Report No. 3391-CHA China: tE1 tDPYbF1 Socialist Economic Development (In Nine Volumes) Annex B: Population, Health and Nutrition 3391 June 1, 1981 (reprinted March 10, 1982) Vol. 3 East Asia and Pacific Regional Office FOR OFFICIAL USE ONLY Document of the World Bank This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. 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: 1977 $1.00 = Y 1.828 1978 $1.00 = Y 1.661 1979 $1.00 = Y 1.541 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. FOR OFFICIAL USE ONLY CHINA: SOCIALIST ECONOMIC DEVELOPMENT ANNEX B POPULATION, HEALTH AND NUTRITION Table of Contents Page No. SUMMARY AND MAIN ISSUES . . . . . . . . . . . . . . . . . . . . . . i-xiii 1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . 1 2. HEALTH AND NUTRITION. 2 A. Post-Revolution Achievements and Current Status. 2 B. Policies for Overcoming Health Problems . . . . . . . . . . 19 C. Health Care Delivery Systems and their Cost .28 3. POPULATION AND BIRTH PLANNING ..36 A. Population Size, Growth, and Distribution . . . . . . . . . 36 B. Birth Planning and Other Factors Explaining China's Fertility Decline .49 C. Implications of Population Change for the Future .61 APPENDIX - Supplementary Statistical Information . . . . . . . . . . 64 SUPPLEMENTARY PAPERS (BOUND SEPARATELY) /1 SP-I Income and Other Factors Influencing Fertility and Mortality in China SP-II Alternative Projections of the Chinese Population SP-III Food Availability and the Nutritional Status of Children in China SP-IV Child Malnutrition and School Retardation in China /1 Copies of these papers may be obtained from the Population, Health and Nutrition Department, Room N-325, World Bank. This document has a restricted distribution and may be used by recipients only in the performance of Itheir official duties. Its contents may not otherwise be disclosed without World Bank authorization. -2- Page No. TABLES IN TEXT 2.1 Estimates of Death Rates and Life Expectancy in China, Selected Years and Places ... . . . . . . . . . . . . .. 5 2.2 Indicators of Mortality, China and Other Countries . . . . . . 6 2.3 Percentage Distribution of Deaths by Cause, China and Model High- and Low-Income Countries . . . . . . . . . . . . 7 2.4 Progress on Selected Parasitic and Infectious Diseases . . . . 9-10 2.5 Nutrient Sources and Availability, 1979 . . . . . . . . . . . . 12 2.6 Energy (Calories) and Protein Availability, China and Other Countries ... . . . . ..... . . . . . . 13 2.7 Malnutrition in China - Percentage of Children Stunted, 1975 ... . . . . . . . ..... . . . . . . . . . 15 2.8 Major Micronutrient Deficiency Diseases . . . . . . . . . . . . 18 2.9 Regional Distribution of Health Care Inputs and Life Expectancy .... . . . . . . ..... . . . . . . . . . . 23 2.10 Health Care Workers - Education and Role . . . . . . . . . . . 25 2.11 Costs of Health Care, 1979 . . . . . . . . . . . . . . . . . . 32 2.12 Public Expenditures on Health Care, China and Other Countries ... . . . . . . ..... . . . . . . . . . 33 2.13 Medical Personnel and Facilities . . . . . . . . . . . . . . . 34 2.14 Medical Personnel and Facilities, China and Other Countries . 35 3.1 Population and Income Growth, China, 1949-80 . . . . . . . . . 38 3.2 Official Figures on Population Totals, Births, Deaths and Rates of Increase, Selected Years . . . . . . . . . . . . . . 40 3.3 Vital Rates and Population Growth, China and Other Countries 42 3.4 Age Distribution of the Population, China and Other Countries ... . . . . . . ..... . . . . . . . . . 44 3.5 Population Totals and Natural Increase Rates, 1980-2005, Alternative Projections ... . . . . ..... . . . . . . . 46 3.6 Percent of Population in Urban Areas, China and Other Countries ... . . . . . . ..... . . . . . . . . . 47 3.7 Cultivated Area per Capita of Agricultural Population in the Mid-1970s: An International Comparison . . . . . . . 49 3.8 Reported Late Marriage Rate and Planned Birth Rate, Selected Areas of China ... . . . . . . ..... . . . . . . . . . 54 3.9 Current and Projected Age Distribution of China . . . . . . . . 62 -3- Page No. FIGURES 1. Life Expectancy in Relation to Income: Developing Countries, 1978 . . . . . . . . . . . . . . . . . . . . . . . 3 2. Percentage Distribution of Deaths by Cause, China and Model High and Low-Income Countries . . . . . . . . . . . . . 8 3. Nutritional Status and Income: Height-for-Age of Older Children. 17 4. Nutritional Status and Income: Weight-for-Height of Older Children ..17 5. Organization of Health and Birth Planning Services . .26 6. Fertility in Relation to Income: Developing Countries, 1978 37 7. Crude Birth and Death Rates, China, 1950-2000 . .41 8. Percent of Married Women of Reproductive Age Using Specified Contraceptive Methods ..52 APPENDIX TABLES Population and Population Projections A.1 Population Totals, Birth, Death and Increase Rates, 1949-79: Official and Semi-Official Data A.2 Birth and Death Rates for Urban and Rural Areas, 1954-79: Official and Semi-Official Data A.3 Population Totals, Birth, Death and Natural Increase Rates, 1980-2030, Under Two Alternative Projections A.4 Alternative Projections of Chinese Working-Age Population by Age Group, 1980-2030 A.5 Alternative Projections of Chinese School-Age Population by Age Group, 1980-2030 A.6 Women Reaching Marriage Age (Age 23), 1980-95, as a Percent of 1980 A.7 Number of Births in China and Hunan Province, 1953-78 A.8 Birth and Death Rates in Gansu Province, Selected Years, 1949-79 A.9 Percent Declines in Crude Birth and Death Rates, Selected Countries Provincial Demographic Data A.10 Provincial Demographic Data: Population Totals and Rates of Natural Increase - 1964, 1978, 1979 A.11 Life Expectancy by Province, 1973-75 -4- Urbanization Data A.12 Percent Urban Population, Various Sources A.13 Percent of Population in Cities, by Province, 1979 Birth Planning Data A.14 The Contraceptive Prevalence Rate and Induced Abortion, 1978 A.15 Couples Holding One-Child Certificates, Selected Areas of China, 1979/80 A.16 Compliance with Birth Planning A.17 The Late Marriage Rate (UMR) in Selected East Asian Countries and in China A.18 Percent Distribution of Live Births by Birth-Order A.19 Examples of Incentives and Disincentives to Discourage More Than One Birth Per Couple, Various Provinces and Cities of China The Health System A.20 Organization of the Ministry of Public Health, 1981 A.21 Numbers of Hospitals and Beds in 1979, by Province Mortality and Morbidity A.22 Major Causes of Death, 1973-75 A.23 Major Causes of Death at Different Ages, Beijing, 1979 A.24 Mortality Rates From Major Diseases, Cities and Counties, 1954-78 A.25 Incidence and Death Rates from Communicable Disease, Nationwide, 1979 A.26 Communicable Diseases in Gansu Province, 1979 A.27 Infant Mortality Rates, Various Sources Nutrition A.28 A Food Balance Sheet for China, 1979 A.29 Food Energy Requirements, China, 1979 A.30 Food Protein Requirements, China, 1979 SUMMARY AND MAIN ISSUES 1. China has achieved remarkably low death rates for its income level, yet it has nonetheless managed to reduce birth rates sufficiently so that its population growth rate is among the lowest in the developing world. This Annex provides a descriptive account of China's success in reducing its popu- lation growth rate and in improving its citizens' health. This summary begins by reviewing the Annex's treatment of health and nutrition, then population; it concludes with an overview of the main issues. Health and Nutrition 2. The determinants of health - as measured by illness as well as death rates - are much broader than is sometimes supposed. One determinant is people's consumption of certain goods and services, including food, housing, fuel, soap and water, as well as medical care. Another is the health environment - climate, standards of public sanitation, and the prevalence of communicable diseases. A third is people's understanding of nutrition, health and hygiene. 3. Chinese health policies reflect an unusually good and early grasp of these determinants, in combination with a strong commitment to improve the health of the mass of the people under tight financial constraints. Raising inc-imes and expanding basic education have in this sense both been part of the drive for better health, as has been food distribution policy. 4. In the area of health care narrowly defined, Chinese policy has had three distinctive features. One is a very strong emphasis on preventive measures and on improving the health environment - by vaccination and infectious disease vector control, and by strict enforcement of elementary aspects of private and public sanitation. An important aspect of the preven- tive emphasis has been a strong 'vertical' organization, with central authorities responsible for campaigns against specific diseases, combined with effective use of the clinical services in support of preventive measures. A second has been very wide diffusion of basic curative care - most notably the barefoot doctors at the team and brigade level - backed up by referral of difficult cases to better equipped and trained personnel at commune health centers and county hospitals. Corresponding arrangements exist in urban areas. A third has been continued reliance on traditional Chinese medicine - personnel and drugs. 5. There are only 2,458 people per (fully qualified Western) doctor in China, as compared with 9,900 in other low-income countries and about 4,310 in middle-income countries. The ratio of population to other medical personnel (including nurses and doctors of Chinese medicine) is even more favorable - 892 excluding barefoot doctors and 365 including them, as compared with 8,790 in other low-income countries and 1,860 in middle-income countries. - ii - 6. In part because the pay of most medical personnel is very low by international standards, this has been achieved at an estimated total annual cost of under $7 per capita, of which $4 is public expenditure. Almost two thirds of expenditures are for drugs. By the standards of low-income developing countries, the level of public expenditure is high - it compares with $2 in India and $1 in Indonesia. But in other low-income countries, large sections of the population, and in particular the rural poor, have little or no access to health care, whereas in China coverage of some sort is virtually universal - a situation found usually only in countries rich enough to spend many times as much per capita on health. 7. It is not possible to disentangle the relative contribution of the health care system from that of the other factors mentioned, but there can be little doubt that it has played an important part in the tremendous impro- vements in health that have occurred since the revolution. Life expectancy (which is determined mainly by infant and child mortality rates) is estimated to have risen from 36 years to 64 years over the past three decades. The incidence of disabling as well as killing diseases such as schistosomiasis, malaria, tuberculosis, trachoma, plague and cholera has been drastically reduced. Case fatality rates have also fallen sharply - in measles, from 6.46% in 1950 to 0.66% in 1979. 8. Progress of this sort has also been made in other developing coun- tries - even the low-income ones, where life expectancy is estimated to have risen from 35 years in 1950 to about 50 years in 1978. But the advance has been much faster in China (a gain of 28 years in life expectancy, as compared with an averagp of 15), and thus the level of life expectancy in China at the present time is well above the average not only for low-income but also for middle-income countries (61 years). Indeed, China's life expectancy is some 16 years greater than would be expected (on the basis of cross-country comparisons) in a country at its income level. 9. Nonetheless, although gains have been impressive, available data indicate that in poorer provinces of China life expectancy is 10 to 13 years less than in Shanghai. Furthermore, data on causes of death indicate that while China's pattern is beginning to look more like that of a high-income country (with cancer and circulatory diseases increasingly important), many millions still die of the more easily preventable diseases of low-income countries. 10. Little of China's gains can be attributed to climatic differences between China (which is half-temperate) and other low-income countries (which are nearly all tropical): cold is a hazard to health, especially among children; China's life expectancy in 1950 appears similar to that of other low-income countries; and life expectancy today in nontropical low-income countries such as Nepal and Afghanistan is well below the low-income average. Instead, on the basis of evidence from other developing countries, the main contributors to China's superior performance are probably fourfold. First, the food rationing system has almost eliminated acute malnutrition, which - iii - appears to contribute to between one third and two thirds of all child deaths in other developing countries. Second, near-universal basic curative and preventive health care has greatly reduced the incidence and fatality rates of common respiratory and diarrheal diseases - which remain major killers in other developing countries (as well as in poorer parts of China). Third, widespread primary education, especially of women, has contributed to improved nutrition and health practices in child-rearing. Finally, lower fertility rates create conditions conducive to the health of mothers and children, and China's population policies have thus had important health benefits./l 11. Within China, despite the near universality of basic coverage, health and health care facilities are unequally distributed. Urban areas are better provided for than rural areas. Similarly, within rural areas, the quality of health care provided at the commune and subcommune levels varies according to income, with some of the poorest brigades and teams having reportedly cut back their provision of services in recent years. These variations are smaller than in most other developing countries, but they are nonetheless a cause for concern. 12. Average food consumption in China at the present time compares well with other developing countries. Food energy consumption, at 2,441 calo- ries per person per day and 103% of estimated requirements, is above that of India and the average for all low-income countries (both around 2,000 calories and 91%), and not far below the average for middle-income countries (2,600 calories and 108%). The 1979 level represents a substantial improvement from the 1957 level of approximately 2,020 calories; almost all this improvement has taken place subsequent to 1977 due to sharp increases in food production. Protein availability per person is also above that of many low-income countries, though below that of such middle-income countries as Korea and Mexico. The evidence suggests, however, that the Chinese diet contains an unusually low proportion of meat and fats. 13. But as research on nutrition has increasingly made clear, the extent of malnutrition in a country is only weakly related to its average food con- sumption. Of far greater importance is the way in which food is distributed, and in particular the relative consumption levels of lower income groups. In this regard, China is way ahead of all but a tiny handful of developing countries - either low-income or middle-income. 14. In urban areas, staple foods have consistently been rationed in the usual way with monthly entitlements that vary with age, sex, and occupation, but which appear to provide for an adequate (though spartan) level of consump- ption. These have to be purchased, but prices have been such in relation to incomes that the great majority of households (and by now virtually all of them) have been able to afford their full allotment. /1 For further discussion of the issues in this paragraph, see World Development Report 1980, pages 53-57. - iv - 15. In rural areas, the Government has guaranteed to sell enough grain to households to make up any gap between the amount of grain distributed as income in kind by their teams and a floor level of 200 kg (of unprocessed grain) per person per year in rice-growing areas and 150 kg in other areas. Again, this ration has to be purchased, but loans and social relief grants are made available where necessary. Rural meat rations, however, are only a quarter to a half of those in urban areas. The floor level, it should be emphasized, is low - equivalent to about 1,400 calories per day for the rice ration and several hundred calories less than that for the mixed grain ration. But it is almost invariably supplemented by food grown on private plots or purchased with money income from collective or private activities (though until recently grain could not be privately traded). 16. Detailed data on the distribution of food intake per person are unavailable. But two sorts of evidence strongly suggest that the Chinese system has, as mentioned earlier, virtually eliminated the acute malnutrition that is common in many developing countries (and that unquestionably contri- butes to early death, ill health and other physical suffering, and mental retardation). One is the high level of life expectancy mentioned earlier, which is associated with an infant mortality rate of 56 per thousand (as compared with 100-200 in other low-income countries). 17. The second sort of evidence concerns the height and weight of school children. Although anthropometric data of this kind are generally biased by lower school attendance among malnourished children, enrollment rates are very high in China. It is thus significant that in the rural and urban schools surveyed, there appeared to be almost no acute malnutrition, as measured by abnormally low weight for height (known as "wasting"). It is also significant that the proportion of children who are chronically malnourished (as measured by abnormally low height for their age, known as "stunting") even in rural schools in the very poor province of Gansu is below that of Asian countries at comparable income levels. 18. However, the anthropometric data do indicate that a substantial proportion of Chinese children are stunted, and that there are major diffe- rences in this regard between poorer and richer parts of the country. Among children aged 3-10, only 5% are stunted in urban areas (less than 2% in Beijing), and this proportion appears to have declined substantially since 1958; but in rural areas, the proportion is anything from 20% to 35%, with the highest proportions in the areas with the lowest personal incomes. (The trend of rural malnutrition over time is not known, although the necessary data were collected in 1959.) The adverse effects of low height - by the standards of rich countries - on mental development and other aspects of personal well being are incompletely documented. But the same Chinese data indicate that it slow,3 indivf,dual children's progress in school.. rhe Chinese Government, moreover, has recently expressed concern about malnutrition in rural areas./l Population 19. No account of either growth or poverty in China can overlook the near-doubling of population sirace 1949 (when it was already over 500 million). By the end of 1980 China's population (excluding Taiwan) was 982.6 million. As in other developing countries, the death rate has fallen rapidly. But the crude birth rat:e, after declining in the 1950s, rose to a peak of 43.6 per thousand in the mid-1960s, when population was growing at a rate above 3% a year. Over the whole period 1949-79, the average annual population growth has been a little under 2%, similar to other developing countries. Since 1965, however,, the bhrth rate has almost halved - a decline faster than that recorded in any other country. As a result, and despite a remarkably low death rate, population growth (1.19% in 1980) is now extremely slow by developing country standards though above that of industrialized countries. The Chinese plan is to reduce the growth rate still further with the goal of limiting total population to 1.2 billion in the year 2000. While this objec- tive may be overly hopeful, past success in fertility limitation suggests that it is not unreasonable to expect the Chinese to come close to that goal./2 20. The official estimates for birth and death rates and for population growth show slight inconsistencies,/3 but even if birth and death rates are adjusted upwards to eliminate the inconsistency to 21.1 and 7.8 per thousand respectively in 1979, they are both very low by comparison with other developing countries. The contrast is particularly striking when income is taken into account. In general, the birth rate tends to be lower, the higher a country's per capita GNP - the lowest rates being in the industrialized countries, the highest in the poor countries of sub-Saharan Africa and the Indian subcontinent. China's birth rate, however, is less than half what would be expected in a country of its income level; it would appear normal in a country with several times China's income. /1 Micronutrient deficiencies appear less serious in China than in many other low-income countries. But mild anemia (caused partly by inadequate iron in the diet, partly by hookworm infestation) is widespread. Rickets, goiter and Keshan disease (caused respectively by vitamin D, iodine and selenium deficiencies) also affect significant proportions of the popu- lation, and have been the subject of government campaigns and research. /2 In late 1979 the goal of population policy had been to achieve a zero population growth rate by 2000; this goal, which is much more ambitious than limiting the population total to 1.2 billion, appears to have been put aside. /3 The quality of demographic data available concerning China is improving, however, and a census currently scheduled in July 1982 should greatly improve the core data base. - vi - 21. One reason for China's unusually low birth rate is its unusually low death rate, and in particular the low rate of infant mortality, which reduces the number of children that a mother needs to bear in order to attain any given desired family size. Another reason is the unusually high proportion of people - and especially women - with at least some primary education, which has been shown by research in other countries to alter attitudes concerning family size and the use of modern contraceptives. But these factors cannot account for the speed with which fertility has recently declined in China; nor are they sufficient to explain the low level it has reached. An important additional cause is the Government's birth planning policy. 22. In this regard, as in others, there have been various changes in direction. In 1956, following the 1953 census, the Government announced a policy of promoting late marriage and birth limitation, but this was soon replaced by ideological polemics against population control during the Great Leap Forward, which started in 1958. Although attempts were made to reintro- duce the birth planning program during the 1960s, it was not until the end of the decade that the program was resumed, expanded and intensified. 23. Since the early 1970s, however, China has had one of the world's most active and effective fertility reduction programs. Contraceptives are universally available and free, as are abortion and sterilization. There has been a successful effort to raise the age of marriage. Study groups in com- munes and brigades (and at analogous levels in urban areas) set birth quotas and allocate births to couples in a particular order. And since 1979, there has been a campaign to promote the one-child family. 24. The program owes its effectiveness partly to the commitment with which it has been pursued by officials at all levels, but also to two sorts of incentives and disincentives. The first is economic - paid vacations or work points for undergoing planned birth operations since the early 1970s, and more recently, in some provinces, financial allowances and priority in education, employment and housing for couples who pledge to have only one child, combined with financial penalties for those who have more than two children. The second is social: intense efforts are made to influence couples to conform with the birth planning policy, both through the media and (more important) through discussions between couples, local officials charged with implementing the policy and other local people. 25. As in most other developing countries, there are as yet compara- tively few old people in China - about 5% of the population is over 65, by comparison with 16% in Sweden. The proportion of the population under 15 (about 35%) is likewise much greater than in the industrialized countries (typically around 25%); but, due largely to the decline in fertility in the 1970s, it is at the low end of the developing country spectrum. As a result, the ratio of population of working age to total population - an important influence on per capita income - is about 60% in China, as compared with 56% in India, 51% in Mexico, and 66% in the USA. Of those of working age, - vii - moreover, so-ie two thirds are actually working - a high proportion by international standards, and one that has risen significantly in the past three decades. 26. Official estimates put the urban population share at 13% in 1979 - very similar to the proportion in 1953, and much lower than the proportions in other developing countries (India, 22%; Indonesia, 20%; all low-income coun- tries, 21%; all middle-income countries, 51%). The low growth and low current share of urban population in China may be to some degree attributable to a current definition of "urban" that is somewhat different from that of most other countries and that used in China in the 1950s. But they undoubtedly also reflect the policy of "industrialization without urbanization" pursued fairly consistently since about 1957. Communes and brigades have been encouraged to establish industries of all kinds in rural areas (which cur- rently account for about 10% of total industrial production); and migration to urban areas has been restricted by the Government. 27. Migration policy has in fact varied over time. During the Great Leap Forward (1958-60), large numbers of rural people were encouraged to come to work in urban industry, but returned to the countryside during the subsequent economic difficulties. Restrictions on migration were then tightened, and indeed during the period of the Cultural Revolution (1966-76) several million urban people (especially the young and the politically discredited) were sent into the countryside, though there was also movement in the opposite direction. Since 1977, however, most of those sent to rural areas have returned, and it remains difficult for rural people to leave their communes with the exception of the few who manage to obtain a university or technical secondary education, or who were able to find employment outside their communes (usually in coal mines or the army). 28. Less is known about migration between rural areas, although it too has been regulated by the Government. There appears, however, to have been no major change in the geographical distribution of population: as in 1949, about 95% of the population lives in the eastern half of the country. Issues: Health and Nutrition 29. Health. Several important classes of decisions face the Chinese leadership concerning health policy. These include: How rapidly (and where) should they expand hospital facilities, and how should they equip (or re-equip) new and existing facilities? How much should inequality in the provision of health services be reduced? What types of training (pre- and in-service) should be provided to health care practitioners? What pharma- ceuticals should be produced, how should they be priced, and who should control their use? (Decisions concerning pharmaceuticals are of particular importance given the very high proportion of total medical expenditure that they account for.) How rapidly should the preventive facilities of the anti- epidemic stations be refurbished (in the aftermath of the Cultural Revolu- tion), and what should be their primary tasks in light of changing patterns of - viii - disease and death? How much assistance should the state provide for medical care in poor areas, and how much of that should be through the health services directly and how much through other measures such as improving water supplies and nutrition levels? What type of data collection and applied research will contribute most to the evolution of China's health care policies? 30. The answers to these and other questions will shape the direction of China's health sector investments in the coming decade, and this Annex, based as it is on a brief review of the sector, can only suggest insights into some of the answers. An important observation, however, is that the appropriate answers to the specific policy questions are highly interrelated and that they should flow from a general sense of health sector strategy. What, then, are the strategic options? Four can be considered: consolidation of existing services, extension of geographical equity, improvement of high-level clinical services, and preventive measures directed toward cancer, circulatory, and pollution-caused diseases. 31. The consolidation strategy would be one of neither expanding the scope nor changing the broad direction of health services; within existing budget constraints, increases in efficiency would be sought. An important aspect of a consolidation strategy is the objective of ensuring that, where progress has already been substantial, achievements are not allowed to erode. This will require continued vigilance and commitment to strong preventive measures and frequent retraining of health workers, especially primary health workers such as the barefoot doctors. 32. The geographical equity strategy would seek both to finance and to provide the material resources required to bring poorer regions of the country up to health levels now found in richer ones. Limited available data imply that a substantial fraction of the population retains disease and mortality patterns much closer to those of typical low-income countries than to the better-off parts of China. Primary health care policies that have proved highly cost-effective already in China would likely continue to succeed if they were more intensively extended geographically. 33. A strategy of improving clinical services would seek to provide improved curative care for the increasingly frequently seen diseases of high- income countries, such as cancer and circulatory disease. Physicians and facilities for handling those diseases are in short supply in China, and demand for them will steadily increase. Treatment of cancer and circulatory diseases, however, is relatively expensive - requiring fully trained physicians and costly drugs and equipment - and relatively ineffective in terms of prolongation of life. 34. A final strategy is that of improving public preventive measures against the diseases increasingly prevalent in high-income areas. Some such measures involve campaigns for improved diet, exercise, and smoking habits; others might be politically unpopular (e.g., punitive taxes on cigarettes); still others, like pollution control on factories, can be very costly indeed. - ix - 35. Clearly, the last three of these strategies can be simultaneously pursued, and elements of current government policy point in each direction. Nonetheless, in a very real sense the strategies are competitors: resources expended on one are unavailable for others. Choices must be made, not only in broad matters of resource allocation, but in specific decisions about facilities, equipment, training, and research. The requirements for pharma- ceuticals, training, and research, for example, implied by a strategy of geographical equity differ substantially from those for, say, a strategy of improving clinical services. It is for that reason that broad decisions of strategy should precede and inform specific resource commitments. 36. In evaluating alternative strategies, the Government should not be too quickly or comprehensively seduced by the appeal of Western medical equipment and technology. Precisely because emotional arguments for the best in medical equipment are always compelling, it is desirable to be very hard-headed in evaluating particular proposals. Greater gains in health and life expectancy are likely to result from investments in consolidating the existing system and in geographical equity than from investments of the same amount in costly technology. 37. Nutrition. As in health, the most important advances have already been made, and acute malnutrition is probably rare. Some disorders due to micronutrient deficiencies remain, whose treatment is often very cost- effective, but here also the Government has been active. The outstanding p:oblem is thus widespread moderate retardation of growth (as measured by low height-for-age), especially in the poorer rural areas. This could result from inadequate diet, from frequent childhood disease or from high energy require- ments needed to support physical activity in rural areas. At present, however, not enough is known about either the causes or the consequences of moderate malnutrition in China. 38. As regards the causes, the problem is partly one of food distribution - some people having to live on or close to the low state-guaranteed minimum grain supply because their cash income or private production provides an insufficient supplement. Thus part of the solution might lie in raising the guaranteed minimum, while making eligibility to purchase grain from the state contingent on the level of private as well as collective food production. In addition, it would be desirable to increase grants and loans for food purchase, as well as making more general efforts to raise the earning power of the rural poor. Likewise, to the extent that slow growth results from high prevalence of disease, particularly diarrheal disease, strengthening of rural health services could be important. 39. The fact that moderate growth failure is widespread in some rural areas, however, may also be in part due to the composition of the local diet, and in particular to low intakes of oils and fats (concentrated sources of calories) and high-quality protein. Insofar as this is the case, efforts could be made to target quality foods to children during what appear to be the vulnerable preschool and early school years. Special low-cost rations of such foods for the child might be a highly desirable incentive to include in the incentive package for the one-child family. 40. As regards the consequences of moderate malnutrition, there is some (including Chinese) evidence that it hinders mental development, as well as reducing physical strength, but not enough evidence to permit general benefit-cost analysis of programs to combat it. In particular, no satisfactory answer can at present be given to the question, "How much might it be worth spending to make the average Chinese (or Indian or Indo- nesian) reach the genetically determined potential of his growth in height?" 41. At the least, however, further efforts to attack the distri- butional and health causes of malnutrition have a relatively strong claim on government resources. It should be stressed, however, that little is known at present about the extent and causes of malnutrition in China, nor about its detailed geographical pattern, and applied research on these subjects can be an invaluable guide to policy. In this connection, the nationwide dietary survey scheduled for 1982 could provide an extremely useful data base. Issues: Population 42. The World Bank's "intermediate" projection of the Chinese population is based on a 1979 estimate of 2.75 for the total fertility rate (i.e. the expected number of children a woman will bear during the course of her child-bearing years), and on the assumption that fertility will decline to replacement level between the years 2000 and 2005. (Even if fertility declines to the replacement level, however, the population would continue growing for many years because of the disproportionate number of women entering childbearing age.) Under these assumptions the Bank's intermediate projection is of a population total of 1.24 billion in the year 2000 - only slightly above the Chinese goal of 1.2 billion. For the Chinese to reach their goal, however, simulations suggest that much more substantial fertility declines between 1980 and 2000 will be required than are assumed in the Bank's intermediate projection; the total fertility rate would need to decline to 1.6 rather than 2.2. The more rapid fertility decline implicit in attainment of the Chinese goal has important implications for the size of the labor force and school age population after the year 2000, but the effects are small before then. Even reducing the total fertility rate to 2.2 by the year 2000 will, however, take a sustained, substantial effort and at least moderate success in implementing the one-child family policy. Policies concerning fertility limitation are thus of high importance. 43. The central question is whether and at what cost the goal of lower fertility over an extended period of time can be attained. Three aspects of this question are pertinent. First, even with economic incentives, will rural parents restrict fertility further - to one child - without alternative guarantees of support in old age? And what sort of guarantees would be credible to parents? Second, will the poorer provinces be able to finance a system of financial incentives to discourage births? And third, will efforts - xi - to increase productive efficiency - e.g. by removing restrictions on labor migration - weaken the tightly-knit system of community pressure, reinforced by common awareness of local land scarcity, that now backs up the goals of birth planning? 44. Though for society as a whole, the increase in the support burden represented by the elderly is not unmanageable, parents today are likely to seek a guarantee of security in old age that is closer to home. In this respect, it is important to distinguish between urban and rural areas in terms of the incentives for having large families. Only for the 10 to 15% of the population working in urban areas is there presently a system of employer- provided social security. In rural areas there is no such system, except in a few well-off communes. In peasant societies, children have always been the best insurance against both near-term difficulties as well as long-term needs. This is surely still the case throughout most of rural China, where not only is there no regular system of old-age security, but no formal system of sick leave. Large families can spread the risks of sickness, poor agricultural harvests (if some members can work in nonagricultural jobs, or work in other communities) and other work interruptions. This is particularly the case in poor communities; the poorer the group as a whole, the less can any individual count on communal beneficence in bad times. 45. Moreover, the security children provide to parents in old age does not come at a high current monetary cost, at least to rural parents. At about age 11 many children begin earning workpoints, at about 50% the adult rate, and at about age 12 they are counted as adults in the allocation among households of food rations. 46. The problem is exacerbated by the continuing disparity, in terms of future support, in the value of sons and daughters. Despite efforts of the Government to raise the status of women, and to exhort parents to value daughters as much as sons (e.g. "women hold up one-half of the sky"), the reality is still that sons provide a better guarantee of future support. A survey of one-child households in Anhui province indicated that of one thousand children of holders of one-child certificates (indicating they have pledged to have no more children), 607 were male and 393 female, indicating the importance to parents of having a son./l (Such a result also raises the difficult issue of the long-run effect of giving priority, in education and employment, to only children, should it turn out that a high proportion of only children are males.) Preference for a son, particularly if there is to be only one child, is not surprising. Marriage in most of rural China is still patrilocal, i.e. women at marriage move to their husband's village; under these circumstances, parents cannot anticipate that daughters will be able to provide financial, or even emotional support. Females in rural areas reportedly receive only about two thirds of the number work points that men /1 "A Survey of Single-Child Families", Anhui Population, Population Research Office, Anhui University, no date. - xii - receive for the same time worked; and women are reportedly much less likely than men to receive the prized nonagricultural jobs in commune enterprises. Women, by necessity and by government encouragement, now work extensively in agriculture, but because agricultural work is the least well paid, women's income remains lower than men's in rural areas. In addition, because agricultural work is relatively easily combined with child rearing - in part because it is easy to work less than full-time and in part because the work is close to home - such work is probably not a disincentive to having many children. 47. Two policy questions thus are: Should the Central Government encourage the establishment in rural areas of more formal systems of old-age support, and help finance them? And should the Government consider imposing on production teams in rural areas regulations to guarantee equal pay for equal work to women and men, and equal access for women to nonagricultural jobs? 48. If further reductions in rural fertility are to be encouraged by a system of locally-financed incentives, problems of cost raise the question of whether poorer areas, where fertility is systematically higher, will be able to finance such incentives. Calculations indicate that at the national level, even if all women who enter childbearing years between now and the year 2000 had only one child, the cost of providing a wage or workpoint subsidy of between 5 and 10% would be less than 1% of estimated 1980 GNP./1 But if such subsidies are completely financed locally, the burden in poorer areas will be relatively greater. The issue is how much local areas can afford and whether, without support from the center, financial incentives can be implemented in the areas where they are most needed to discourage births. The financing of incentives seems a particularly pressing issue, given that even what is viewed as acceptable pressure to keep births down has been used as much as possible already at the local level. (There are scattered reports of "excesses" and coercion in implementing birth planning goals; and there are recent discus- sions in public sources of the problem that statistics, including those on births, have occasionally been falsified by local party officials.)/2 49. One factor that may have encouraged smaller family size, or at least provided a rationale for a community goal of reducing family size, is pressure on land. With migration to urban areas severely restricted, the implications of high fertility are obvious, both for the family of many children, among whom private land plots must be divided, and for the community of many neighbors' children, who will need to be absorbed into the community workforce, further reducing the marginal product of labor. This is in /1 See Appendix Table A.19 for examples of incentive systems now in place. /2 For example, see Sun Yefang, "Consolidate Statistics Work, Reform the Statistics System," Jingji Guanli No. 2, February 15, 1981 (quoted in Foreign Broadcast Information Service, March 26, 1981). - xiii - contrast to the situation in most poor countries where parents may believe that additional children increase the probability that at least one will obtain regular work in an urban area, a windfall that could enable that one to support the rest. A loosening of the policy of restricted migration - which may follow if there is more investment in light industry, in textiles and in manufactured goods for export - would of course reduce the importance of this one incentive for fewer births in rural areas. Though migrants to urban areas would presumably adopt the lower fertility of urban residents, only extremely large migrant flows would change the proportion of the population becoming urban enough to offset any increases in rural fertility. 50. In addition to the above three direct policy issues relevant to birth planning, there are two related points that should be considered. The first is that adequate medical technology is required for IUDs, steriliza- tions, and abortions, and that strengthening the medical system in areas now poorly served is probably important to continuing fertility reduction. This is an important factor in considering the merits of the "geographical equity" strategy for continued health sector investment. The second point concerns the importance of improved data collection and applied research; with further fertility reductions likely to be increasingly difficult, it will be important both to have the data with which to assess progress and the research tools for identifying the most cost-effective interventions. 1. INTRODUCTION 1.01 This Annex deals with China's policies, and its considerable achievements, in two areas of human development. One concerns the size of the population, its growth rate, and its geographical distribution. The second concerns the population's physical well-being, its health and nutri- tion. A third major area of human development - education and training - is treated separately in Annex G. China's post-revolution leadership has consistently placed high value on improving health and nutrition standards, though the relative emphasis on preventive and curative and rural and urban services has changed with time. Policy objectives toward population limitation evolved more slowly but are now well-established. 1.02 In consequence of the policies it has followed, China has achieved remarkably low death rates for its income level, yet it has nonetheless managed to reduce birth rates sufficiently so that its population growth rate is among the lowest in the developing world. This Annex describes and attempts to account for China's success in reducing population growth and in improving its citizens' health. It begins with health, discussing declines in mortality, morbidity and malnutrition, and the circumstances and policies that led to those declines. It then turns to discussion of the size and growth of the population and the factors that have led to China's remarkable decline in fertility. Despite these successes, however, important problems and issues remain; these are discussed in the preceding summary section. 1.03 Analyses of progress in health and population are necessarily based both on epidemiological and demographic data and on complementary data concerning the resources, utilization, and distribution of health and birth planning services. The pages that follow are based on available data, including relevant data assembled by the mission, but it is important to note at the outset that important data gaps exist and available data are of uneven (and often unknown) quality. A particularly critical data gap is the virtually complete absence of information on morbidity, infant mortality, and life expectancy in poor regions; the absence of such data can lead to underestimation of the magnitude of remaining problems. The quantity and quality of data available to outside analysts is nonetheless improving rapidly, though the Cultural Revolution period has left enduring limitations on the data gathering and analytic capacities of all parts of the Chinese Government; these problems, and the operation of the statistical system in general, are discussed in Annex A. - 2 - 2. HEALTH AND NUTRITION 2.01 This section begins by reviewing evidence on current mortality, morbidity, and nutrition levels in China and how they have evolved in the past 30 years. It then turns to discussion of the reasons for this progress - in terms both of health sector policy and of the changes in other aspects of the environment that affect health. It closes with a brief description of the institutions in China for health services delivery and an assessment of their costs. A. Post-Revolution Achievements and Current Status 2.02 Mortality. Figure 1 illustrates China's success in improving its population's health with a comparison of life expectancy there with the norm for other low income countries. Life expectancy is perhaps the best single indicator of a country's health status,/l and the dramatic declines in death rate that followed the revolution of 1949 have pushed China's life expectancy to a level that would be expected of a country with several times its per capita income. China's estimated life expectancy of 64 years/2 far exceeds the 50-year average of other low-income countries and is even noticeably better than the 61-year average for middle-income countries. There is, however, substantial variation in estimated life expectancy across provinces - from 59 years in the mid-1970s in Guizhou to 72 in Shanghai municipality (Appendix Table A.11) - and in the provinces with lower life expectancies continued reduction in mortality rates remains an important health goal. Elsewhere the currently high levels of life expectancy suggest the difficulty of substantial further improvements; future health gains are likely to come at higher cost, and to emphasize reductions in morbidity and improvements in nutrition more than reductions in mortality. /1 Figure 1 is based on life expectancy rather than death rates. Crude death and birth rates (that is, the number of births and deaths per thousand population per year) only partially reflect individual levels of mortality and fertility, as each is affected by the age distribution of the population. For any given level of life expectancy, crude death rates are higher the greater the proportion of old people in the popula- tion. The life expectancy measure is purged of these age distribution effects, but of course it is less closely linked to the overall rate of population growth than are the crude death and birth rate measures. /2 The official life expectancy reported for 1979 is 68.2 years. See Table 2.2, footnote a. - 3 - Figure 1: LIFE EXPECTANCY IN RELATION TO INCOME: DEVELOPING COUNTRIES, 1978 80 Cuba Hong Kong Sri Lanka 0 Costa Rica *Argentina 70 - is. China Maiaysia* Mexico Thailand Korea B > Ph0lippines NORM FOR 89 DEVELOPING COUNTRIES < Egy p t *Algeria Pakistan Bolivia X 50O -India Indonesia LU o~/ Nigeria ul *Congo *Ivory Coast UBangladesh 41Nepal 40 Senegal Ethiopia 0 $500 $1,000 $1,500 $2,000 $2,500 $3,000 $3,500 GNP PER PERSON, 1978 a/ Life expectancy at birth is the average number of years a newborn could be expected to live if current mortality conditions were to continue throughout his or her lifetime. Source: Updated from Nancy Birdsall, Population and Poverty in Developing Countries, World Bank Staff Working Paper No. 404 (Washington, DC: 1980) Figure 1-3B (reproduced from Population Bulletin 35:5, Washington DC, Population Reference Bureau, December 19801. See Appendix B of Staff Working Paper for an explanation of the procedure used to derive the line shown. China and Cuba are not included in the estimation of this line, but their locations on this figure do indicate their life expectancy and GNP per person. World Bank - 22591 2.03 Table 2.1 documents the increases over time in life expectancy in China, and the accompanying decreases in crude death rates. Outside analysts have made allowances for the probable under-reporting of births and deaths so that outside estimates of the crude death rate are systematically substan- tially higher than the official Chinese figures. By any account, however, there have been dramatic improvements that were consolidated in the early 1960s, after recovery from the severe agricultural difficulties during the Great Leap Forward. Table 2.2 provides comparisons of China with other low-income countries and shows in more detail than did Figure 1 the extent of China's achievements. It is interesting to note, however, that other centrally-planned economies have also typically placed strong emphasis on health, and that life expectancies in Cuba (72 years) and the Democratic Republic of Korea (63 years), to take two examples, are also high. 2.04 China's patterns of mortality indicate that it is well on its way through what has been labelled the "epidemiological transition," in which mortality from infectious and parasitic diseases is much reduced, and the fraction of deaths due to cancer and circulatory diseases is much increased. Table 2.3 and Figure 2 document the extent to which this has happened for China; they indicate that mortality patterns in China are about midway between those for typical low- and high-income countries. 2.05 Morbidity. Much has been written concerning China's success in reducing the prevalence of important endemic diseases, particularly para- sitic and infectious diseases, but relatively little detailed statistical information is available. Table 2.4 provides summary information on progress that has been made on a number of the more important parasitic and infectious diseases./1 Even though the epidemiological evidence is scanty, it is clear from data that are available, including data on mortality, that there has been great progress. Cholera, plague, and venereal disease, for example, were rampant in pre-revolution China; they are now virtually eradicated. Though tuberculosis and schistosomiasis remain major problems, even with these there has been much progress. Nonetheless the apparently high remaining prevalence of ascariasis (roundworm infection), though not of major concern in itself, suggests that much progress remains to be made in hygiene, at least in rural areas. 2.06 Malnutrition. Issues of nutrition can be approached either through examination of food production, processing, distribution, and consumption, or through indicators of a population's nutritional status (distribution of heights and weights, prevalence of specific nutritional disorders). The two approaches are complementary and, taken together, they provide a picture of the nutritional status of a population. The paragraphs below discuss both nutrient availability and available information on nutritional status. /1 Appendix Tables A.25 and A.26 provide current incidence and case fatality data on the infectious diseases currently found in China. - 5 - Table 2.1: ESTIMATES OF DEATH RATES AND LIFE EXPECTANCY IN CHINA, SELECTED YEARS AND PLACES Crude death rate (per 1,000 population/year) Life expectancy (in years) Semi- National Nation- World offi- World Cancer Semi- wide Bank /c Banister /a cial /b Bank /c Survey /d Official 1948/49 35-45 28 36/e 1950 > 30 18 1957 15-20 10.8 57/a 1961 > 35 1963 15 10.1 1970 7.6 1973-75 8.3-9.3/d 61.7-64.9/d 1975-78 7.3 68.2/e 1979 7.8 6.2 63.9 64 If ----------------------------------------------------------------------__-----__- Specific places Life expectancy (years) Farm areas, 1929-31 (22 provinces) 34.8/g Nanjing, 1935 33.57g Manchuria, 1953-55 43.47g Ch'ang Ch'un, 1958 61.67g Anhui, 1973-75 65.77W Guizhou, 1973-75 59.3Th Heilongjiang, 1973-75 70.47W Shanghai, 1979 73.17e Beijing, 1979 70.97e /a See Chapter 4 of Judith Banister, China's Pattern of Population Growth (Stanford University Press, forthcoming) for these estimates (or references to them) and a discussion of the rationale for them. /b See Appendix Table A.1, for the sources for these estimates, except for the 1948/49 estimate, which is cited in Banister, note /a above. /c See Supplementary Paper SP-II, Table 2. These figures are for the World Bank's 'intermediate' population projection for China. /d These estimates of the crude death rate and life expectancy are based on data made available from the National Cancer Survey in China, which is described in "National Survey of Cancer Mortality in China," by Li Bing and Li Junyao, Chinese Journal of Oncology, March 1980. Demographic analyses from these data undertaken by J. Banister and S. Preston ("Mortality in China," Population and Development Review, March 1981) provide a range estimates from 61.7 to 64.4; Yung Shao-De and colleagues provide figures of 63.62 for males and 66.31 for females, yielding a (weighted) average of 64.9 (Appendix Table A.l1). /e See news release, Xinhua News Agency, April 30, 1980. Tf See "The Economic Development of China," by Ding Chen, Scientific American, September 1980, p. 159. /g For references for these figures, see Table GM.5 of liaitung King and F.B. Locke, "Selected Indicators of Current Health Status and Major Causes of Death in the People's Republic of China," US National Cancer Institute, 1980. /h Appendix Table A.l1. - 6 - Table 2.2: INDICATORS OF MORTALITY, CHINA AND OTFHER COUNTRIES Infant Crude mortality death rate rate Life (per thousand (per thousand expectancy Locale and date population) live births) (years) China, 1975 8.3-9.3 53-63 61.7-64.9 China, 1979 /a 7.8 56 64 US Chinese, 1968-72 .. .. 75 India, 1978 14.0 .. 51 Cuba 6.0 25 72 Korea, Dem. Rep. 8.0 .. 63 Indonesia, 1978 17.0 .. 47 Sri Lanka, 1978 6.0 .. 69 Nepal, 1978 21.0 .. 43 Thailand, 1978 8.0 68 61 Low-income developing countries, 1978 15.0 .. 50 Middle-income developing countries, 1978 11.0 .. 61 /a The official figures for 1979 indicate lower mortality rates than those used here. The official crude death rate is 6.29; the official infant mortality rate is 12 in cities and 20-30 in rural areas; and the official life expectancy is 68.23 years. Sources: For China, see Table 2.1 for death rates and life expectancy and Appendix Table A.27 for infant mortality. For US Chinese, see King and Locke, footnote /g on Table 2.1. For other countries, see World Bank, World Development Report 1980, pp. 144-145 and 152-153. - 7 - 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 respiratory diseases 25.5 43.7 10.8 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 Notes: 1. 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. 2. Appendix Table A.23 contains data on causes of death by age group in Beijing (1979); figures from these are closer to those of the model high-income country than are the figures from China as a whole. Sources: For China, 1973-75, see Appendix Table A.22. For the model low- and high-income countries, see Health Sector Policy Paper, World Bank, 1980, p.13. -8 - Figure 2: PERCENTAGE DISTRIBUTION OF DEATHS BY CAUSE, CHINA AND MODEL HIGH AND LOW-INCOME COUNTRIES 45 -3 7 , Model Low- ElIncome Country 40 - D China E Model High-Income 35- o ~~~~~~~~~~~~32.2 J3 _B30 - ,,,ND 25 _255 25!5. 25- Lu ,u 20 - 15 SE_M_152 cu a, 10.8 10 Infectious, Parasitic, Cancer Circulatory and Respiratory Diseases D iseases Source: Table 2.3. World Bank-22593 - 9 - Table 2.4: PROGRESS ON SELECTED PARASITIC AND INFECTIOUS DISEASES Disease Progress Parasitic Diseases Schistosomiasis This disease is internationally widespread and prevalent (snail fever) in areas, like those for rice farming, where the water- dwelling snail host can both breed and come into contact with man. Schistosomiasis has generally proved impos- sible to eradicate and difficult to control. Estimates vary, but perhaps 10 million Chinese were afflicted in the immediate post-revolution era, and 2 to 2.5 million (in 13 provinces including Shanghai) are afflicted now. Snail-infested agricultural areas have been reduced from about a million hectares to perhaps 250,000 hectares. Malaria For thousands of years, malaria has been prevalent in southern parts of China at altitudes below about 1000 m. As many as 30 million individuals were estimated to be afflicted in the late 1950s, though the case fatality rate of malaria, then and now, is low. Intensive efforts to control the mosquito vector have substan- tially reduced malaria's prevalence, though incidence data in Appendix Table A.25 indicate about 2.4 million new cases in 1979. Ancyclostomiasis Hookworm is widespread in southern China, and estimates (hookworm) of the late 1950s suggested that about 50 million per- sons were afflicted in Shanghai and in 14 southern pro- vinces. Blood loss from hookworm can exacerbate anemia, particularly when diets are low in iron. Improved environmental sanitation has reduced the prevalence of hookworm, but the problem remains widespread. Kala-azar Kala-azar, a parasitic disease afflicting the spleen and liver, had been a problem principally in northern China. It is now virtually completely eliminated (see Appendix Table A.25). Ascariasis Roundworm infestation of the intestine is perhaps the (roundworm) most prevalent parasitic disease in the world, and it is principally caused by inadequate environmental sanitation. Generally regarded as fairly harmless, it may have adverse nutritional consequences. Ascariasis remains widespread; the mission was informed, for example, that in Lanzhou about 34% of children under 7 are infected and that perhaps 87% of children in the surrounding rural areas are infected. - 10 - Table 2.4: (continued) Disease Progress Infectious Diseases Tuberculosis Tuberculosis was the leading cause of death in pre- liberation China, with an estimated mortality rate of 200 per 100,000 population per year./a By 1975, TB had become the 9th cause of death and the mortality rate had dropped to 43/100,000 (Appendix Table A.22). This was accomplished through environmental improvement, pro- vision of curative services, and, principally, wide- spread administration of the effective BCG vaccination. Trachoma Trachoma is an infectious eye disease that can lead to blindness and that had been an extreme public health problem in China - half the population was estimated to have been afflicted in the mid-1950s. While no data appear to be available on current prevalence, it is clear that the problem is now greatly reduced. Venereal diseases These had been major problems before 1949 and, through cure and social change, they have been almost completely eliminated. Diarrheal disease Cholera has ceased to be a widespread killer, though it and cholera remains endemic in parts of China. Prevalence of other diarrheal diseases has probably been greatly reduced./b Measles Measles is a common childhood disease throughout the world, but it poses a threat to life only among children already ill or malnourished. In China, the fatality rate for measles was 6.46% in 1950, declining to 1.7% in 1956 and 0.66% by 1979 (Appendix Table A.24). /a See "Tuberculosis Control in New China," by Peking Tuberculosis Research Institute, Chinese Medical Journal, July 1977. lb See Technical Visit on Control of Diarrheal Diseases, World Health Organi- zation, January 1981. Sources: Unless otherwise noted, material in this table comes from three sour- ces: (a) J.W. Salaff, "Mortality Decline in the People's Republic of China and the United States," Population Studies, vol. 23, 1973; (b) H. King and F.B. Locke, "Selected Indicators of Current Health Status and Major Causes of Death in the People's Republic of China," US National Cancer Institute, 1980; and (c) J. Banister, China's Pat- tern of Population Growth, Stanford University Press, forthcoming (Chapter 4). - 11 - 2.07 A fundamental measure of a country's success in meeting its popu- lation's economic needs is the extent to which undernutrition is eliminated. Insufficient food intake results in retarded growth in stature; it lowers activity levels, ultimately to the point of severely impairing work capacity and motivation; it retards intellectual development;/l and severe malnutri- tion leads to substantially increased risk of disease and death. China has a generally adequate level of nutrient availability both with respect to requirements and in comparison to low and middle-income countries (see Tables 2.5 and 2.6). If food were equally distributed, 103% of caloric requirements and 163% of protein requirements would be met./2 Data on aggregate nutrient availability, however, such as presented in Tables 2.5 and 2.6, provide only partial measures of success both because malnutrition has multiple causes and, more important, because inequalities in distribution (particularly of protein) can leave large fractions of a population malnourished even when aggregate supplies are more than adequate. Thus a valuable complementary guide to the prevalence of malnutrition is data from anthropometric surveys, particularly of height-for-age and weight-for-height of children. 2.08 The means (and standard deviations) of the distributions of anthropometric statistics provide important insights into the extent of malnutrition, and substantial amounts of new anthropometric data were gathered for the mission to complement data provided by the Ministry of Public Health. These data are not necessarily representative of the entire country, but they do cover many regions, and a number of general observa- tions can be made with some confidence; the analyses underlying them are reported in detail in Supplementary Paper SP-III to this Annex. 2.09 Three contrasts emerge clearly from the analyses that ,aave been undertaken. These are: (a) urban nutritional status has improved dramatically between the mid-1950s and the mid-1970s; /1 Supplementary Paper SP-IV utilizes data collected for the mission by the Ministry of Education to examine the effect of children's malnutrition on their progress in school. Even the relatively moderate malnutrition (particularly as measured by height for age) that exists in China tends to result in children falling behind their peers in school. /2 The requirements used in Table 2.6 are those of the Food and Agriculture Organization of the UN. The mission has separately calculated energy and protein requirements for China using the available data on the age distribution of the population and average weights at different ages; Appendix Tables A.29 and A.30 show these calculations. The mission calculations result in lower requirement levels than those provided by the FAQ, in part because we probably use lower estimates for average adult weight than does the FAD. - 12 - Table 2.5: NUTRIENT SOURCES AND AVAILABILITY, 1979 Annual Daily per capita consumption per capita Food Foodstuffs consumption energy Protein Fats (kg) (calories) (grams) (grams) Vegetable Rice 97.1 974 17.0 2.1 Wheat 59.3 576 16.4 2.3 Other grains 38.3 382 8.4 1.6 Tubers 29.5 76 1.0 0.2 Pulses 7.2 67 4.4 0.3 Vegetable oil 2.3 53 0 6.0 Soya products 3.8 39 3.6 1.4 Sugar 3.7 39 0 0 Vegetables 84.5 52 3.2 0.5 Fruits 5.9 4 0.1 0 Animal Pork, beef and mutton 10.9 101 3.4 9.4 Other meat 1.6 3 0.5 0.2 Poultry 2.9 10 1.0 0.6 Fish 3.3 12 1.9 0.4 Eggs 3.4 14 1.1 0.9 Milk 3.5 9 0.6 0.5 Animal fats 1.2 30 0 3.3 Total 349.7 2,441 62.6 29.8 Vegetable 331.6 2,262 54.1 14.5 Animal 26.8 179 8.5 15.3 Source: Appendix Table A.28. Note: Production data from 1957 and 1977 reported in Annex A allow estimates to be made of caloric availability in those years. Supplementary Paper III (Appendix Tables 8 and 9) provides food balance sheets estimating per capita caloric availability in 1957 of 2,024 per day and in 1977 of 2,044 per day. Per capita protein consumption was estimated to be 58.4 grams per day in 1957 and 54.1 in 1977. - 13 - Table 2.6: ENERGY (CALORIES) AND PROTEIN AVAILABILITY, CHINA AND OTHER COUNTRIES Per capita daily availability of Energy Protein % of % of require- Total require- % animal Country Calories ment (grams) ment and pulse China, 1979 2,441 103 62.6 163 26 Bangladesh 1,812 78 36.0 100 18 Brazil 2,562 107 62.7 161 56 Hong Kong 2,883 126 86.0 257 59 India 2,021 91 50.0 136 26 Indonesia 2,272 105 47.0 130 13 Korea, Rep. of 2,785 119 73.0 183 21 Mexico 2,654 114 66.0 173 41 Nepal 2,002 91 48.0 121 19 Pakistan 2,281 99 63.0 165 32 Sri Lanka 2,126 96 43.0 121 16 Low-income countries 2,052 91 n.a. n.a. n.a. Middle-income countries 2,590 108 n.a. n.a. n.a. Sources: For China, Table 2.5. For other countries, information on energy availability is for 1977 and comes from the World Bank, World Development Report 1980, pp. 152-153. Information on protein avail- ability comes from the World Bank's Social Indicators Data Sheet, October 1980. Energy and protein requirements are those calculated by the Food and Agricultural Organization of the UN in May, 1977. - 14 - (b) urban nutritional status has improved somewhat between 1975 and 1980; and (c) though rural nutritional status has improved (where data are available), nonetheless nutritional status, as measured by height-for-age, is markedly worse in the rural areas around the cities surveyed than in the cities themselves./l The second and third of these conclusions conform reasonably well to what one would predict from food supply data (see Annex C, Agricultural Development) and probable patterns of prevalence of diarrheal disease. The first conclusion is somewhat surprising given that aggregate per capita food availability changed little between 1957 and 1977. Improvements may, however, have occurred during that period in the relative position of cities vis-a-vis rural areas; Lardy has documented a tendency in that direction in terms of food supply./2 In addition, improvements in health and sanitary conditions in cities may have increased efficiency of food intake and thus improved nutritional status. Unfortunately, at present virtually no rural anthropometric data are available from the late 1950s with which to explore this issue further. 2.10 Table 2.7 displays urban-suburban and age differences in malnutrition by presenting figures on the fraction of children unduly low in height, given their age. Low height-for-age, know as 'stunting', is perhaps the most widely used indicator of long-term (through perhaps relatively mild) malnutrition. The most striking feature of Table 2.7 is the much higher fraction of stunted children in suburban areas than in urban areas. The high rate of stunting indicated among young teenagers probably results from late maturation rather than permanent stunting. Low weight-for-age is another widely used measure of malnutrition; in China, however, children-s weight-for-height tends to be high. This partially compensates for low height-for-age in terms of weight, and the number of children malnourished in terms of low weight-for-age is very small./3 /1 In 1975, for example, a sample of 7-year-old boys in Beijing proper averaged 122 cm in height; their counterparts in rural parts of Beijing municipality averaged 114 cm, a difference corresponding to well over one standard deviation. Figure 3 illustrates rural-urban differences in height from the same survey for four cities and the suburban areas around them. /2 See N. Lardy, "Food Consumption in the People's Republic of China" (World Bank, mimeo, 1980). The note to Table 2.5 indicates that per capita caloric availability in 1957 was about 2,024 and that in 1977 it was 2,044; no data were available on rural-urban differences. /3 In 1975 approximately 1% of children were badly malnourished in terms of weight-for-age, according to the MOPH; badly malnourished was defined as "Gomez" categories 2 or 3. The prevalence of malnourishment by this definition was eight times greater in rural than urban areas. - 15 - Table 2.7: MALNUTRITION IN CHINA - PERCENTAGE OF CHILDREN STUNTED, 1975 Males Females Urban National National Urban National National Age Beijing urban suburban Beijing urban suburban 3-3.5 1.7 4.4 21.8 0.3 4.4 24.2 5-5.5 1.3 5.9 21.5 1.4 3.8 24.5 7-8 1.1 4.4 26.1 1.9 5.8 26.8 9-10 1.2 4.5 23.0 4.8 6.9 33.0 11-12 8.4 10.6 37.1 6.2 13.1 43.6 13-14 16.1 22.7 50.0 4.8 11.1 34.8 15-16 10.6 14.9 39.0 3.0 4.0 10.0 17-18 4.1 7.6 23.6 2.0 2.7 7.5 Source: Supplementary Paper Sp-III, Table 2.1, provides the estimates on which this table is based. Notes: (i) "Stunting" is defined in terms of a child having low height for his age; specifically a child is defined as stunted if his height is less than 90% of the median height for children of that age according to the NCHS standard (see discussion in Supplementary Paper SP-III). Nutritionists regard stunting as the appropriate measure for chronic (but not necessarily severe) malnutrition. (ii) The national urban areas for which data are reported in this table are from a survey of nine cities - three in northern China, three in central China, and three in the south. The suburban areas are ones located just outside these nine cities; they are, therefore, probably somewhat better off than typical rural areas. The data from urban Beijing are from the same survey. - 16 - 2.11 It would be useful for policy if the anthropometric data could provide insight into the extent to which the undernutrition that does exist in China results from shortages of particular foodstuffs more than from shortages in overall food supply - i.e. if it were possible to form a judgment whether diet quality rather than quantity is a problem. While the patterns in rural areas of very low height-for-age combined with adequate weight-for-height (Figures 3 and 4) are consistent with the hypothesis of a poor quality (possibly low animal protein) diet,/l further research would be required to establish this conclusion. Figures 3 and 4 also illustrate a relation between provincial income level and height-for-age, though the effect is fairly weak. 2.12 One important nutritional concern, that of pregnant and lactating women, is one to which China seems to have devoted considerable attention. Poor maternal nutrition is one important cause of low (i.e. less than 2,500 grams) birthweights of children, and low birthweight increases the probability of neonatal illness or death. Medical visitors to China report that antenatal care results in a very low prevalence of low birthweights./2 2.13 In addition to information on problems of inadequate energy or protein intakes, some data are available on prevalence of disorders due to deficiencies of a number of specific micronutrients in the diet (Table 2.8). Many of the data are available only for children. Generally speaking, micro- nutrient deficiencies appear to be less of an issue in China than in many low-income countries. However, mild anemia is widespread - in part because of inadequate iron intake in the diet, and in part because of iron losses due to hookworm infestation. Other deficiency diseases that remain important in China are rickets (vitamin D deficiency), goiter (iodine deficiency), and Keshan disease (selenium deficiency). There is relatively little vitamin A deficiency, which, in a number of other countries, is an important cause of impaired vision or blindness. Control of goiter has been the subject of extensive campaigns in recent years and will probably cease to be an important /1 Staff of the Department of Nutrition and Food Hygiene (of the Institute of Health, Chinese Academy of Medical Sciences) expressed their concern to the mission about the low levels of fats and oils and of animal pro- tein in the Chinese diet. Adding to their concern for low average levels of animal protein availability was the observation that its consumption is much more unequally distributed than is that of other foodstuffs; some rural dwellers, they estimated, consume only 1% of their total protein as animal protein. /2 See "Report of a Trip to China to Develop a Collaborative Program in Health Services Research," by Dr. C.E. Taylor, November 1980. Le Monde (February 25, 1981) reports the World Health Organization to ascribe a 6% prevalence of low birthweight to China nationwide; this must be an underestimate, given that Taylor reports the Beijing average to be 6%. - 17 - Figu!re 3: NUTRITIONAL STATUS AND INCOME: HEIGHT FOR AGE OFOLDER CHILDREN 0 *1 U au I *n0 w *0~~~~~~ 04 -11.5 -2 bo PROVINCIAL COLLECTIVE INCOME Urban......... Source: Supplementary Paper SP-III Rural Figu,re 4: NUTRITIONAL STATUS AND INCOME: WEIGHT FOR HEIGHT OF OLDER CHILDREN 0 c0 ~~~~0~~~ 0jt44 -t ~;-2-.5 nba~~~~~~~~~~~~~~~~~~~~~~Ubn...... Sorc:Supemntr Ppr P-I RI - 18 - Table 2.8: MAJOR MICRONUTRIENT DEFICIENCY DISEASES Deficiency Current status Rickets (Vita- Either insufficient exposure to sunlight or insufficient diet- min D defi- ary intake of vitamin D can lead to rickets, the consequence ciency) of which is inadequate bone development. This has histori- cally been a major problem in North China and remains so; a 1979 10-province survey of over 70,000 children 3 years old and younger found a prevalence of rickets of 29%. There was virtually no difference between rural and urban areas. The role of large monthly doses of vitamin D in prevention is now being studied. Anemia (iron Anemia, which leads to low energy levels, can result from deficiency) iron-deficient diets or from losing the blood's iron because of parasitic infection or menstruation. As with many developing countries, anemia is widespread in China; a 1979 survey of children 1 month to 7 years of age in Beijing and Shanxi found 47% moderately anemic (hematocrit of 9-12 g/mm) and 2.4% severely anemic (hematocrit less than 9 g/mm). Keshan disease Keshan disease, named for a county in China where it is (Selenium severely endemic, is found in many of the hilly and moun- deficiency) tanous regions of China; prevalence in those regions reaches 1% of children under ten years old. In the recent past the case fatality rate was close to 80%; improvements in treatment methods has reduced this to 13%. Selenium supplementation of food appears to be an effective preventive measure. Goiter (iodine Iodine is an essential ingredigient in the hormones produced deficiency) by the thyroid gland in the throat, and its absence in the diet causes the thyroid to swell with the visible symptoms of goiter. High prevalence of goiter is associated with cretinism, and there is some evidence that moderate iodine deficiency is also harmful. A 5-year goiter control program (providing iodized salt and, sometimes, injections of iodized oil) has recently been judged successful in 607 counties of North China. Over 10 million individuals have been cured and 130 million are being protected. Sources: For rickets and anemia, information supplied by MOPH. For Keshan disease, Department of Nutrition and Food Hygiene, Chinese Academy of Medical Sciences, and "Epidemiological Studies on the Etiologic Relationship of Selenium and Keshan Diease," Chinese Medical Journal, v. 92, 1979. For goiter, article in People's Daily, October 30, 1980. - 1 9 - problem in the near future. Keshan disease seems to be found exclusively (or almost exclusively) in perhaps half a dozen provinces in China; it is virtually unknown elsewhere in the world. It frequently leads to death in adolescence through heart failure, and almost half of nutrition research in China is directed to understanding this disorder. Selenium supplementation of food in affected locales seems promising. 2.14 In concluding the discussion of nutrition it is worth noting that success in improving nutrition levels does have the (minor) disadvantage that improvements can be expected eventually to result in increases in the average heights and weights of the population at all age levels. For adults this translates into increased food requirements (Appendix Tables A.29 and A.30). A rough calculation suggests that per capita food requirements are now growing at a rate of about .15% per year for this reason, and that this rate will increase to about .25% per year by the year 2000. This compares with the 1.2% current annual increase in requirements resulting from population increase. B. Policies for Overcoming Health Problems 2.15 Health Problems. What accounts for China's success in reducing mortality and morbidity? The major sources of health problems in developing countries can usefully be divided into four broad categories - overpopulation, malnutrition, environmental pressures, and infectious and parasitic diseases. The paragraphs that follow discuss the relation between these factors and China's success in reducing mortality. The subsequent subsections provide a description of how China's health and nutrition policies have addressed these problems. An important fact underlying much of China's success is the relatively high literacy rate of the population, and this point is briefly discussed. 2.16 Population and health policies join together in a number of important ways in that improved health eventually tends to reduce the population growth rate and that smaller families allow for higher nutritional and environmental health standards. Close child spacing and large numbers of children can reduce per capita food availability and shorten the period of relatively good nutrition and immunological protection that breast-feeding provides; crowding increases problems of environmental sanitation and facilitates the spread of communicable diseases. Slowing population growth can thus facilitate improvement in health standards. And the reverse is also true: reducing child mortality results in a decreased demand for children, and the provision of adequate maternal and child health (MCH) and other credible curative services in a community creates both a mechanism for and receptivity to the introduction of contraceptive and sterilization services. Thus China's success with population control, to be discussed in Chapter 3, has no doubt been an important factor in improving health conditions and reducing mortality, particularly infant mortality. - 20 - 2.17 Malnutrition can take either of two major forms. The first is general inadequacy of food intake, principally energy and protein, and is labeled protein-energy malnutrition (PEM). The second consists of inade- quate intakes of individual nutrients, which can result in specific defi- ciency diseases. It is thoroughly documented that PEM reduces resistance to disease and increases the probability that disease will lead to death. Malnutrition was discussed at greater length in Section A, and it suffices to note here that, despite the continued prevalence of some malnutrition, greatly improved nutrition levels have no doubt contributed to improved health. 2.18 Two important environmental conditions contribute to health prob- lems in many low-income countries. The first and predominant of these is lack of access to regular water supplies and hygienic sanitary facilities. Lack of access to water makes hygiene difficult /1 and facilitates trans- mission of water-borne diseases (principally gastroenteric), though this is less of a problem in China than in many other countries because of the general Chinese practice of boiling drinking water. The UN General Assembly, in recognition of the near universality of water-supply problems, designated the decade of the 1980s as the "International Drinking Water and Sanitation Decade," and China is participating in that effort. China's massive efforts to improve water supply and sanitation have contributed importantly to reduction of mortality. Nonetheless, there is much room for progress as the comments on ascariasis in Table 2.4 made clear./2 2.19 A second important environmental factor contributing to poor health is inhalation of polluted air. Smoking and industrial pollution cause chronic bronchitis and cardio-pulmonary disorders, and these are dis- eases that can sharply impair productivity throughout much of an individual
Группа Всемирного банка · Pre-2003 Economic or Sector Report
China - Socialist economic development (Vol. 3 of 9) : Annex B: Population, health and nutrition
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