Health Needs Assessment in People’s Republic of China

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DEVELOPMENT SERVICES INTERNATIONAL

Health Needs Assessment in People’s Republic of China

November 19 – December 4, 2001

by P. William and Yvonne M. Dysinger

(Revised January 17, 2002)

Introduction

China is the oldest continuous major world civilization, with records dating back about 3,500 years. For centuries it has outpaced the rest of the world in the arts and sciences, but in the first half of the 20^th century, China was beset by major famines, civil unrest, military defeats, and foreign occupation. In the 1920’s, Sun Yat-sen established a revolutionary base in South China and set out to unite the fragmented nation under the Kuomintang (KMT). After Sun’s death in 1925, Chiang Kai-shek took control and at first entered into alliance with the fledgling Chinese Community Party (CCP) but in 1927 turned on the CCP who fled into the mountains of eastern China. In 1934, driven out of their mountain bases, the CCP’s forces embarked on their “Long March.” The bitter struggle between the KMT and CCP continued openly or clandestinely through the 14 year long Japanese invasion (1931-1945) even though they nominally formed a united front against the Japanese. After the defeat of the Japanese in 1945, the war between the Communists under Mao Zedong and the KMT under Chiang Kai-shek continued until by 1949 the CCP occupied most of the country and the KMT moved to Taiwan where it established its “provisional capital” in Taipei. On the mainland, Mao Zedong established a dictatorship that, while ensuring China’s sovereignty, imposed strict controls over everyday life. Ideologic struggles within the CCP resulted in the Cultural Revolution in 1966 which lasted almost a decade. In February 1972, President Nixon traveled to Beijing, Hangzhou, and Shanghai where the “Shanghai Communique” began normalizing relations between the USA and China. Mao died in 1976 and after 1978, his successor Deng Xiaopeng gradually introduced market-oriented reforms and decentralized economic decision making. Output quadrupled in the next 20 years and China now has the world’s second largest GDP. In 2001, the Olympic Committee approved China’s application for the 2008 games and in October China was officially accepted into the World Trade Organization (WTO). Most Chinese feel these events assure a bright future for China.

Located in Eastern Asia, China occupies an area of 9,596,960 sq. km. (about 3.7 million sq. mi)—slightly smaller in area than the USA but the 4^th largest country in size (after Russia, Canada and the USA). Its terrain consists of plains, deltas, and hills in the east and mountains, high plateaus and deserts in the west. About 10% of the land is considered arable; 43% is pasture land and about 14% is forests and woodlands. The climate varies from tropical in the south to sub-arctic in the north. The GDP per capita is US $838, but in purchasing power parity is $3,600. Its composition by sector is agriculture (15%), industry (50%) and services (35%). The GDP real growth rate is 8%. (all are 2000 est.) The work force of 711 million is agricultural, 50%; industry and commerce, 23%; and services, 27% (2001 est.). The administrative divisions of the government are 23 provinces (“sheng”)--including Taiwan as the 23^rd, 5 autonomous regions (“zizhiqu”), and 4 municipalities (“shi”) plus the two special administrative regions of Hong Kong and Macau.

It’s population of 1,273,111,290 (July 2001 est.) makes it the most populous country on earth and it is increasing at about 1%/year. 25% of the population is 0 – 14 years of age, 68% is aged 15 – 64, and 7% 65 years and over. 36% of the population is urban; 64% is rural. Han Chinese make up 91.9% of the population; the Zhuang (16 million), Uygur (7 million), Hui (9 million), Yi (7 million), Tibetan (5 million), Miao (8 million), Manchu (10 million), Mongol (5 million), Buyi (3 million), Korean (2 million) and others make up the other 8.1%. Mandarin is the official language spoken by over 70% of the population and is taught in all schools and is the medium of government. Seven other major dialects are spoken--Cantonese, Wu, Minbel (Fuzhou), Minnan (Hokkien), Xiang, Gan and Hakka, plus the minority languages of the groups mentioned above. The Pinyin system of the Romanization of the language was officially adopted in 1979. In religion, the country is officially atheist, but contains Daoists (Taoists), Buddhists (100 million est.), Muslims 2-3%--18 million, and Christians 1% (est.)—4 million catholics and 10 million protestants; unofficial estimates are much higher. Only two Christian organizations are sanctioned by the government: a Catholic church (without official ties to the Vatican) and the “Three-Self-Patriotic” Protestant church which officially meets on both Saturday and Sunday. Unauthorized (mostly home) churches have sprung up all over the country. (World Factbook 2001—China; USD. of State, Background Notes, China, 9/ 2001)

Selected References

Population Reference Bureau, World Population Data Sheet, PRB 2001.
WHO: The World Health Report 1998.
People’s Medical Publishing House: 1999 Year Book of Health in the People’s Republic of China. Editor in Chief, Zhang Wenkang (current Minister of Health).
Senior Policy Seminar on Health Reform and Development in China, Guangzhou, China, April 14-16, 1999.
UNICEF: Assessment of the Situation of Children and Women in China, 15 September 2001 (pre-publication copy).
UNICEF: HIV/AIDS Prevention Education Teacher’s Guide, World Affairs Press, 2001. Editor in Chief: He Jinglin.
Zhejiang Health, Li Lanjuan, MD, Director General, Zhejiang Health Bureau, May, 2001.

Summary of Findings

The Population Reference Bureau reports the following 2001 statistics on China:
1. Crude birth rate (annual births/1000 total population) 15
2. Crude death rate (annual deaths/1000 total population) 6
3. Density (population/sq. mile) 344
4. Infant mortality rate (infant deaths/1000 live births) 31
5. Life expectancy at birth, males (years) 69
6. Life expectancy at birth, females (years) 73
7. Maternal deaths (per 100,000 live births) 95
8. Total fertility rate (ave. no. of children/woman during lifetime) 1.8
9. Average age at first marriage, all women 22
10. Births attended by trained health workers (%) 89
11. Children who are exclusively breast fed to age 4 months (%) 64
12. Contraceptive use among married women 15-49, modern methods (%) 81
13. Females giving birth by age 20 (%) 8
14. Female (age 15+) participation rate in labor force, 1995 (%) 74 (# 1)

A study reported in the August 18, 2001 issue of the British Medical Journal reports that while

China is home to 20% of the world’s population, its residents smoke 30% of the world’s cigarettes. “The Chinese government is the largest cigarette producer in the world.” This creates an obvious conflict of interest when it comes to smoking cessation programs. Two-thirds of all the young men in China become smokers and half the smokers will eventually be killed by their habit. With “present smoking patterns, about one-third of all the young men in China will eventually be killed by tobacco.”

The Dec. 1-2, 2001 issue of CHINA DAILY reported on “global coalition fights tobacco harm.” It reports that one person dies every 32 seconds in the Western Pacific Region (of WHO)

from tobacco related causes. Most potential victims will never know what hit them because they have little or no information on the health risks of tobacco use. Finding new customers in the developing countries in Asia and the Pacific is an attractive option for the international tobacco industry as it adjusts to shrinking North American and Western European markets. Tobacco threatens not only people’s health but their ability to contribute to social and economic development. WHO is leading the “framework convention on tobacco control” (FCTC) which seeks to bring about increases in tobacco taxes, bans on advertising and curtailing investment rules which favor the tobacco industry. WHO points out that a 10% cigarette price increase worldwide could persuade 40 million current smokers to quit and could prevent at least 10 million premature smoking-related deaths. The target for signing the FCTC is May 2003.

Loma Linda University collaborating with the China National Health Education Institute and the World Health Organization, with funding from the Global Mission Office of the SDA Church, provided “advanced health technology” training in health education for tobacco cessation to more than 30 persons from more than 17 provinces in China between 1995 and 1999. This project mostly used personnel from the LLU School of Public Health, especially Dr. & Mrs. Hervey Gimbel, and was coordinated in the field by Barbara Choi, RN, DrPH who worked out of an office in Beijing. Beginning in April 1996, month long conferences were held twice a year.

The disappearance of government guaranteed housing, medical services, pensions, and other basic services and the revamping of the state-owned enterprise system are posing new kinds of challenges to ordinary families. The rapid economic and social transformation in China over the past 20 years has brought great benefits but its unevenness has also led to increased urban-rural disparities and widening economic gaps between people living in the developed coastal regions and under-developed north-western and south-western provinces. This particularly affects the 380 million children in China. For example, the under five mortality for China as a whole is 39/1000 but this varies from Shanghai with a low rate of 8/1000 to Xinjiang with a rate of 68/1000. There are an estimated 50 million children whose basic needs are unmet. These children are principally found in poor and minority areas in the interior and mountainous regions of the under-developed north-western and south-western provinces. (# 5, pp 1 – 3)

Unemployment, urbanization and migration patterns result in an estimated 100 million “floating population” which moves about—mostly from rural to urban areas—in search of work. This includes an estimated 5 million children. These largely receive no education because they are officially registered as rural residents and cannot enter urban schools without paying out-of-catchment-area tuition which is prohibitively high for most migrants. In some areas, migrants have organized and recruited rural teachers to act as tutors to their children. Conditions in most of these schools are inadequate. (# 5, pp 2, 14)

The number of abandoned children in China seems to be on the rise. There are 128 Child Welfare Institutions in China which are currently accommodating around 20,000 abandoned children. Some are also placed in the more than 1,000 Welfare Centers who help not only children but also old people and some people with mental problems. China is beginning to use approaches such as residential care and foster families. The majority of the estimated annual 10,000 cases of trafficking in young women and teenage girls occur when they migrate in search of work and become victims of some form of sexual exploitation—forced marriage or prostitution. There is also an estimated 200,000 street children who may come from migrant families but are mostly those who come to urban areas by themselves as a result of family problems and the harsh conditions they face in rural areas. (#5, pp 3, 4)

“According to the Chinese Academy of Social Sciences (CASS), domestic violence occurs in 30% of families which means hundreds of millions of people are affected. Awareness of the issue is low—even doctors who have seen all kinds of domestic abuse have never thought of the fact that abuse against women is a social problem rather than a simple domestic matter.” (# 5, p.5)

Gender discrimination is common in China. Son preference, along with smaller family size, has placed girls in infancy and early childhood at increased risk. Rising sex ratios show in the 2000 census that there are 117 boys to every 100 girls born. (The world average is 106-8 boys to 100 girls.) Sex selection comes through sex selective abortions and non-registration of female births. (# 5, p. 6) The discrimination girls face often plagues women as well. Many women in rural areas are left to shoulder the bulk of agriculture production, family care, and community work while their husbands work in cities. There is also evidence that women are being laid off from state industries more commonly than men. Women’s lower educational levels also curb their opportunities for new jobs and limit their capacity to develop their full potential as women and as mothers. (# 5, p. 7) “In some cases insufficient family awareness, low family organization and coping skills, limited knowledge of children’s issues, or dysfunctional family behavior with respect to care and rearing of children will further hamper children’s development.” (# 5, p 8)
China currently spends 0.3% of its GNP on health care, of which even less is for basic health care (compared to an average of 4% in developing countries, and 12% globally). Education commands a higher proportion of GNP (around 2.5%), but nevertheless basic education still faces shortfalls in funding their goal for education of 4%of GNP. Decentralization of fiscal responsibility has complicated the problems of financing basic services in poor counties and in assuring or improving the quality of services. Basic education in China is both compulsory for the first 9 years and nominally free. Although schools do not charge tuition fees, they do charge administrative fees and fees for books and teaching materials. According to one report, educational expenditure accounts for as much as 50% of the disposable income of families in poor areas. (# 5, pp. 9, 10)

The illiteracy rate is declining slowly, but female illiteracy remains high. In 1999 it was stated to be 22% nationally, more than double the male illiteracy. The lowest female illiteracy is in Beijing where it is 10%. In Tibet, female illiteracy is 62%. In remote areas of other western provinces there are villages where at least 90% of women over age 40 are illiterate. Nearly all girls born today will have much greater access to education than their grandmothers enjoyed. (# 5, p. 11)

The escalation of health care costs in the 1990’s by 400 per cent is a clear indication of the need for health system reform. Increased costs are largely brought about by the privatization of the health services. Fiscal decentralization of health services is a burden on poor townships and counties. They are not able to meet their obligations in running basic health services. Local health personnel often become pre-occupied with income generating activities under a deregulated and unsupervised environment that contributes to the rapid increase in health care costs. For example, there is much over-prescription of medications to provide income generation. The cost of drugs makes up 60% of health care costs in China, and for rural areas, drugs make up to 80% of the cost of health care. (World-wide, the burden of drugs makes up less than 20% of health care costs.) Currently only 50% of the urban population and 10% of the rural population are covered by government or work unit sponsored health insurance. (# 5, p 16)

Much of the progress in health indices can be attributed to the establishment of a centrally supported health-care network for basic services with coverage even in the most remote communities. In the past decade, however, the rate of progress has been slowing, and in some poor rural areas there is an actual reversal of the positive trends. The once renowned cadre of “barefoot doctors” has not been replaced. The decline in health indicators is a direct result of reduced access to good services. A UNICEF supported survey in 1999 of 400 village health posts found that almost 2/3 of the workers did not keep routine records and less than half of them were able to sterilize needles and syringes properly. (# 5, pp 15, 16)

Nearly one third of under five children are infected with the hepatitis B virus. This indicates that unsafe injections are a major route for transmission of blood-borne disease which could also lead to explosive outbreaks of HIV infections once it is introduced into a community. China is self-sufficient in producing hepatitis B vaccine and coverage in 1999 was over 90% in urban areas and 60% in rural areas. In rural areas in the poor Western provinces, however, the coverage is less than 10%. The main reason is cost. Inadequate funding and low income for preventive health workers in rural areas causes high charges for immunization as a means of income generation. The net result is a declining trend in “expanded program of immunization” (EPI) coverage in poor areas. It is not unusual to find counties with EPI coverage below 50%. Unsafe injections and excessive charges are major management issues for improvement in preventive health services for rural China. (# 5, p 17)

Based on a 1987 survey, it is estimated that there are 8 million disabled children. This estimate will be updated by a new survey in 2001. Cultural patterns in China lead to discrimination against disabled children and delay in rehabilitative efforts by parents who either deny the disability exists or seek cures through medicinal means without being aware of their efficacy. The reliance of doctors and other health workers on selling injections and medicines to support themselves (rather than on fees for service) often results in incorrect or overuse of antibiotics, one of the causes of deafness. Many disabled children face deep-rooted discrimination in society and are denied access to basic services that prepare them to be productive citizens. (# 5, pp 17, 18)

The reduction of malnutrition is a major unfinished challenge for western and rural parts of China. Sub-clinical vitamin A deficiency is 23% in poor rural areas when the baseline level for large cities is 3.8%. Protein-energy malnutrition afflicts the majority of the poor in rural China. In 2000, 14% of rural children were underweight and 20%, stunted. These are mostly found in central, southern and western China. Close to 30% of all women suffer from iron deficiency anemia. (It has been shown that reduction in iron deficiency anemia can improve work productivity by 10 – 20% in previously iron deficient women.) Nutrition in all its dimensions has yet to be considered holistically at the national level. China is actually in a good position to build on the success of the rapid reduction in iodine deficiency through universal salt iodization. By reform and revitalization of the salt industry, iodized salt coverage went from 39% in 1995 to 91% in 1999. Foods fortified with vitamin A and iron could be introduced in a similar manner.

(# 5, pp 19 – 21)

A 1999 national survey carried out by the National Statistics Bureau shows that sanitary latrine access in rural areas is only 24%. 300 million people (25% of pop.) do not have access to safe drinking water. A survey in Longxi County of Gansu province found that in the 557 school latrines, only 38% had complete roofs and walls, 97% had a soil pit without cement lining and 89% had flies and maggots; 0.4% were flush toilets. An estimated 190 million, 40 million and 70 million children under 14 are infected with roundworms, hookworms and whipworms respectively in China based on the latest national survey in 1992. 109.8 million people are at risk by living in naturally high fluoride regions and 38 million are suffering dental fluorosis and 1.7 million are crippled with skeletal fluorosis due to high fluoride content from tea, air pollution, food and water. 14.6 million are at risk of arsenic poisoning from drinking water or tea if the WHO standard of keeping arsenic below 0.01 mg/l is applied. Presently there are more than 18,000 poorly sanitated towns in China, an 8-fold increase over 1978. The number is growing by 800/year. Most small towns have no sewage system—waste and wastewater are discharged commonly into open drainage canals. Small town inhabitants keep many rural habits which can easily cause health problems in crowded urban areas. (# 5, pp 24 – 27)

About half of China’s population is exposed to one or more natural disaster risks each year. On average, 200 million suffer annual disasters, of whom several thousand are killed and about ¼ of these are children. The economic loss from natural disasters in China ranges from 3 – 4% of its GDP, compared to 0.3 % in the USA and 0.5 % in Japan. The economic damage of the 1998 summer floods amounted to one third of the annual government fiscal revenue. The commonest disasters are floods and typhoons, earthquakes, and droughts and snowstorms. The effects of disaster for children include 1) destroyed environmental sanitation; 2) interruption of schooling; 3) psychological trauma; and 4) increased poverty—destruction of assets and interruption of income generation. (# 5, pp 27 – 29)

The National Center for AIDS Prevention and Control reported in the Nov. 30 issue of Beijing Weekend that as of Sept. 2001 there were a cumulative total of 28,133 HIV positive cases reported in China, 1,208 with AIDS and 641 deaths. Of these, 68.7% were due to IV drug injection, 6.9% to sexual intercourse, 5.6% from blood (plasma) donation, 1.4% from blood-related products, 0.2% mother to child, and 17.3% from unknown causes. The age groups most infected are the 20 – 29 year olds (56.9%) and the 30 – 39 yr. Olds (24.1%). The three Chinese regions with the highest number of infected people are Yunnan, Xinjiang, and Guangxi. The seriousness of the situation is not the number of cases reported, but the fact that the reported cases has been increasing at the rate of 30%/year—doubling cases every 2-1/2 years. The reported cases is always lower than the actual cases which are estimated to be between 600,000 and 1 million. Based on this, the UN AIDS program estimates that China will have 5 million HIV infected persons by end of 2005 and 20 million by the end of 2010. The epidemic has now exploded and now is the most critical time to seek to contain what is probably China’s currently most serious public health threat. (# 5, pp 21, 22; # 6, pp 22, 23; personal report from UN AID office)
The regular report on surveillance of diseases in China in 1997 is based on the findings of 145 surveillance spots randomly selected which cover more than 10,000,000 people and is considered representative of the country as a whole. A total of 51,759 deaths were reported, giving a death rate (adjusted) of 591.19/100,000. 3,937 were caused by infectious diseases and maternal and child diseases (44.97). (All death rates are shown in parenthesis and are adjusted rates per 100,000 population.) 39,478 were non-communicable diseases (450.91); 5,520 were accidental deaths (63.04); and 2,824 were of unknown causes. Compared to the year previous, infectious and maternal/child deaths decreased; non-communicable diseases increased; and accidental deaths were unchanged. Cardiovascular and cerebrovascular diseases (184) remain the main cause of death and are increasing. Death rate from malignant tumors of the bronchus continued to rise at an annual average rate of 4.4%, going up from (14.47) in 1991 to (18.66) in 1997. It ranked first for all cancer and was particularly high in the rural areas among males. Chronic respiratory disease ranked second as a cause of death (110.17) and was higher in rural than in urban areas. Deaths due to accidents (63.03) ranked 4^th. Deaths due to traffic accidents ranked first in this category but deaths due to suicide and self-inflicted injury ranked 1^st among the rural female population. Suicide among rural women was (16.69). (# 3, pp 45, 46)

The CHINA DAILY newspaper reported in December 2001 that there were about 617,000 road accidents in 2000 which killed 94,000 people and injured 420,000. These figures are up 49%, 12%, and 46% respectively. 2000 year statistics indicate the number of vehicles had reached 60 million while total highway mileage was only 1.4 million kilometers. “Clearly, China’s highways are not able to adequately accommodate the number of vehicles in the country and this rapid growth of motorization has resulted in significant increases in the number of road accidents.” Traffic accidents ranked 1^st among all deaths from accidents. They have increased by 52.7% since 1991, an annual increase, on average, of 7.5%. (# 3, p 47)

“The range of disease among the Chinese population is undergoing a process of change… Attention must be drawn to this important and urgent public health problem.” Heart disease and strokes remained an important cause of death and were a major cause of premature death and disability. Liver cancer ranked 2^nd to lung cancer among cancer deaths. Since it occurs at a young age, it is the most harmful cancer. Suicide remains the 1^st cause of death among all accidental deaths and injuries among the rural population, especially among rural women. Sexually transmitted diseases have shown a marked increase. (# 3, p 47)

Sixteen of the 26 reportable infectious diseases increased in 1998 over 1997 (% increase of cases). These were cholera (925), syphilis (77), typhus (48), gonorrhea (48), Kala Azar (27), encephalitis B (26), TB (25.5), diphtheria (14), leptospirosis (10), hemorrhagic fever (10), scarlet fever (7), typhoid (6.3), hepatitis (5.4), anthrax (3.8), rabies (3.5), and malaria (1.25). Cases of the other 10 diseases decreased, including dengue fever, AIDS, measles, brucellosis, epidemic encephalitis, poliomyelitis, plague, pertussis, infantile tetanus, and dysentery. The Morbidity, Mortality and Fatality of the top 10 infectious diseases in 1998 is shown in this table: (# 3, p. 48)

Rank No. of incidences No. of deaths Fatality rate

1 hepatitis 781,671 TB 606 rabies 87.39

2 dysentery 659,222 hepatitis 602 plague 33.33

3 TB 458,963 encephalitis B 386 AIDS 13.04

4 gonorrhea 220,722 infantile tetanus 368 diphtheria 10.00

5 typhoid 56,861 hemorrhagic fever 333 infantile tetanus 9.74

6 measles 53,030 dysentery 304 epidemic enceph. 5.54

7 hemorraghic fever 45,537 leptospirosis 288 anthrax 3.84

8 syphilis 33,824 cholera 235 encephalitis 3.24

9 malaria 31,326 rabies 208 leptospirosis 2.51

10 scarlet fever 14,566 epidemic encephalitis 199 cholera 1.99

“In order to promote progress in the control of non-communicable diseases in China, the MoH has further strengthened its management, direction and supervision of 22 model locations at community level. A training course was organized in March… The model locations have continued to search for ways to develop their comprehensive control activities at the community level through health education and health promotion, with the main emphasis on prevention and the integration of prevention with treatment… Activities carried out at model locations have laid a good foundation for the further development and in-depth investigation of ways to develop the control of chronic diseases in the future.” (# 3, pp 61, 62)

The government policy is for increased emphasis on Traditional Chinese Medicine (TCM) and its integration with western trained medicine. The policy does not appear to have had much effect. In 1952 there were 306,000 TCM personnel; by 1975 TCM personnel were down to 228,635; by 1990 they were up to 368,462, and by 1998, they were down to 339,666. (This latter figure includes 3,134 Mongolian doctors, 1,995 Tibetan doctors, 736 Uigurian doctors, and 209 Thai doctors.) The number of TCM hospital beds at county level and above, however, have increased from 222 in 1952, to 1,675 in 1975, 160,899 in 1990 and 229,000 in 1998. In comparison, there are 5,535,682 regular medical personnel and 3,143,020 regular hospital beds and these have greatly increased in recent years. (# 3, pp 239, 248)

There were 45,023 health institutions within the Health Sector in 1998. Of these, 7,873 were hospitals at the county level and above; 22,560 were township health centers, 70 were sanitoriums, 1,586 were clinics, 1,760 were specialized disease prevention and treatment centers, 3,156 were health and anti-epidemic centers, 2,601 were MCH centers, 2,018 were drug inspection institutes, and 398 were medical research institutes. These institutions held a total of 2,003,080 beds and employed 3,459,315 personnel of which 2,687,999 were health professionals. Of the latter, 1,148,321 were doctors and assistant doctors and 816,045 were senior nurses and nurses. Of the 7,873 hospitals, 59 belonged to the central Ministry of Health, 377 belonged to the provincial Bureau of Public Health (BOPH), 1,822 belonged to the district/city BOPH, 1,983 belonged to city (county level) BOPH, and 3,632 belonged to the county BOPH. 4,019 of these were general hospitals, 2,229 were TCM hospitals, and 1,625 were other kinds of hospitals. (# 3, Tables 20 & 21, pp 250 - 252)

The industrial and other sectors in 1949 owned 404 health institutions; by 1998 these had increased to 94,198. Of the 94,198 health institutions, 7,297 were hospitals, 429 were sanitoriums, and 83,322 were clinics. These held a total of 741,782 beds and employed 1,254,808 personnel of whom 458,924 were doctors and assistant doctors. (# 3, Table 23, pp 252, 253)

The number of villages in China increased from 716,639 in 1985 to 732,411 in 1998. 89.5% of these villages in 1998 had health units. Of the 728,788 health units in villages, 325,115 were owned by the village community, 89,310 were owned by village doctors or aides, 39,044 were set up by township health centers, 259,849 were privately owned, and there were 15,470 others. In these village health units there were 990,217 village doctors, 337,416 village health aides (barefoot doctors?), and 337,416 birth attendants. Between 1985 and 1998 the number of village doctors increased from 643,022 to 990,217; the number of village health aides decreased from 650,072 in 1985 to 337,416 in 1998; the number of birth attendants decreased from 513,977 in 1985 to 337,416 in 1998. (# 3, Table 24, p 253)

Total visits to outpatient departments in general hospitals in 1997 were (x 10,000) 78,437.3. Of these, 48,319.5 were in hospitals under the health sector; 28,951.2 were in hospitals in industrial or other sectors; 1,077.3 were in hospitals under collective ownership; and 89.3 were in private or other hospitals. (# 3, Table 31, p 260)

The utilization rate of hospital beds at hospitals at county level and above decreased from 80.9% in 1990 to 60.2% in 1998. In TCM hospitals, the rate decreased from 73.6 (1990) to 49.8 (1998). In hospitals affiliated with medical colleges the rate decreased from 98.6 in 1990 to 83 in 1998. In industrial and other sector hospitals the utilization rate decreased from 69.8 to 53.2 between 1990 and 1998. In hospitals under collective ownership it decreased from 69.5 to 52.2. In health centers it decreased from 43.4% to 33.2% between 1990 and 1998. (# 3, Table 32, pp 260-261)
The ranking of the 10 main diseases of inpatients in city hospitals of the health sector were:

1965 % 1989 %

1. Diseases of the digestive system 18.99 Diseases of the digestive system 20.13

2. Dis. of the respiratory system 18.17 Dis. of the respiratory system 17.75

3. Infectious disease (excl. TB) 12.19 Injury and poisoning 12.46

4. Diseases related to pregnancy & delivery 7.25 Dis. related to pregnany/delivery 6.42

5. Injury and poisoning 6.25 Infectious diseases (excl. TB) 6.02

6. Dis. of the urinary system 3.55 Tumors 3.69

7. Parasitic diseases 2.78 Heart diseases 3.66

8. Eye diseases 2.68 Dis. of urinary system 3.40

9. Dis of female genital organs 2.58 Benign neoplasms 3.14

10. Tumors 2.24 Eye diseases 2.27

The ranking of the 10 main diseases of inpatients in county hospitals of the health sector were:

1. Diseases of the digestive system 19.31 Diseases of the digestive system 22.94

2. Infectious diseases (excl. TB) 16.93 Dis. of the respiratory system 17.35

3. Dis. of the respiratory system 14.27 Injury and poisoning 14.39

4. Dis. related to pregnancy/delivery 6.43 Infectious dis. (excl. TB) 8.32

5. Injury and poisoning 6.13 Dis. related to pregnancy/delivery 6.80

6. Parasitic diseases 4.01 Disease of the urinary system 3.32

7. Diseases of the urinary system 2.69 Heart diseases 2.82

8. Tuberculosis 2.69 Cerebrovascular diseases 1.88

9. Skin diseases 2.53 Tumors 1.77

10. Diseases of female genital organs 1.92 Benign neoplasms 1.68

(# 3, Tables 33 & 34, pp 261-263)

Ranking of 10 main diseases (ICD-9) of inpatients in hospitals of health sector in 1998 were:

City hospitals County hospitals

1. Diseases of the digestive system 14.91 Injury and poisoning 20.84

2. Injury and poisoning 14.91 Diseases of the digestive system 17.02

3. Diseases of the respiratory system 14.79 Dis. of the respiratory system 16.64

4. Diseases related to childbirth & delivery 7.12 Dis. related to childbirth/delivery 7.74

5. Dis of the Genito-urinary system 6.30 Parasitic diseases 6.64

6. Tumors 5.58 Dis. of the genito-urinary system 5.50

7. Heart diseases 5.35 Heart diseases 4.03

8. Cerebrovascular diseases 4.82 Cerebro-vascular diseases 3.58

9. Parasitic diseases 4.79 Dis. of the nervous system/organs 3.14

10. Dis. of the nervous system & sense organs 4.44 Tumors 2.34

(# 3, Tables 35 & 36, p 264)

Costs of health care in general hospitals--county level and above, in the health sector in 1998:

a) average medical expense per outpatient visit (yuan) (# 3, Table 37, p 265)

--in hospitals belonging to MOH 139.7

--in hospitals belonging to provincial BPOH 106.4

--in hospitals belonging to district/city BPOH 74.8

--in hospitals belonging to city (county level) BPOH 57.7

--in hospitals belonging to county BPOH 41.8

b) average medical expense per inpatient (yuan)

--in hospitals belonging to MOH 7,076.3

--in hospitals belonging to provincial BPOH 5,564.2

--in hospitals belonging to district/city BPOH 3,212.2

--in hospitals belonging to city (county level) BPOH 1,975.9

--in hospitals belonging to county BPOH 1,365.7

The “China Daily” newspaper on Dec. 1, 2001 had an editorial with the headline, “Improve Rural Health Care.” It stated that “among the country’s 1.26 billion population, nearly 900 million are people living in rural areas. The government’s 9.78 billion yuan (US $1.2 billion) investment into rural public health work in 1999 accounted for only 15.3 percent of the country’s total. An investigation carried out by the Ministry of Health indicates that “some farmers who fall ill are unwilling to see a doctor or get hospitalized for fear of high costs… Another factor....is the poor quality of medical services available in these rural areas… For a long time the rural cooperative medical system… played a major role… (but this system) has lost its economic base and is gradually being phased out… The potential need to build the (new) cooperative medical care system is huge…because the farmers income is very low and residents cannot afford the fees needed to take part in medical care security… This calls for a medical care relief system.”

Zhejiang Province is one of the better developed coastal provinces in southeast China and is the

site of the Loma Linda affiliated Sir Run Run Shaw Hospital in Hangzhou.. In our visit with Dr. Li Lanjuan, the Director-General of the Zhejiang Province Health Bureau, we were given a report which lists the following key health development policies:

1) Rectifying the function of the government and implementing a line—management

over the entire health sector;

2) Establishing and implementing the integrated regional health development planning, rearranging and improving the health resources settings;

3) Strengthening the community health services and building the new health-care

system;

4) Perfecting the comprehensive preventive medicine system;.

…………..

13) Pushing forward the establishment of information system so as to improve the

management efficiency. (# 7, p 18)

The following statement was published in April, 1999. To extend “the Long-range Objectives to the Year 2010 and ensure the successful achievement of the cross-century magnificent goals, the Communist People’s Congress (CPC) Central Committee and the State Council have made the following decisions”: (To give the flavor, direct quotes have been abstracted from this document.)

1) “The objectives of health work are to take Marxism-Leninism, Mao Zedong Thought and

Deng Xiaoping‘s theory of building socialism with Chinese characteristics as our guide, to adhere to the Party’s basic line and principles, to continue to deepen health reform… By the year 2010 we shall establish a relatively perfect nationwide health system which adapts to the socialist market economy and meets people’s health needs…

2) “The guiding principles of health work during the new period are to focus on rural areas, to give top priority to the prevention of diseases, to attach equal importance to traditional Chinese medicine and western medicine, to rely on science, technology and education, to mobilize all sectors of society to participate in health work, and to serve people’s health and the socialist modernization drive…

3) “The government assumes chief responsibility for developing health undertakings. Therefore, governments at all levels should try to increase investment in health care and mobilize all sectors of society to raise funds necessary for health development. Citizens should gradually increase spending for their own medical treatment and health care. By the end of this century (2000) we shall strive to ensure that total health expenses for the whole society account for about 5% of GDP.

4) “… We should open even wider to the outside world, strengthen international exchanges and cooperation in the field of health and take the initiative to utilize advanced foreign scientific and technological achievements and draw on foreign managerial experience.

5) “The purpose of health reform is to invigorate health work, give full play to the initiative of

medical institutions and medical personnel, continue to raise the quality and efficiency of health services and better serve people’s health and the socialist modernization drive…

6) “Medical security system for workers and office staff in the cities and towns should be

reformed… The state, the work unit and the individual rationally bear the insurance premium. Social medical insurance for workers and office staff is placed under the management of local governments… “Medical institutions and personnel…should take an active part in the reform, provide medical treatment according to illness, make rational diagnosis and prescription and put a stop to waste…we should… take the initiative to develop all kinds of supplementary medical insurance.

7) “The system for managing health work should be reformed…

8) “We should reform the system of urban health services, take the initiative to develop community health services… Grass-roots medical institutions should serve local community and families, prevent diseases, diagnose and treat commonly-seen and frequently-occurred diseases and provide therapeutic and rehabilitative services to the disabled, health education, technical services related to family planning and health care for women and children and for the aged and disabled…

“Large hospitals in the cities concentrate on diagnosing and treating acute, serious and difficult diseases and…should continue to raise their medical scientific and technological level, develop applicable technology, provide guidance to and train medical personnel from grass-roots medical institutions… It is imperative to correct the current arbitrary establishment of medical institutions earnestly.

9) “… Medical institutions should establish a responsible, stimulating, restrictive, competitive

and dynamic operating mechanism through reform and strict management… We should…reduce the ratio of income from pharmaceuticals to the total income of medical institutions… institutions of preventive health care can engage in proper paid services to meet the different needs of all sectors of society. Meanwhile, supervision and management of those health services should be tightened.

10) “Because rural health work is an important matter… Party committees and governments at all levels should pay attention to it and take effective measures to improve it earnestly…

11) “We should take the initiative to develop and improve the system of cooperative medical

services prudently… Through health education and publicity we should raise the peasant’s awareness of the importance of self-care and mutual help and encourage them to take an active part in cooperative medical services… As a way of cooperation, the compensation system for preventive health care should continue to be implemented… and gradually provide public health services to more rural people.

12) “We should strengthen rural medical institutions and improve the three-tiered medical service network in county, township and village… We should earnestly run county hospitals better and raise their capability of providing comprehensive services. We should continue to strengthen county health and epidemic prevention stations, county MCH centers, and township and town hospitals… Township and town hospitals should make a success of preventive health care… Village medical institutions should mainly be run by the collective.

13) “We should consolidate the contingents of rural medical personnel at the grass-roots level and raise their professional competence… The income of a rural doctor in the village medical institution run by the collective should be no less than that of a local village cadre… Non-medical personnel are strictly prohibited from holding medical technical posts…

14) “We should establish the system under which urban medical institutions assist their

counterparts in rural areas… Before urban medical technical personnel are promoted to posts of physician-in-charge and deputy chief physician, they must be assigned to work in county or township medical institutions for six months to one year.

15) “We should pay great attention to doing a good job in health work in poverty-stricken areas

and in areas inhabited by ethnic groups…and help those areas concentrate on building basic health facilities, improve the supply of drinking water and prevent endemic and infectious diseases.

16) “Government at all levels should assume overall responsibility for public health and

preventive health care, strengthen institutions of preventive health care and allocate necessary funds for the prevention and control of major diseases… We should mobilize the masses to take comprehensive measures to concentrate on eliminating or controlling some infectious and endemic diseases which pose a serious threat… We should step up efforts to prevent and control diseases transmitted through blood and take the initiative to prevent and treat such non-communicable diseases as cardio and cerebral vascular diseases and tumors.

17) “We should conscientiously do a good job… (to) improve sanitation conditions. Undue

emphasis on seeking economic growth at the cost of environmental pollution and health damage is forbidden.

18) “… pay great attention to health education, raise the people’s awareness …and their capability of self-care…discard superstition and undesirable customs and habits, to take an active part in the physical exercises… foster rational nutrition and to cultivate fine hygienic habits and culturally advanced way of life and healthy psychological quality.

19) “We should…strengthen health care for women and children… We should take the initiative to provide health care for aged, prevent and treat geriatric diseases, prevent injury and disability and rehabilitate the disabled.

20) “The patriotic health campaign is an effective way of mobilizing the people…prevent and mitigate the incidence of diseases and promote the building of culturally advanced towns and villages. Activities to eliminate the four pests (mosquitoes, flies, rats and cockroaches) should be conducted constantly in urban and rural areas.

21) “The traditional Chinese medicine with unique features and advantages is a fine traditional culture… The traditional Chinese medicine and modern medicine supplement each other… Party committees and governments at all levels should conscientiously carry out the policy of giving equal importance to the traditional Chinese medicine and the western medicine… strengthen their unity, learn from each other…

22) “… We should adhere to the principle of ‘letting a hundred flowers blossom and a hundred schools of thought contend’ and make academic research in traditional Chinese medicine thrive… It is necessary to pay great attention to giving play to the advantages and role of traditional Chinese medicine in rural health work… We should take the initiative to create conditions for introducing the traditional Chinese medicine to all the countries of the world.

23) “… We should reform and improve the way the production of traditional Chinese medicine materials is organized and managed…

24) “… We should promote the combination of health science and technology with the prevention and treatment of diseases, accelerate the commercialization and use of scientific and technological achievements and step up efforts to disseminate applicable technology… We should promote international exchanges and cooperation in the field of health…We should also do a good job in providing medical aid to foreign countries.

25) “… We should improve the training of postgraduates, the academic degree system and the system of continuation education… We should accelerate the development of general medicine and train doctors who can become general practitioners…and concentrate on doing a good job in providing regular training to rural medical personnel… We should teach medical personnel to develop the spirit of Dr. Norman Bethune, to foster medical professional ethics of rescuing the dying and healing the wounded, of devoting themselves to their duties, work and profession, of filling themselves with ardor and sincerity, of blazing new trails and improving their medical skills, of being ready to make contributions and of practicing medicine in a civilized way, and to conscientiously resist money worship, individualism and all unhealthy tendencies which harm people’s interests.” (# 4, pp 15 - 22)

A background paper was prepared in April, 1999 on the “Current Situation and Problems in Health Reform and Development in China” by the Ministry of Health (MoH). It is a draft document—not intended for general circulation. It points out that since the 1980’s, health work in China has achieved great success as measured by health institutions, hospital beds and health technical personnel. In the 1980’s the principal problem was the increasing demand for services from a health system that had been destroyed during the “cultural revolution.” Health reform at that time brought about active investment by the government and society which promoted the rapid increase in doctors and hospital beds and medical equipment.

By the 1990’s health reform faced the question of how to adapt to the market economy system and allocate health resources rationally. The following profound problems were gradually exposed:

1) The amount of health resources continued to be enlarged and centralized in the cities. The

actual quantity in many cities was 1/3 to ¼ more than was needed while in rural areas the resources were at a very low level. Rural buildings are “worn out, the equipment is simple and crude, the technical level of doctors are not high. Many township health centers are in dilemma… The quantities of community health service are low and the qualities are not high.”

2) The demand of society for hospital service decreases and the utilization rate decreases. People began to purchase drugs and treat themselves. The number of visits in national hospitals decreased by 15% in 10 years; the number of in-patients decreased by approximately 15%; and the utilization rate of beds decreased by 20%. This induced hospitals to begin to “contend for patients” by purchasing unnecessary equipment and to develop serious competition between institutions. “The amount of money for special facilities of every hospital bed increased from 464 yuan in 1990 to 24,852 yuan in 1996.”

3) Since 1990, “the total health expenses of our country increased too rapidly—significantly higher than that of the GNP. Average health expenses increased from 65.6 yuan in 1990 to 272.82 yuan in 1997.” Between 1990 and 1997, the average cost of outpatient visits increased from 10.9 yuan to 61.6 yuan; average hospitalization costs increased from 437.3 to 2,384.3 yuan—annual increases better than 25%. The drug expense accounted for 61.4% of medical expenses in 1990; 49.7%, in 1997. (# 4, pp 27 – 34)

In another background paper for the Senior Policy Seminar in April, 1999, an analysis of the

“Current Status and Trends of Urban Medical Service System in China” was done. Their data supports the fact that there is decreased utilization of urban medical services as costs increase (with cost of drugs making up more than half the total cost (67.1% of outpatient expenses; 53.7% of inpatient expenses.) Their analysis also indicates that medical workers’ technical efficiency has also been decreasing. An indicator is the increase of complaints. The “appeals of medical dispute more than doubled” between 1997 and 1998—mostly about wrong diagnosis or missing diagnosis.

This data suggests that if price (inpatient and outpatient) is doubled, demand will be decreased by 30%. The medical and health budget of the government has strong influence on health costs. If the budget increases by 1%, the total expenses for outpatient and inpatient service will decrease by 3%. This analysis suggests that for too long the number of sick beds and the number of doctors were the main indices of health development. It suggests that the government must now “strongly restrain the providers of medical services.” The greatest challenges to urban medical system reform are:

1) Rapid urbanization. In China, the number of cities increased from 193 in 1978 to 663 in 1996 and the percentage of population in cities increased from 17.9% to 30%--perhaps as high as 40% if the “covert” population is included. This produces environmental pollution and the “deterioration of the nature-supporting system” which brings new pressure on medical services.

2) A rapidly aging population. By 2010, persons above age 60 will make up 15% of the total population. With an “incomplete social security system,” the aged will put increased demands on the medical and health services.

3) Change in disease patterns. Non-infectious and chronic diseases are now a major health problem and these will increase the difficulty of controlling expenses for medical services.

4) The need of “reform of the security system.” The requirement of “low level and wide coverage” and the “strict restraint of the expense control will force the medical and health services to change a great deal.

This analysis suggests that many measures that were advocated 20 years ago when it was necessary to meet the demand for more services must now be “gotten rid of.” “We should gradually change the way of payment, and change the payment by service item into a single payment unit, that is, put several payments together.” This will force medical providers to “bear their own risks, and urge them to provide higher-quality but lower cost medical services.” It also suggests “separate accounting on medical services and medicines.” It also points out that since the 1990’s doctors income “has greatly increased… Therefore, investigating and standardizing the payment to the doctors will be an extraordinarily important task.” (# 4, pp 38 – 53)

Another background paper is on the reform needed in hospital ownership. The medical service system in China is “established upon the central planning economy which is mainly formed by the State owned and the Collective. The former includes county and above county level government-owned comprehensive and specialized hospitals, enterprise-owned hospitals, and some town-owned hospitals. The latter includes block-owned hospitals and some district-owned hospitals, as well as many clinics in the countryside and small towns.

“The number of private clinics, private hospitals, joint-venture hospitals, share-holding

hospitals, share-cooperative hospitals and hospital groups have been growing quickly since the 80s.” Though still comparatively small in number, there is a strong trend towards their increase.

By 1997 there were 60,927 medical institutions with 3,088,662 employees supervised by the Ministry of Public Health. Among these, 28,874 hospitals were state-owned with 2,530,504 employees and 32,053 collective medical institutions with 558,158 employees. At the same time there were 125,264 private clinics with 161,465 employees. Also, there were 7,345 enterprise-owned hospitals and 89,011 internal clinics with 1,316,449 employees in total.

The total revenue of MOPH supervised hospitals was Y131,614 billion in 1997. Although these receive annual subsidy from the government, as a percentage of their total budget it is annually decreasing. Hospitals are no longer receiving sufficient income to adequately support themselves and their development.

The local governments at county level and below have had serious difficulties in fiscal financing since the decentralization reform in 1986. This leads to insufficient investment in medical institutions and, even worse, insufficient funding to continue full operations. “In order to survive and develop, raising money from employees, interests sharing and risk sharing have become a practical choice for small hospitals… in this situation.” (# 4, p. 54)

In summary, China is a developing country that has made extraordinary progress in achieving

good health indices. Weaknesses in its health system are evident, however. The effort to achieve high quality medicine has been too successful in the East to the extent that there are now too many unutilized hospital beds, very many highly qualified physicians, and a system that is now considered too expensive. This expensive emphasis has prevented the rest of the country (particularly the poor western provinces) from achieving even basic services for the entire population and in some places, the previous good health indices have begun to deteriorate. This is causing the following policy decisions: a) to put greater emphasis on basic services at the community level (community health centers); b) increase the emphasis on health education and preventive care; c) increase the emphasis on primary health care, especially out-patient care in contrast to hospital care; d) use initiative to experiment with new, more effective approaches to disease control, including not being afraid to learn from the West; and e) continue the effort to bridge the gap between “western” and traditional Chinese medicine.

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