Aresearch report issued in 2001 by the Commission on Macroeconomics and Health, which is under the World Health Organization (WHO), put forward a concept for developing countries to increase input in public health to reduce poverty and stimulate economic development.

This concept offered people a new angle with which to view a nation's public health development.

Statistics reveal that from 1950 to 1980, per capita income in the country recorded lower growth, while major indicators of human development achieved a much higher improvement. These included the average schooling time of people aged above 15, average life expectancy, infant mortality rate, and indicators to reflect the quality of people's life and social equality.

After the founding of the People's Republic of China in 1949, the country quickly finished the first public health revolution from the basis of low economic development. Owing to the success of the health revolution accompanied by a widespread use of vaccines and antibiotics, some infectious diseases such as malaria and black plague became under control or eliminated. A basic public health service system was established and promoted in rural and urban areas.

Under such a strategy, the public could get health services without high charges. During that period, the quality of people's life was higher compared with per capita gross domestic product (GDP).

An improved health condition of Chinese people provided the necessary human resources for the economic takeoff that has occurred since the 1980s.

The period from 1980 to 2000 - after the nation undertook its reform and opening-up policies - was characterized by a rapid increase of per capita income, but the improvement in major human development indicators was comparatively slow. Though the country realized the goal of quadrupling total GDP and per capita GDP ahead of its self-imposed deadline of 2000, it failed to reach the important social development target of offering primary health services to everyone by the turn of the millennium.

It could thus be concluded that during 1950-1980 economic development and public health progress were linked but became separated during the 1980-2000 period.

Economic development is the pre-condition for public health service improvement, but economic progress cannot automatically and naturally lead to improved health care. It depends on efficient economic and social policies to ensure that the public can share the fruit of economic progress and improved health care.

Currently, main indicators on public health in China have reached the level of medium-income countries in the world. But the large population, unbalanced regional development and overwhelming share of rural population determines that public health remains a prominent issue in terms of economic development.

One of the challenges confronting the country's public health sector is the widening gap in health service supply between urban and rural areas.

For a long time, the supply of public services, including the health service, has been focused on urban areas. After economic reforms in rural areas in late 1970s, which were characterized by the adoption of the household contract responsibility system, the rural co-operative medical service system established after 1949 collapsed with the weakening of the rural collective economy. This has further deteriorated the medical service situation in rural areas.

It is not rare for farmers to fall into poverty if their family members suffer serious illness. Low health conditions also dampen farmers' ability to get work and consequently become rich.

Just like the unbalanced economic development between the east and west, there are also gaps in public health development in these regions. The number of hospital beds per thousand people in Beijing, for example, is 6.28. It is 5.75 in Shanghai, but only 1.51 in the southwest province of Guizhou.

For the rural population in the suburbs of Beijing and Shanghai, more than 97 per cent have access to tap water, but in central and western provinces such as Gansu and Shaanxi, that figure is less than 40 per cent.

Low health conditions in western areas remain a burden and an obstacle for local people to break away from poverty and achieve economic prosperity.

The government has set a target of building a well-off society in an all-round way in the coming two decades and the development of public health is an important part of this.

As a first step, the goal that everyone can enjoy primary health service should be realized by 2005. Between 2006 and 2020, the country should work to ensure that everyone can enjoy health services of a higher level. While promoting the coverage of public health service, service quality will also be improved.

Government investment in this field is regarded as the most efficient and also contributes to improving social equality.

So the government should enlarge investment in this sector. In 2000, total expenditure in the health service accounted for 5.3 per cent of GDP, a little bit higher than the minimum standard of 5 per cent set by the WHO. Of the total expenditure, only 39.4 per cent came from the government and other social sectors. In developed countries, this rate is as high as 71 per cent.

The government's input to the public health sector was only 1.71 per cent of State fiscal expenditure, compared with around 14 per cent in developed countries like the United States and Britain.

The short supply of public funds has handicapped the government's ability to improve the public service by targeting the general public, especially those with low incomes.

In the field of public health, the role of the government and the market should be re-adjusted. Services like anti-epidemics, maternal and child hygiene, access to safe drinking water and sanitation of public toilets are typical products of public interest and should be shouldered by the government. Personal health care, as a private product, should be left to the market.

Government investment should be tilted in favour of rural areas and low-income groups. The focus of government funds should be shifted from big hospitals in cities to health institutions at township and village levels.

The development of public health should be embedded within the framework of the country's macro economic development. In this way, the public health sector, while contributing to steady economic progress, can also achieve its own development.

The pro-active fiscal policy and the strategy of expanding domestic demand, for example, should be integrated with the work in disease prevention and the upgrading of the public health service. More money from State treasury bonds should be used in improving medical facilities and sanitary conditions in rural areas, and in the research and development of key public health projects.

The improvement of the public health service should be listed as an important part of the country's poverty relief campaign. Currently, various poverty relief funds hold 20 billion yuan (US$2.4 billion) in China, but less than 3 per cent was used on public health. Improved health conditions will help relieve the burden of local people in developing the economy.

Hu Angang is director of Centre for China Study under Chinese Academy of Sciences; Hu Linlin is with the School of Public Policy and Management of Tsinghua University.

(China Daily HU ANGANG and HU LINLIN 04-24-2003)