiento de agua y la mayor atenci6n a la higiene y el saneamiento, han aumentado la esperanza de vida desde cerca de 32 anios en 1950 a 69 anios en 1982, lo que es s6lo alrededor de seis aiios menos que en los paises industriali- zados con economia de mercado. Sin embargo, el progreso en el mejoramiento de las condiciones de salud esta lejos de ser uniforme, y existen grandes diferen- cias entre las zonas rurales y urbanas (y tambien entre las rurales). 2. Las influencias multisectoriales responsables 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 reevaluarse a la luz del con- siderable volumen de nuevas informaciones de que se dispone. 3. A fin de ayudar al personal del Banco que trabaja en proyectos de salud en China, y tambien a los profesionales de la salud en general, este exa- men del sector comienza seiialando los logros del pais en materia de control de la poblaci6n, estado de salud y nutrici6n. A continuaci6n en una secci6n espe- cifica se examinan las politicas, las fuentes de financiamiento y 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 sanita- rios, y reducci6n de la fecundidad. Posteriormente se 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 conclusiones del estudio. Logros 4. Poblaci6n. El censo de China realizado el 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 condiciones demograficas aun varian marcadamente entre las distintas regio- nes 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 aproximadamente 38 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 anios cincuenta 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 anio en 1981 de su punto bajo regis- trado a fines del decenio de 1970 de apenas sobre el 1% anual. 5. Las disminuciones de la fecundidad han sido mucho mas rapidas en las zonas urbanas que en las rurales. La tasa de natalidad en estas ultimas, deri- vada indirectamente de 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 seniala una 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 estimaciones de 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 estimaciones oficiales 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 inmediatamente posterior a 1949 a casi 70 anios a 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 apreciablemente mas altas que las del Gobierno. La notificaci6n incompleta de los nacimientos y muertes de ninios menores de un anio bien podria explicar esta diferencia y, de ser asi, indica que los problemas relacionados con los cuidados prenatales e inmediatamente posnata- les en China merecen mas atenci6n de lo que sugieren los datos oficiales. 7. Se han efectuado estimaciones de 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 esti- maciones varian desde 59 anios en Guizhou a 72 en Shanghai, lo que denota dife- rencias interprovinciales muy 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 esperanza de 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 anios menos que en las tipicas. El analisis de los datos sobre las tasas de mortalidad que se han derivado del censo de 1982 lleg6 a conclusiones similares. Esta diferencia entre zonas rura- les 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 condiciones en 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 espe- ranza de vida que se acaban de senialar. El 6xito considerable del pais en su lucha contra las enfermedades infecciosas ha dado por resultado no s6lo una mayor esperanza de vida sino tambien el surgimiento de nuevas causas principales de morbilidad y mortalidad. En las zonas urbanas y en gran parte de las rura- les, las enfermedades parasitarias e infecciosas han sido en gran medida reemplazadas como causas de muerte por las enfermedades del coraz6n, el cancer, los accidentes cerebrovasculares, las enfermedades respiratorias cr6nicas y los accidentes en general. Por ejemplo, la tasa de mortalidad a causa de enferme- dades del coraz6n aument6 de 71 por 100.000 en 1958 a 141 por 100.000 en 1979 en cuatro distritos urbanos de Pekin. Los ninios menores 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 servicios m6dicos. 9. Esta transformaci6n, que ya ha ocurrido en los paises industrializa- dos, se conoce actualmente como la "transici6n epidemiol6gica". Si bien las caracteristicas de 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 enfermedades transmisibles, como la disenteria, la tuberculosis y la hepatitis, siguen siendo importantes proble- mas nacionales. En las regiones mas pobres, las condiciones de salud probable- mente van 20 anios a la zaga de las logradas en otras zonas mas avanzadas. Ade- mAs, en zonas geograficas o climaticas vulnerables, las enfermedades infecciosas y parasitarias como la lepra, el paludismo y la esquistosomiasis siguen siendo problemas graves. 10. Estado nutricional. Los datos disponibles indican mejoramientos cons- tantes en el estado nutricional de los nianos en 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 correspondientes a 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 ninios de 9 anios). Estos datos son dificiles de interpretar sin otros comparativos de 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 importantes 6xitos 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 malnutrici6n se ha reducido considerablemente y ya no puede considerarse un problema importante. Por contraste, muchos ninios en las zonas rurales continuian sufriendo una malnutrici6n entre moderada a seria. Una encuesta de 16 provincias y municipalidades realizada en 1979 pro- porciona la base para evaluar las diferencias urbano-rurales e interprovinciales en la malnutrici6n infantil. Pueden observarse caracteristicas evidentes de malnutrici6n moderada en las zonas rurales, con un porcentaje estimado de 12,7% de ninios varones de 7 aiios de edad en zonas rurales que tienen crecimiento atro- fiado en las 16 provincias encuestadas; en Sichuan, la cifra asciende a 37%. En las urbanas, s6lo el 2,6% de los ninios estan 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 ali- mentos se estimaron en 96 yuan por habitante urbano en 1981 y representaron mAs del 4% del PIB). La persistencia de un nivel apreciable de subnutrici6n en las zonas rurales de China of rece pruebas adicionales de que la transici6n epidemio- l6gica esta lejos de terminar y que es necesario continuar prestando atenci6n a los problemas de las enfermedades tipicas 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 campafias para mejorar el saneamiento ambiental, eliminar las "cuatro plagas": ratas, moscas, mosquitos y chinches, efectuar vacunaciones contra las enfermeda- des infecciosas y curar 6stas, y controlar los vectores de los principales tras- tornos endemicos como el paludismo y la esquistosomiasis. La movilizaci6n de las masas desempen16 una 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 disponibilidad de pro- ductos farmac6uticos en 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 con- trol de las enfermedades hasta ahora parece estar desempeniando s6lo una funci6n marginal en el tratamiento de los problemas actuales de las enfermedades cr6nicas. 13. La preocupaci6n de China respecto a la salud y prevenci6n de enferme- dades 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 suminis- tro de agua potable, los metodos apropiados y sanitarios de eliminaci6n de dese- chos, la disminuci6n de la fecundidad y los mejoramientos generalizados en edu- caci6n han sido objetivos importantes de politica. La capacidad administrativa y la voluntad politica del Gobierno chino, no obstante algunos reveses ocasiona- les, han sido factores fundamentales para 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 disponibilidad de servicios hospitalarios y 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 disponibilidad de 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 enfermedades se acercan mAs a las enfermedades cronicas 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 puiblicas econ6micamente viables orientadas a postergar el comienzo y a administrar las consecuencias de las enfermedades cr6nicas, con el cambio cualitativo requerido en 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 disponi- bles, serA necesario planificar cuidadosamente la formaci6n de los recursos humanos del sector; es fundamental en esta planificaci6n proporcionar 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 importancia debida a la medicina comunitaria y preventiva. 15. El financiamiento y los gastos del sector de salud. Los gastos tota- les del sector de salud en 1981 se estiman en aproximadamente Y 15,0 per capita, de los cuales Y 14,3 se destinan a gastos de operaci6n y Y 0,6 a gastos de capi- tal. 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 siste- mas de prestaci6n de servicios y los gastos por insumos de recursos. El finan- ciamiento 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 aproximadamente el 40% del total; el sistema guberna- mental suministra alrededor del 32%, y el sistema de las empresas estatales, que atiende exclusivamente a los empleados de las empresas y a sus cargas familia- res, entrega el 25% de los servicios totales. Recientemente se 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 prActicamente no existen datos pertinentes, pero cuya con- tribuci6n al exito de muchos esfuerzos preventivos, en especial los asociados con el saneamiento ambiental, 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, --aproxi- madamente Y 26 per capita en comparaci6n con menos de Y 3 per capita. Los gas- tos 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 curati- vos. La prActica de la medicina tradicional recibe aproximadamente el 14% de la asignaci6n total. Problemas y desafios 19. Los esfuerzos de China por reducir la incidencia de las enfermedades transmisibles y la frecuencia de la malnutrici6n --disminuyendo asi considera- blemente las tasas de mortalidad-- han llevado a un aumento notable de la espe- ranza 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 condiciones de salud en las ciudades son efectivamente muy 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 infraestructura econ6mica y admi- nistrativa, y los niveles educacionales son probablemente bajos. 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 enfermedades cr6nicas ha pasado a ser una preocupaci6n importante. El esquema actual de las causas de mortalidad en China es muy similar al de los paises industrializados: las enfermedades del coraz6n, el cAncer y los accidentes cerebrovasculares encabezan la lista. Los tratamientos de estas enfermedades que 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 actualmente dos 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 trata- miento 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 rura- les 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 dis- tritos pobres; esos planes deben incluir consideraciones epidemiol6gicas, anali- sis 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 apli- car 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 coopera- tivos de salud en estas zonas despues de la introducci6n de los sistemas de res- ponsabilidad 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 inevitable- mente descuidan las medidas preventivas publicas, no obstante que han desempe- nado una funci6n vital en el exito logrado en esta esfera. AdemAs, las activi- dades 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 transmisibles ha 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 relativamente dificil 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 relativamente ineficaces 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 enfermedades transmisibles e infecciosas, que tuvo el efecto de elevar la espe- ranza de vida sobre todo al reducir la mortalidad entre niiios de menos de un anio y ninios pequenios; 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 enfermedades cr6nicas daran por resultado beneficios en bienes- tar que son mAs que proporcionales a su efecto limitado en la esperanza de vida. 24. Pueden adoptarse de inmediato algunas medidas para prevenir las enfer- medades 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 (elevada presi6n sanguinea). El exceso de consumo de sal conduce a enfer- medades del coraz6n y a accidentes cerebrovasculares evitables, que actualmente constituyen un importante problema de salud pulblica en China. El consumo de tabaco ha sido excepcionalmente alto 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 respiratorias cr6nicas 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 tendientes a prevenir las enfermedades cr6nicas. 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 financieramente accesible; la rehabilitaci6n de personas parcial o totalmente incapacitadas por 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 apropiadamente capacitados, incluidos los medicos que pueden proporcio- nar atenci6n eficaz sin depender de m6todos importados que utilizan equipo y procedimientos sumamente costosos.  - xxviii - 26. Un ultimo factor para lograr la segunda revoluci6n en materia de aten- ci6n de la salud sera el diseiio de una estructura de seguros y financiamiento que fomente la prevenci6n de enfermedades y desaliente la actual tendencia a emplear excesivamente los servicios. La estructura de seguros debe proporcionar fuertes desincentivos a la introducci6n de procedimientos de elevado costo que esten unicamente al alcance de unos pocos. Al utilizar sumas deducibles eleva- das 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 prudentemente los 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 innova- ciones son fundamentales tanto 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 ingresos bajos 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 proporcionar s6lo 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 ninguin mejoramiento para la vasta mayoria, o analisis cuidado- sos e innovaciones para 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 elaboraci6n de la base de esta estrategia, con sus repercusiones financieras, politicas y 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 establecimiento de instituciones capaces de innovaciones, experimentos y analisis de los problemas de salud puiblica. El mejoramiento de las escuelas de medicina, en especial de las 13 escuelas princi- pales, puede desempeniar una funci6n clave en este Ambito, siempre que los profe- sores tengan intereses de investigaci6n y de docencia que trasciendan los ade- lantos tecnicos en las ciencias biol6gicas y la medicina clinica. La iniciativa del Ministerio de Salud Piublica de establecer un Centro Nacional de Medicina Preventiva y un Centro de Investigaci6n sobre 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 Piublica otorga al mejoramiento de la asignaci6n de recursos y las capacidades administrativas --en todo el sis- tema 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 innovaci6n y eficiencia, deben considerarse varios problemas especificos (que se analizan en el Capitulo 5 del Informe). A continuaci6n se presentan algunos de los puntos principales.  - xxix - 29. El financiamiento de la atenci6n de la salud en las zonas pobres. Mientras el Estado tiene la responsabilidad de financiar la atenci6n de la salud en las zonas urbanas, en las rurales se aplica la politica de autosuficiencia (es decir, financiamiento local 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 importante de politica que debe resolver el Gobierno es si postergar los esfuer- zos 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 requeriria el financiamiento del gobierno central, pero el efecto de las inversiones en salud en estas zonas probablemente excede- ria las repercusiones de las inversiones en regiones mis pr6speras del pais; por consiguiente, la preocupaci6n en cuanto a la eficiencia reforzaria las conside- raciones de equidad en favor de una politica de esta naturaleza. 30. Clinicas comunitarias importantes. La politica del Gobierno consiste en fomentar el establecimiento de 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 pequenios hospitales (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 adecuadamente calificado 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 investigaci6n sobre siste- mas 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 princi- pios epidemiol6gicos no s6lo a las enfermedades no infecciosas sino tambien a la evaluaci6n de las medidas de control de enfermedades y a la calidad de los cui- dados 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, occidental y 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 continuamente y prevenir las enfermedades cr6nicas.  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 demo- graphique 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'en- viron 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 recense- ment 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'es- perance 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'expliquer par des differences de revenu. L'analyse statistique des resultats de l'enquete sur le cancer a montre que l'esperance de vie dans les r6gions urbaines etait en moyenne de 12 ans superieure a celle des r6gions rurales types; dans les r6gions rurales a faible revenu (cWest-a-dire celles oii le revenu par habitant etait inf6rieur a 50 yuan en 1979), elle 6tait de cinq ans inferieure a celle des r6gions types. L'analyse des taux de mortalite tir6s du recensement de 1982 a donne des r6sultats analogues. Ces differences entre les villes et les campagnes sont plus marquees que dans la plupart des autres pays en developpement, ce qui confirme l'importance des mesures prises par le Gouvernement pour ameliorer la situation dans les campagnes. 8. Des 6pidemies periodiques, ainsi qu'une importante morbidite due aux maladies infectieuses et a la malnutrition qui 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 infectieuses n'ont pas seulement contribu6 a augmenter 1'esp6rance de 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 parasitoses et les maladies infectieuses ont 6t6 remplac6es dans des proportions importantes, en tant que causes de deces, par les maladies cardiaques, le cancer, les congestions cerebrales, les accidents et les affections respiratoires chroniques. 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 morta- lite est la plus elevee mais chez les individus d'age moyen et les per- sonnes ag6es, et ce sont les groupes d'age plus vieux qui sont proportion- nellement les plus grands consommateurs de soins m6dicaux. 9. Les pays industrialises ont deja franchi le stade que l'on d6signe aujourd'hui sous le nom de "transition epid6miologique". Mais cette transition est toujours en cours en Chine rurale, alors que la phy- sionomie de la pathologie urbaine ressemble de plus en plus a celle que l'on trouve dans les pays a haut revenu. Certaines maladies transmis- sibles - dysenterie, tuberculose et hepatite - sont toujours des problemes nationaux importants. Sur le plan sanitaire, les regions pauvres de Chine ont probablement vingt ans de retard sur les plus developpees. De plus, dans les zones climatiques ou geographiques vulnerables, les maladies infectieuses et les parasitoses (lepre, paludisme et schistosomiase) continuent de poser de tres serieux problemes. 10. Etat nutritionnel. Les chiffres dont on dispose semblent indi- quer une am6lioration r6guliere de 1'etat nutritionnel des enfants chinois d'age scolaire, du moins dans les villes. Les donn6es relatives aux modi- fications de l'etat nutritionnel s'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 difficile d'interpreter ces chiffres sans les comparer a ceux qui portent sur des p6riodes ant6rieures ou qui concernent d'autres pays en developpement. Ces taux de croissance sont cependant aussi 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 augmentations se poursuivent pendant une bonne partie du XXIe siecle. 11. Dans les regions urbaines, la malnutrition a 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 municipalites permet de mesurer les differences de malnutrition enfantine existant entre les villes et les campagnes et entre les provinces. L'image qui s'en d6gage est celle d'une malnutrition rurale moder6e : dans les 16 provinces etudiees, environ 12,7 % des garcons de sept ans souf- fraient d'un ralentissement de 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 alimentation plus abondante et de meilleure qualit6 (on estimait les subventions aux produits alimentaires dans les villes a 96 yuan par habitant en 1981, c'est-a-dire a plus de 4 % du PIB). La persistance d'une s6vere sous-nutrition dans les regions rurales montre que la transition epimediologique est loin d'etre termin6e et que les autorites doivent continuer de s'attaquer aux maladies qui sont caract6ristiques pour 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 population et de lutter contre les maladies transmissibles. De grandes campagnes ont 6te lancees peu apres 1949 pour ameliorer la salubrite de l'environnement, pour 6liminer les "quatre pestes" (rats, mouches, moustiques, punaises des lits), pour vacciner la population contre les maladies infectieuses et les gu6rir et pour maitri- ser les vecteurs des grandes maladies endemiques comme le paludisme et la schistosomiase. La mobilisation des masses populaires a joue un role d6cisif dans le succes de ces campagnes. L'affectation de ressources aux actions preventives (et aux services curatifs qui pouvaient exister en zone urbaine) a eu pour effet d'amener les populations rurales 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 culturelle a permis de satisfaire. Ces efforts vigoureux dans le domaine de la m6decine preventive ont 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 pr6vention ne 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'augmen- tation 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 habi- tant, 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 finan- cement, 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 tra- vail (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 sec- teur sant6 et entrent pour 58 % dans les d6penses totales; a eux seuls, les m6dicaments occidentaux absorbent 49 % du total des depenses du sec- teur. 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 assu- rance; 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 cura- tifs. 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 per- mis une forte baisse des taux de mortalite) se sont traduits par une aug- mentation 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'inqui6tude majeure. Les causes de deces en Chine sont actuellement les memes que dans les pays industrialis6s : cardiopathies, cancer et congestions cerebrales viennent en tate de liste. Les traitements appliqu6s dans les pays occidentaux sont extr&mement coateux et moder6ment efficaces. Mais les traitements exig6s par les malades et les efforts m6dicaux pour les guerir representent souvent des depenses considerables dont l'effet sur la sante est relativement faible. 20. Le secteur de la sante se trouve donc plac6 aujourd'hui devant deux d6fis : a) premierement, mener a bien la premiere r6volution sanitaire en 6tendant aux r6gions oui le taux de mortalit6 et le nombre des deces par maladies infectieuses restent 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 combineront la pr6vention, les traite- ments a faible coat, des techniques de rehabilitation et de soins "humains". Les problemes a resoudre sont considerables mais toute reussite dans ce domaine, fat-elle incomplete, sera d'une immense valeur non seulement pour la Chine mais pour la communaute internationale tout entiere. 21. Mener a son terme la premiere revolution. Des disparit6s tres importantes subsistent encore dans les services de sante et la situation sanitaire entre les provinces, a l'int6rieur des provinces, et entre les campagnes et les villes. Les soins de sante ont ete amelior6s dans les zones urbaines et la prochaine tache prioritaire consiste maintenant, comme le reconnait le Ministere de la sant6 publique, a consolider les progres r6alises dans certaines regions rurales et a assurer la meme qua- lite de prestations aux r6gions plus pauvres. Il va donc falloir elaborer des plans d6tailles pour abaisser les taux de mortalit6 et de morbidite causes par certaines maladies particulieres dans les regions pauvres, en tenant compte des facteurs epidemiologiques, des conditions financieres et des besoins en personnel, de leur formation et de leur distribution. Etant donne la pauvret6 de la plupart des regions oui la premiere revolution des soins de sant6 doit etre menee a son terme, un financement exterieur (du Gouvernement provincial ou central) sera indispensable pour prendre les- mesures qui permettront de faire disparaltre les disparites entre les diff6rentes situations sanitaires. Meme s'il ne s'agit pas de sommes consid6rables au regard des subventions que l'Etat accorde actuellement aux citadins, elles n'en seront pas moins difficiles a trouver. 22. L'un des phenomenes qui ont une importance particuliere sur l'evolution des soins de sante dans la Chine rurale est le d6clin des sys- temes d'assurance maladie des cooperatives rurales 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 assurances coop6ratives, mais ce chiffre etait tomb6 a 58 % en 1981. Pres de 50 % de la population rurale doit donc prendre integrale- ment a sa charge les frais medicaux et ce pourcentage va tres probablement augmenter encore. Cette 6volution a deux consequences defavorables : en premier lieu, les grands progres que le partage des risques permet d'ac- complir dans l'inter8t du bien-etre de la population se trouvent perdus en raison de l'absence d'une assurance maladie. Meme si les systemes de coop6ratives rurales avaient de nombreux defauts et etaient notamment dans l'impossibilite de 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 mobi- lisation d'une main-d'oeuvre ben6vole risquent particulierement de souf- frir du systeme du "lopin individuel" et d'aboutir a la r6apparition de parasitoses et de maladies infectieuses si d'autres mecanismes de finance- ment ne sont pas mis en place. 23. Objectifs de la deuxieme r6volution sanitaire. Les succes rem- portes dans la lutte contre les maladies transmissibles ont deplace les problmes de sante et les ont transferes sur les groupes plus ages parti- culi&rement vuln6rables aux maladies chroniques, dont la plupart se pretent assez difficilement a des mesures de prevention. I1 faut donc en priorit6 mettre au point des strategies efficaces mais en meme temps peu couateuses pour les combattre. Le grand danger serait de ceder a la tenta- tion de s'inspirer des techniques tres on6reuses qui se sont r6v6lees relativement inefficaces et qui, meme dans les pays a revenu eleve, ont mis tres lourdement a contribution leurs ressources 6conomiques. Aucune mesure, qu'elle soit preventive ou curative, contre les maladies chro- niques n'aura jamais un effet aussi spectaculaire sur l'esp6rance de vie que la lutte contre les maladies transmissibles et infectieuses. Celle-ci a permis en effet d'augmenter l'esperance de vie en r6duisant la mortalite infantile et juvenile; mais pour tragique que soit la mort d'un enfant, le d6c6s pr6matur6 d'un adulte actif est moralement et 6conomiquement beau- coup plus couiteux pour la famille et la societe. Les programmes de lutte contre les maladies chroniques auront donc sur le bien-etre des effets benefiques qui seront plus que proportionnels a l'effet limite qu'ils auront sur l'esp6rance de vie. 24. Certaines mesures de prevention des maladies chroniques peuvent etre prises des a pr6sent, en particulier en ce qui concerne la consomma- tion de sel et de tabac. La consommation de sel est beaucoup plus 6lev6e en Chine que dans la plupart des autres pays et l'incidence de l'hyperten- sion y est par consequent 6levee (et en augmentation). Une consommation excessive de sel est une cause de cardiopathies et de congestions cere- brales qu'il serait possible d'eviter et qui sont l'un des problemes majeurs de sante publique dans la Chine d'aujourd'hui. La consommation de tabac est exceptionnellement elevee 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 fau- dra 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 rap- port 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 popula- tion 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 soi- gner 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 tech- niques 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 Gouvernement con- 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 eloignees des hopitaux de r6gion. Elles permettront en 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 probablement difficile de trouver le personnel quali- fi6 pour ces cliniques, la r6volution culturelle ayant en particulier oblig6 les medecins au "retour a la terre", et il faudra pr6voir des inci- tations suffisantes pour le personnel, notamment en matiere d'6quipement et de conditions de travail. 31. Capacit6 d'evaluation scientifigue et recherche sur les systemes de sant6. Les techniques medicales modernes etant tres coateuses, l'eva- luation de l'efficacite des techniques (nouvelles et traditionnelles) de diagnostie, de traitement et de pr6vention prend actuellement beaucoup plus d'importance. Les grandes 6coles de medecine font souvent oeuvre de pionniers lorsqu'elles introduisent de nouvelles techniques medicales et elles devront se doter des moyens qu'exige cette 6valuation. Les prin- cipes d'6pid6miologie ne devront pas s'appliquer seulement aux maladies non infectieuses mais aussi a l'evaluation des mesures de lutte contre la maladie, a la qualite des soins et a l'affectation des ressources au sys- tcme de sant6, autrement dit a la recherche sur 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'importance qui s'attache a "prevenir d'abord", on n'a prete que peu d'attention a la pr6- vention des maladies comme les maladies cardiovasculaires, le cancer et les affections respiratoires chroniques. Meme dans de nombreuses regions rurales, ces maladies sont responsables de la plupart des d6ces. La crea- tion (ou la designation) des institutions qui seront chargees de la sur- veillance 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 -- development Of a heavy industrial base and elimination of 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 dramatically the 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-provincial variations that r ain in death rate, birth rate, life expectancy and 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 supplementary papers are listed after the table of contents.) Principal results of the demographic model appear in Annex Table A.2; official demographic data 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 malnutrition that were principally responsible for 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 proportions of middle-aged and older persons. This chapter reviews trends in fertility and mortality in the Chinese population and accompanying changes in patterns of morbidity and malnutrition; it concludes with a section summarizing the 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 underlying variation in experience very much in mind. 2.03 For many years data concerning population 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 particu- lar, 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 distri- butions from the 1982 census for three populous and typical provinces. 1, These data have allowed construction of 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: Population Census 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 FERTILITY AND 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 Supplementary Paper No. 1. 2.04 Table 2.1 shows substantially higher 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/ Supplementary Paper 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 The Total Fertility Rate 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 World Bank-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 compilations of much of the available data. - 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 demographic data from China, see Supplementary Papers 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 Development Review, 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.  Figure 2.2 Expectation of Life at Birth. 1950-1982 70- 60- 50 ~40- 30 1950 1955 1960 iw6 1970 1975 1980 1985 Ylear W000d Bor*c- 25708  - 10 - (ii) While the general pattern of improvement shown in Table 2.1 agrees with official figures, Bank estimat1e 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 inter- provincial 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 da 0 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 epidemioloF 0cal 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 PERCENTAGE DISTRIBUTION OF DEATHS BY CAUSE, CHINA AND MODEL HIGH- AND LOW-INCOME COUNTRIES Percentage distribution of deaths China Model low- Model high- Cause 1973-75 income country income country Infectious, parasitic and 25.5 43.7 10.8 respiratory diseases Cancer 10.3 3.7 15.2 Circulatory diseases 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 classification may, therefore, exist. The percentage of deaths due to tuberculosis is 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 information about these areas that are just beginning the epidemiologic transition and 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-represent relatively 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 environmental management. 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