Tackling health transition in China

1MPS I%13 POLICY RESEARCH WORKING PAPER -1 81 Tackling Health Transition rt x in zChina sam tus, i oft-7 nave erodled recently. The three mffain c-auses of this have been ch-anges i4n goernov ent Shaikh I. Hossain filnancing of thfe heafth sector, the shift to, a more imar eti oriened ecornomy, an a shift towarod rore no~nco,rmm ,ni abie diseases .and inij uries, the prevention of which has not been a tzaditionai pa rt of ChVia-ff's public heaith-i programns. The World Bank China and Mongolia Department Rural and Social Development Division August 1997  POLICY RESEARCH WORKING PAPER 1813 Summary findings Over the past three decades, China has made What accounts for relatively stagnant, even commendable strides in improving the health status of its deteriorating health indicators, and what strategies population. Between 1965 and 1995, its infant mortality should be designed to address them as China enters the rate declined from 90 per 1,000 live births to 36. During 21st century? Overall, Hossain argues, the recent erosion the same period, life expectancy at birth rose from 55 to in health gains stems from three factors: 69 years and the maternal mortality rate fell from 26 to * Changes in government financing of the health 15 per 100,000 deliveries. sector have increased inequity, inefficiencies, and costs This performance compares favorably with that in for medical treatment. similar Asian economies. China's infant mortality rate, * The main contributors to the burden of disease have for example, was less than half the rate predicted for its shifted from maternal conditions and infectious diseases income level. Similarly, life expectancy at birth was toward noncommunicable diseases and injuries, the higher than that in many comparable Asian countries. prevention of which has not been a traditional part of These favorable results conceal more recent trends, China's public health programs. however. Since the early 1990s, mortality rates have * The shift to a more market-oriented economy has increased in many provinces, particularly among infants changed environmental and behavioral risk factors, thus and children under age five. And health status and diversifying the types of disease across regions. health-related process indicators have improved more Hossain suggests strategies for mitigating China's slowly than in the mid-1980s. current and emerging health problems. This paper - a product of the Rural and Social Development Division, China and Mongolia Department - appeared in an earlier version as chapter 2 of World Bank, "China: Social Sector Expenditure Review, 1996," China and Mongolia Department, Washington, D.C., 1996. Copies of the paper are available free from the World Bank, 1818 H Street NW, Washington, DC 20433. Please contact Clydina Anbiah, room T7-015, telephone 202-458-1275, fax 202-522-1778, Internet address shossain@worldbank.org. August 1997. (35 pages) The Policy Research Working Paper Series disseminates the findings of work in progress to encourage the exchange of ideas about development issues. An objective of the series is to get the findings out quickly, even if the presentations are less than fully polished. The papers carry the names of the authors and should be cited accordingly. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors. They do not necessarily represent the view of the World Bank, its Executive Directors, or the countries they represent. Produced by the Policy Research Dissemination Center  Tackling Health Transition In China by Shaikh I. Hossain An earlier version of this paper appeared in Chapter 2 in,"China: Social Sector Expenditure Review, 1996". I am grateful to Jere Behrman, Jagadish Upadhyay and Nicholas Prescott for helpful comments. Comments from participants in a seminar held in Beijing are also appreciated.   2 Introduction Over the period of three decades, China has made commendable strides towards improving the health status of its population. Between 1965 and 1995, China's infant mortality rate declined from 90 per 1,000 live births to 36, during the same period, life expectancy at birth rose from 55 to 69 years, and maternal mortality rate fell from 26 to 15 per 100,000 deliveries. When compared with similar Asian economies, China's performance has also been favorable as its infant mortality rate for example was less than one-half of the rate predicted for its income level (fig 1). Similarly, life expectancy at birth was higher than many Asian comparators (fig 2). These impressive gains in health status have been the direct products of the government's political resolve and imperative in the early 1970s, when the proliferation of public financed community and preventive health programs rapidly expanded access to basic health care and broadened its coverage. However, these positive indicators conceal more recent trends. Since the early 1990s, mortality rates have increased in many provinces, particularly among infants and children younger than age 5. Moreover, the countries whose mortality rates among these two groups were already low in 1965--Malaysia, South Korea, Thailand and Sri Lanka--continued to show larger percentage declines in these indicators than did China. Likewise, these countries have showed larger percentage gains in average life expectancy and they have made greater progress in such process indicators as coverage for immunization and births attended by trained personnel (Annex 1, Table 1). In China itself, improvements in health status and health- related process indicators have been slower than similar advances made in the mid-1980s. What accounts for these relatively stagnant and sometimes deteriorating health indicators, and what strategies should be designed to address them as China enters 21st century? Overall, as this paper argues, the recent erosion in gains stems from three factors. One, changes in government financing for the health sector have created greater inequity, inefficiencies and raised the costs of medical treatment. Two, the major contributors to burden of disease have changed from maternal and infectious toward non-communicable diseases (NCD) and injuries, the prevention of which has not been a traditional part of public health programs (PHP), and three the shift to a more market oriented economy has changed environmental and behavioral risk factors, thus diversifying the types of disease across regions. The paper has three sections. In section I, the current problems in health sector are discussed, while section II presents emerging health problems of China and the final section provides strategic directions to mitigate both current and emerging health problems of China.  Figure 1 Relationship Between Infant Mortality Rate and GNP per capita, 1994 Infant mortality rate (per thousand live births) 140 OBhutan 120 - 100 ONepal * Lao PDR Bangladesh 80 - Myanmar ndia 60 - 0 Papua New Guinea 0 Mongo Indonesia 40 - Viet Nam * Philipl s OChina OThailand 20 0 Sr Lanka a 0 0 500 1,000 1,500 2,000 2,500 3,000 3,500 GNP per capita (US$) Figure 2 Relationship Between Life Expectancy at Birth and GNP per capita, 1994 Life expectancy at birth (year) 80 Sri Lanka mtys 70 Chinailand S- Viet Nam