World Bank Reprint Series: Number 397 Nicholas Prescott and Dean T. Jamison ne iiistrlbution and hnpact of Health Resource Availability in C ea Reproduced by permission of John Wiley and Sons Limited, England, from the In!tertifftiotalJournal of Healthl Planninig and Aftveiti,men,e,. vol. I (1985), pp. 45-56. INTERNATIONAL JOURNAL OF HEALTH PLANNING AND MANAGEMENT, VOL. 1, 45-56 (1985) THE DISTRIBUTION AND IMPACT OF HEALTH RESOURCE AVAILABILITY IN CHINA* NICHOLAS PRESCOTr AND DEAN T. JAMISON The World Bank, 1818 H Street, NW, Washington, DC 20433, USA SUMMARY Since 1949, China's progress in mortality reduction has far exceeded that experienced by other developing countries with comparable levels of national income. This achievement has taken place irn the context of a development strategy oriented, in part, to the elimination of the worst aspects of poverty. Using recent cross-section data, this paper provides a statistical assessment of the extent to which health resources are evenly distributed in contemporary China, and the degree to which improvements in health resource availability may account for the observed variation in mortality levels. Contrary to expectation, the analysis finds that substantial inequalities do remain in the distribution of health resources, and that these differentials are principally associated with levels of urban income and urbanization. However, these differen.zes in health resource availabil- ity do not appear to explain the significant variation which also persists in mortality levels, a finding consistent with the results of similar analyses for developed countries. KEY WORDS: China; Mortality; Hospital beds; Health manpower; Regression analysis INTRODUCTION Before 1949, China's population suffered a crippling burden of disease and premature death. Perhaps the most striking success of China's subsequent struggle against poverty and inequality has been a dramatic increase in life expectancy, accompanied by a reduction in the burdein of illness. Life expectan- cy has more than doubled from only about 32 years in 1950 to 69 years in 1982-some twenty years greater than the average for other low-income countries, and only six years less than in the industrialized market economies. The successes associated with modern Chinese health policy have attracted considerable attention throughout the developing world. Indeed, China's policy emphases on prevention, barefoot doctors, and community resource mobiliza- tion strongly influenced the 1978 Alma-Ata declaration on achieving Health for All by the Year 2000 through a strategy of primary health care. The implementa- tion of these policies has also been accompanied by a rapid growth in the availability of conventional health resources, as measured in terms of hospital beds and health manpower. Since 1952 the availability of hospital beds has increased sevenfold from 0.28 to 2.07 per 1000, while that of doctors has nearly doubled from 0.74 to 1.32 per 1000 (State Statistical Bureau, 1984). *The views arid interpretations in this paper are those of the authors and should not be attributed to The World Bank, to its affiliated organizations or to any individual acting on their behalf. 0749-6753/85/010045-12$01.20 (C 1985 by John Wiley & Sons, Ltd. 46 N. PRESCOIT AND D. T. JAMISON These developments in policy, resource availability and mortality reduction provoke important practical questions about the lessons that may be learned from China's experience to help guide other developing countries which have set ambitious goals for health improvement. To what extent has China equalized the distribution of health resource availability? And to what extent can these improvements in resource availability account for the dramatic gains in life expectancy which China has achieved? In this paper we provide a statistical assessment of evidence relevant to answering these questions. Related papers assess factors influencing fertility levels in China (Birdsall and Jamison, 1984) and nutritional status (Jamison et al., in preparation). Extensive background material and data sources for the Chinese health sector are provided in Jamison et al. (1984) and Prescott et al. (1983). Most previous literatLQre attempting to assess the impact of aggregate mea- sures of health resource availability has examined cross-country variation. To take an example that used countries as the unit of analysis, and data from 131 member states of the World Health Organization, Fulop and Reinke (1981) found that, controlling for a country's income level and other characteristics, an increase in the number of physicians per capita was statistically significantly associated with higher levels of life expectancy. The magnitude of the effect was, however, small; they estimated that a 35 per cent increase in the number of physicians per capita would be required to effect a one-year gain in a country's life expectancy. Auster et al. (1969) condtii. 'ed an early study of this genre; using data on individual states of the USA they tound availability of medical services to have a beneficial (though weak) effect on mortality rates. Higher average levels of education, on the other hand, had a strong beneficial effect on mortality. Mendelson and Orcutt (1979) have used similar methods to assess the impact of air pollution on mortality; they showed that specific pollutants can be clearly related to mortality of particular types in particular age ranges. Cochrane and her co-workers (Cochrane, 1980; and Cochrane et al., 1982) have reviewed many analyses, concluding that improved education levels lead to reduced mortality and improved health. Paradoxically, the evidence relating health service availability to improvements in mortality reveals a mixed picture. In contrast to Fulop and Reinke, Cochrane et al. (1978) and Newhouse and Friedlander (1980), to take two examples, found no beneficial relation between niedical inputs and mortality or physiological measures of health status, respec- tively. The reviews of Cochrane (1980) and Preston (1976) concerning the effect of income levels on mortality also showed mixed results. In the sections that follow in this paper, we utilize similar methods to examine the case of China and extend previous research by assessing determinants of the distribution of resources. We begin with a discussion of data and methods; then follow sections presenting the main results. A final section draws conclusions. DATA AND METHODS The empirical basis for our analysis is provided by cross-sectional data available for the 29 provincial-level administrative units in China (provinces, autonomous regions and municipalities). These data are relatively recent, relating in most HEALTH RESOURCE AVAILABILITY IN CHINA 47 cases to the years 1981 or 1979, and for the most part are available for all 29 provincial units. The definitions for the variables used are presented in Table 1. Our measures of health resource availability are both physical and financial. Data on hospital facilities are for total hospital beds of all types; general hospital beds (excluding hospitals of traditional medicine, hospitals affiliated with medical colleges, mental hospitals, tuberculosis hospitals, commune health centers and certain other categories); and commune health center beds only. Data on health manpower are for all salaried health workers; all doctors (including senior plus assistant doctors of Western and traditional medicine, but excluding barefoot doctors); and barefoot doctors only. With the exception of commune health centers and barefoot doctors, each of these physical resources does, in principle, serve the entire population of each province, so that its Table 1. Provincial variables: Definitions HOS81 Total hospital beds per 1000 population, 1981 H0S79 Total hospital beds per 1000 population, 1979 GENHOS81 General hospital beds per 1000 population, 1981 SHW81 Salaried health workers per 1000 population, 1981 SHW79 Salaried health workers per 1000 population, 1979 DOC81 Total doctors (senior plus assistant Western and traditional) per 1000 population, 1981 CHC81 Commune health center beds per 1000 rural population, 1981 BFD81 Barefoot doctors per 1000 rural population. 1981 REXP81 Public recurrent expenditure on health, 1981 (yuan)'$ CEXP8i Public capital expenditure on health. 1981 (yuan)* LEXP75 Life expectancy at birth, 1973-75 (years) CDR81 Crude death rate, 1981 (per 1000) A UT Dummy variable indicating autonomous region or not ILLIT82 Per cent of population who are illiterate or semiliterate and aged over 12 years, 1982 TOTINC81 Total income per capita, 1981 (yuan)* URBINC81 Urban income per capita, 1981 (yuan)* RURINC81 Rural income per capita, 1981 (yuan)* TOTINC79 Total income per capita, 1979 (yuan)* URBINC81 Urban income per capi:a, 1981 (yuan)* RURINC79 Rural income per capita, 1979 (yuan)* URB81 Proportion of population in urban areas, 1981. URB79 Proportion of population in urban areas, 1979 *US$1.00 = Yuan 1.71 in 1981 and US$1.00 = Yuan 1.55 in 1979. 48 N. PRESCOtT AND D. T. JAMISON availability can be measured as the ratio per 1000 population in the province. In contrast, barefoot doctors and commune health centers serve exclusively the rural population and, hence, are measured as ratios per 1000 rural population in each province. Our financial measures of health resource availability refer to budgetary appropriations through the Bureau of Public Health at provincial and lower levels (prefecture and county) of government, excluding state subsidies to the Government and Labor Insurance schemes. These budgetary outlays, measured separately for recurrent and capital expenditure per capita, are quantitatively important and account for about one quarter of estimated total health expenditure in China (Prescott and Jamison, 1984). Our measures of mortality are limited and somewhat unsatisfactory. The life expectancy data refer to levels prevailing between 1973 and 1975: they have been estimated by Young (1981) for 24 of the 29 provincial-level units on the basis of data generated by the national cancer survey, which was undertaken durinlg those years. The data on crude death rates for 1981 were generated by the Population Census carried out in 1982. More recent provincial data on life expectancy or age-specific death rates would have been preferable, but await publication of the detailed results of the 1982 Census. Our data set also includes estimates of total, urban and rural income per capita; and the percent urban population for 1979 and 1981. Since official estimates of the provincial distribution of incomes are not available, or are incomplete, we have constructed our own estimates for both 1979 and 1981. Urban income per capita is measured as the average urban wage rate in each province, weighted by the national average urban participation rate in those two years. Rural income per capita, for 1979 and 1981 respectively, is estimated by inflating provincial collectively distributed income per capita and rural house- hold expenditure per capita by the national ratios of rural net income to these variables. For each province, total income per capita is then derived as the population-weighted average of urban and rural income per capita. The data on percent urban population in each province are official estimates defined to include the population of cities, county towns, and some towns below the county level, but to exclude their agricultural sub-populations. Finally, we use the illiteracy rate in 1982 as an inverse proxy for the level of education. This measures the percent of the population who are aged over 12 years and who are illiterate or only semiliterate. The statistical procedures we use are straightforward. First, we analyze coefficients of variation in the cross-sectional data on health resource availabil- ity, in order to evaluate the distribution of these variables across provinces. In general, our hypothesis is that these variables are relatively evenly distributed given the egalitarian emphasis of China's development strategy. We then use ordinary least squares to regress these dependent variables on other indepen- dent variables in order to test hypotheses about the determinants of the interprovincial variations that we observe specifically we test and expect to reject the hypothesis that provincial differences in resource availability are systemati- cally associated with different levels of income and urbanization, and to confirm the hypothesis that mortality levels are not determined by the availability of health resource inputs (as found in some of the analyses referred to previously). HEALTH RESOURCE AVAILABILITY IN CHINA 49 We recognize that the aggregated and cross-sectional nature of our statistical observations precludes the inference of firm causal conclusions, but the empiric- al results are nonetheless strongly suggestive. EMPIRICAL RESULTS: HEALTH RESOURCE AVAILABILITY Interprovincial variations The summary statistics, for the variables we have used, are given in Table 2. This Table shows that the range of variation, from minimum to maximum values, in our measures of provincial health resource availability is quite large. For example, the availability of total hospital beds in 1981 (HOS 81) varied from only 1.38 per 1000 in Guangxi to 4.29 per 1000 in Shanghai; while recurrent expenditure per capita in the same year (REXP 81) varied from 2.24 yuan in Anhui to 15.33 yuan in Tibet. A more revealing test of relative equality is, however, provided by examining the shape of these distributions. For this purpose, we use the coefficient of variation across provinces, measured as the ratio of the standard deviation to the mean of the distribution of provincial resource availability. The greater th:e Table 2. Provincial variables: summary statistics Mean Min Max Standard N (unweighted) deviation HOS81 2.29 1.38 4.29 0.71 29 HOS79 2.00 1.32 4.26 0.68 29 GENHOS81 1.21 0.65 2.29 0.49 29 SHW81 3.69 2.07 9.00 1.74 29 SHW79 3.30 1.79 8.28 2.55 29 DOC81 1.57 0.88 4.20 0.80 29 CHC81 0.87 0.35 1.48 0.30 29 BFD81 1.73 0.56 2.85 0.58 29 REXP81 4.39 2.24 15.33 2.84 29 CEXP81 0.77 0.27 2.41 0.56 28 LEXP75 65.53 59.25 71.97 3.65 24 CDR81 6.54 4.95 9.92 1.14 29 AUT 0.17 0 1 0.38 29 ILLIT82 36.38 15.10 78.39 14.48 29 TOTINC81 270.66 183.81 471.03 69.60 29 URBINC81 438.57 369.24 613.43 56.20 29 RURINC81 238.31 158.35 456.51 69.48 29 TOTINC79 186.34 99.63 386.22 64.15 29 URBINC79 370.08 311.58 517.63 47.42 29 RURINC79 152.59 73.51 359.40 55.22 29 URB81 0.19 0.08 0.58 0.14 29 URB79 0.18 0.07 0.57 0.14 29 50 N. PRESCOTT AND D. T. JAMISON coefficient of variation the greater the degree of inequality, and conversely. Contrary to our hypothesis these estimates, shown in Table 3, clearly indicate the existence of substantial inequalities in all types of health resource availabil- ity. The degree of inequality is less pronounced for hospital beds and health manpower, but is extreme for the distributions of both recurrent and capital expenditure per cap- Table 3. Coefficients of variation in health resource availa- bility Coefficient of variation Hospital beds: HOS81 0.31 GENHOS81 0.41 CHC81 0.35 Health manpower: SHW81 0.47 DOC81 0.51 BFD81 0.34 Health expenditure: REXP81 0.92 CEXP81 1.04 Determinants Our hypothesis of a relatively equal distribution of resources reflected the expectation that China's redistributive development strategy would have mod- ified the influence of inequalities of income level and urbanization which typically account for the unequal distribution of resource availability in other developing countries. We now provide a multivariate test of the hypothesis that these determinants are unimportant in explaining the inequality which we do observe. Our resource availability variables for each province are weighted averages of their urban and rural values which we do not observe directly. Thus, in general, our dependent variable in province i, which we denote Zi, can be written as an identity: Zi = (URBZj)URBi + RURZj (1-URBi), (1) where URBi denotes the proportion urban in the province and URBZi and RURZi denote the value of Zi in urban and rural areas, respectively. We hypothesize that the urban and rural values of Zi are linear functions of urban and rural incomes, respectively. Thus: URBZi = a() ± o (URBINCQ); and (2) RURZi = a1 + P1I (RURINCi). (3) HEALTH RESOURCE AVAILABILITY IN CHINA 51 Substituting equations (2) and (3) into equality (1) we obtain the reduced form: Z; = ca + (a( - al)URB1 + 6(3(URB1NCG)* + f31(RURINCQ)*, (4) where URBINCi* = (URBINCj)(URB1), and RURINCi* = (RURJNCj)(l-URB1). Estimation of the reduced form equation (4) as a multiple regression equation enables us to assess the direction, magnitude and statistical significance of the relationship between our measures of resource availability and levels of urban income, rural income and urbanization. It also enables us to estimate elasticities measuring the percentage change in resource availability that is statistically associated with ai percentage change in each of these independent variables. The regression results for equation (4) are presented in Table 4. These results are extremely powerful, with high values of R2 indicating that this specification of the regression model explains much of the observed variation in all types of health resource available, especially in the density of health manpower. In addition, the individual regression coefficients estimated for urban income and urbanization are consistently significant at the 95% confidence level. Rural income levels, however, are generally not statistically significant, except in the determination of recurrent expenditure levels. T'hese results clearly fail to support our initial hypothesis; rather, they strongly indicate that all types of health resources are more densely available in a province the greater the level of its urban income and the higher the level of urbanization. The magnitude of the impact of these independent variables is shown by the estimated elasticities presented in Table 5. These are defined as the partial Table 4. Determinants of health resource availability Dependent variables Independent variables HOS81 GENHOS81 SHW81 DOC81 REXP81 CEXP81 URBINC81* 0.028 0.037 0.045 0.029 0.161 0.026 (2.944) (5.681) (4.572) (4.418) (4.005) (2.538) R URINC81* 0.025 * (0.256) (-0.483) (1.(69) (0.930) (3.624) (0.395) URB81 -9.417 -15.466 -9.524 -8.700 -63.291 -10.148 (-2.066) (-4.987) (-2.030) (-2.758) (-3.315) (-2.057) AUT .. 1.857 ... (2.193) Constaint 1.596 1.099 1.323 0.519 -2.438 0.302 R2 0.673 0.688 0.943 0.878 0.681 0.405 Notes: ** denotes a value less than 01.01 t-statistics are given in parentheses 52 N. PRESCOTT AND D. T. JAMISON derivative of the dependent variable with respect to the independent variable, divided by the ratio of the dependent to the independent variable. For equation (4) the relevant partial derivatives are: aBZ - = 30(URB), (5) URBaNC - 31 (1-URB), (6) a Z U-U = (a(-a1) + f30(URBINC) - 1(RURINC). (7) We evaluate the elasticities using the estimated regression coefficients (from Table 4) together with the relevant sample means (from Table 2). The results indicate that levels of urban income have the greatest quantitative impact on resource availability. With reference to Tablc 5, it can be seen that a one per cent increase in urban income is associated with: a 1.0 per cent increase in the density of hospital beds and salaried health workers; a 1.5 per cent increase in the density of doctors; a 2.5 per cent increase in the density of general hospital beds; and, about a 3.0 per cent increase in levels of both recurrent and capital expenditure. The impact of levels of urbanization is quantitatively much smaller, although consistently positive. In this case the pattern of results is somewhat different, with urbanization exerting greater impact on the availability of health manpower and less on recurrent expenditure levels. The impact of rural income levels is negligible except for recurrent expenditure. Table 5. Elasticities of health resource availability Independent variables Dependent variables URBINC81 RURINC81 URB81 HOS81 1.02 0.00 0.24 GENHOS81 2.55 0.00 0.12 SHW81 1.02 00 0.53 DOC81 1.54 0.00 0.49 REXP81 3.10 0.33 0.02 CEXP81 2.85 0.00 0.31 Urban-rural differentials Our regression estimates also permit us to extend our analysis of inequalities in resource availability by providing indirectly the parameters of the structural equations (1) and (2) from the coefficients estimated for the reduced form equation (4). Again, using these coefficients and the sample means given in Table 2, we can estimate levels of urban and rural resource availability given HEALTH RESOURCE AVAILABILITY IN CHINA 53 Table 6. Urban-rural differentials in health resource availability Urban Rural Ratio HOS81 4.45 1.60 2.78 GENHOS81 1.84 1.10 1.67 SHW81 11.54 1.32 8.74 DOC81 5.54 0.52 10.65 REXP81 4.88 3.52 1.39 CEXP81 1.56 0.30 5.20 average levels of urban and rural income in China. These estimates are provided in Table 6 and again indicate that levels of resource availability are typically much higher in urban than in rural areas. Most striking are the estimates that there are approximately nine times as many salaried health workers, eleven times as many doctors, and five times as much capital expenditure per capita in urban areas as in rural areas. EMPIRICAL RESULTS: MORTALITY LEVELS China's impressive achievements in mortality reduction have not been uniform throughout the country. Life expectancy in the mid-1970s was estimated to vary from 59 years in Guizhou to 72 years in Shanghai. Crude death rates, estimated from the 1982 Census, ranged from 4.95 per 1000 in Heilongjiang to 9.92 in Tibet. However, we can note that the degree of variation in provincial mortality levels is far less than for the availability of health resources. Indeed, the coefficient of variation is only 0.06 for life expectancy and 0.18 for the crude death rate. Based on the results of similar analyses conducted for other countries, we would expect that these provincial differences in mortality levels are not systematically associated with provincial differences in the availability of physic- al health resources. As before, we test this hypothesis using multivariate regression analysis to relate our mortality measures to our variables on resource availability. In this case, however, the lack of data on urban and rural values of resource availability precludes using the original reduced form specification of the model. Instead, we simply regress provincial mortality on provincial resource availability, while controlling for average income and education. For the life expectancy analysis, severe data limitations require us to use 1979 values, and in some cases 1981 or 1982 values, of the independent variables as proxies for their relative values up to the period 1973-75, a distinctly unreliable procedure. In all of the regression results, presented in Tables 7 and 8, we find no statistically significant favorable effects, on life expectancy or the death rate, of any measure of health resource availability. Indeed, the pattern of results suggests the opposite conclusion. The only consistently significant finding is that increases in life expectancy, and reductions in the crude death rate, do appear to 54 N. PRESCOTr AND D. T. JAMISON Table 7. Determinants of life expectancy, 1973-4975 LEXP75 Independent variables [1] [2] [3] [4] [5] TOTINC79 0.018 0.035 0.034 0.033 0.016 (2.078) (2.574) (1.672) (1.894) (1.666) ILLIT82 -0.125 -0.130 -0.128 -0.122 -0.127 (-3.142) (-3.66) (-3.188) (-3.059) (-3.143) HOS79 -- -2.071 ... ... (-1.575) SHW79 - * -0.693 * ... (-0.852) DOC81 *- * - -1.325 ... (-0.984) BFD81 *... ... 0.697 (0.718) Constant 66.521 68.241 66.013 65.676 65.840 T? 2 0.527 0.559 0.521 0.527 0.579 Note: t-statistics are given in parentheses. be associated with improvements in literacy. However, the measurement errors inherent in these analyses severely qualify the value of these inferences. DISCUSSION AND CONCLUSIONS The analysis presented in this paper suggests two principal conclusions. The first is that, despite the egalitarian emphasis of China's development strategy (Trescott, 1985), the distributions of both physical and budgetary resources in the health sector remain substantially unequal. not only between provinces but also between urban and rural areas. Contrary to expectation, these inequalities appear to be very largely determined by levels of urban income and urban za- tion. This finding would not be at all surprising in almost any other developing country. But the fact that it appears to be also true in China emphasizes the great practical difficulty in achieving an effective redistribution of health resources to benefit poor rural populations. Indeed, current trends in Chinese economic policy are likely to increase these inequalities. The fiscal decentralization reform introduced in 1980 is intended to promote self-reliance on own fiscal revenues to finance services provided at each level of government. The resulting loss of fiscal transfers from higher levels of government has, if anything, made it more HEALTH RESOURCE AVAILABILITY IN CHINA 55 Table 8. Determinants of the crude death rate, 1981 CDR81 Independent variables [11 [2] [3] [4] [5] URB81 0.600 -3.381 -11.955 -7.759 0.337 (0.378) (-1.549) (-2.877) (-2.366) (0.201) ILLIT82 0.047 0.042 0.032 0.029 0.046 (3.067) (2.928) (2.268) (1.909) (2.929) HOS81 ... 0.946 ... ... (2.447) SHW81 ... ... 1.003 ... (3.199) DOC81 *- ... ... 1.442 ... (2.823) BFD81 * - ... 0.192 (0.570) Constant 4.657 3.425 3.843 4.618 4.417 T2 0.268 0.386 0.460 0.423 0.249 Note: l-statistics are given in parentheses. difficult to finance expansion of rural health services, and is likely to further increase differentials between urban and rural areas. Furthermore, increasing income inequalities generated by the recent rural responsibility reforms will also tend to exacerbate existing inequalities in health services provision within rural areas. The second conclusion is that there appear to be no significant improvements in life expectancy that are associated with higher per capita availability of health manpower or hospital beds in a province. This finding must, however, be regarded as very tentative in view of the unsatisfactory nature of the data analyzed, although it is consistent with the results of some analyses in other countries. One explanation for the result may be that preventive policies and activities have accounted for much of the mortality decline experienced in China, and that these activities have been more uniformly distributed than health resource inputs. Health workers and hospital facilities may, nevertheless, play an important role in providing access to care, and in reducing the incidence and adverse consequences of morbidity. The analysis suggests that limited, if any, further gains in life expectancy can be expected from quantitative increases in the supply of health resources of the kind that have been analyzed. Furthermore, related analyses in Prescott et al. (1983) conclude that increases in income levels are associated with increases in age-adjusted morbidity rates for hypertension and in age-adjusted mortality rates for cancer. Thus, neither 56 N. PRESCOTT AND D. T. JADIISON quantitative expansion of the existing health system nor general improvements in living standards hold much hope for further gains in life expectancy. Hence, an important priority may be to develop qualitative improvements in health manpower and hospital facility management combined with new preventive policies directed against the chronic diseases that are emerging from the epidemiological transition induced by China's past successes in communicable disease control. REFERENCES Auster, R., Leveson, I., Sarachek, D. (1969). The production of health, an exploratory study. J. Hum. Resources, 4(4), 411-436. Birdsall, N., Jamison, D. T. (1984). Income and other factors influencing fertility in China. Population Develop. Rev. 9, 651-675. Cochrane, A. L., St Leger, A. S., Moore, F. (1978). Health Service 'input' and mortality 'output' in developed countries. J. Epidemiol. Community Hlth, 32, 200-205. Cochrane, S. (1980). The socioeconomic determinants of mortality: the cross national evidence. In Cochrane, S., Leslie, J. and O'Hara, D. (Eds). The Effects of Education on Health, WVorld Bank Staff Working Paper No. 405. Washington, D.C.: The World Bank. Cochrane, S., Leslie, J., O'Hara, D. (1982). Parental education and child -health: intracountry evidence. Hlth Policy Educ, 2, 213-250. Fulop, T., Reinke, W. (1981). Statistical analysis of interdependence of country health resource variables, with special regard to manpower-related ones. Bull. Wd Hlth Org. 59, 129-141. Jamison, D. T., Evans, J. R., King, T., Porter, I., Prescott, N., Prost, A. (1984). China: The Health Sector, a World Bank Country Study, Washington, D.C.: The World Bank. Jamison, D. T., Leslie, J., Piazza, A. Nutrient availability and other correlates of anthropometric status: international and Chinese interprovincial data. In preparation. Mendelson, R., Orcutt, G. (1979). An empirical analysis of air pollution dose response curves. J. Environ. Econ. and Management, 6, 85-106. Newhouse, J. P., Friedlander, L. J. (1980). The relationship between medical resources and measures of health: some additional evidence. J. Hum. Resources, 15 (2), 200-216. Prescott, N., Jamison, D. T. (1984). Health sector finance in China, Wld. Hlth. Statistics Q., 37, 387-402. Prescott, N., Jamison, D. T., Birdsall, N. (1983). Determinants and consequences of health resource availability in China, Technical Note Series, Population, Health and Nutrition Department, Washington, D.C.: The World Bank. Preston, S. H. (1976). Causes and consequences of mortality declines in less developed countries during the 20th century. In Easterlin, R. A. (Ed.) Population and Economic Change in Less Developed Countries. Chicago: The University of Chicago Press. State Statistical Bureau, People's Republic of China (1984). Statistical Yearbook of China. Hong Kong: Economic Information and Agency. Trescott, P. B. (1985). Incentives versus equality: what does China's recent experience show. Wld Dev., 13(2), 205-217. Young, S. (1981). Analysis of life expectancy in China, 1973-1975. J. Population Econ. (Beijing).