China: The development of the health system during the Maoist period (1949–76)

Abstract The Maoist period (1949–76) is considered an outstanding stage in Chinese history for its improvements in public health and welfare. In particular, the decrease in infectious diseases led to reduced mortality rates and increased life expectancy. This success can be attributed to the policies implemented in the health-care system during this period. However, different stages defined this process. The aim of this article is to determine whether health inequality in China was evident and consistent during the whole period. To determine this, provincial data were drawn on to undertake a comparative study in the allocation of health resources in different regions. In order to understand the dynamics of the health system during this period, the article focuses on one province in particular, that of Henan. The findings indicate that there were variations in the distribution of health resources among provinces during the Maoist era. The available figures indicate that there was a general increase in health resources in China. However, this did not prevent Henan province from experiencing a great decline in its health system during the Cultural Revolution (1966–76). Future research must be carried out to determine whether the inequality of health inputs in China during the Maoist period was positively correlated with the inequality of the health outputs nationwide.


Introduction
Since the 1980s, the health of the Chinese population has improved and entered a new nutritional and health transition linked to the spread of obesity, diabetes, and cardiovascular diseases. 1 Some scholars suggest that the decline of infectious diseases among the Chinese population in recent decades might be associated with the increase in incomes, rather than the efficiency of the health system. 2 The transition towards a market economy after the late 1970s opened the way to the emergence of economic and social inequalities in China. 3 In the health sector these inequalities are also evident between urban and rural areas, 4 as well as between different provinces. 5 This reflects the fact that health-care reforms have sometimes been deferred in order to concentrate on economic reforms. 6 While health inequalities have been studied intensively for the years following the economic reforms, there is less literature on inequalities in the health-care system during the Maoist period . Already in the 1980s, international health agencies claimed that China had taken the path of an epidemiological transition during this period, by reducing mortality and birth rates by 50 per cent and 40 per cent, respectively, and increasing life expectancy from 44 years to 68 years. 7 This success was attributed to the great improvements in the health system in a country with lower incomes than in any industrialised country in the past, achievements that were described as unique in the developing world. 8 During the Maoist period the clear objective was to spread an egalitarian health-care system to the whole country and reduce existing health inequalities, which had increased during the Republican era . 9 However, the evidence indicates that, while there were health improvements at the national level, there were also great inequalities in health between the rural and urban populations. 10 A range of publications has concentrated on health outputs during this period, 11 yet to my knowledge, few have studied the specifics of the distribution of health resources in China. 12 Previous studies claim theoretically, that the geographical distribution of health resources contributes to health improvements in a society. 13 Therefore, the supply side of inputs (health resources) has an impact on the demand side of outcomes (access to health care). 14 The aim of this article is to investigate the distribution of health resources in China during the Maoist period.
Yip claims that the focus on economic reforms contributed to the deterioration of the quality of the health system and dismantled the near-universal health system of the previous decades. 15 The aim of this article is to investigate whether the inequalities that exist in the health sector today were already present prior to the economic reforms. To this end, I will analyze the distribution of health-care resources among the different provinces in China, 16 using the allocation of health resources to understand and evaluate the impact of the Maoist period health reforms.
A second aim of this article is to investigate the particular case of Henan Province, an agricultural region located in the Central Plain and characterised as one of the most populated provinces in the country (see Map 1). The great demographic density of this region, nearly 95 per cent of whose population was rural throughout the Maoist period, adds particular interest to Henan as a case study. Therefore, the second question I aim to answer in this article is whether the distribution of health resources in Henan Province was constant at the different stages of the Maoist period.
During the 27 years of the Maoist period, the health system assumed different forms in response to demand and social structure, but more importantly, to the prevailing political circumstances as well. Four different phases can be identified: (1) the Initial Stage (1949-57); (2) the Great Leap Forward (1958-61); (3) the Adjustment Stage ; and (4) the Cultural Revolution . At that time, health policies were focused on preventive medicine linked to national political campaigns and investments in medical institutions and medical personnel. In this article, I examine the distribution of health resources at each of these stages. While a general increase in the supply of health inputs can be identified, the distribution of these resources reveals inequality gaps between the different provinces.
In this article, the overview of the health system in China during the Maoist period is based on institutional health indicators compiled from four Chinese statistical sources: Comprehensive Statistical Data and Materials on 50 years of New China (1950China ( -1998 (Xin Zhongguo Wushi Nian Tongji Ziliao Xupian); and a new data-set including different health indicators from the Provincial Archive of Public Health Records (Weishengzi), the China Statistical Data Compilation , and the 1988 National Survey of Fertility and Contraception. 17 For Henan, I have used the Henan Provincial Gazetteers -1985 Yearbook. 18 The use of aggregate data published by the government implies certain limitations for this study. First, the reliability of official statistical data in China cannot be assured, especially for the Maoist period. I address this issue in Section 3, where in certain provinces some figures appear to have been exaggerated, particularly during the GLF stage. Secondly, the aggregated data cannot be used to assess the development and availability of health resources at the micro-level. Recent studies concerning the state of the health system following the economic reforms use household data such as the China Health and Nutrition Survey (CHNS), China Health and Retirement Longitudinal Study (CHARLS), China Institute for Income Distribution data-set (CHIP), and China Family Panel Studies (CFPS). The data in these datasets lack information on the allocation of health resources during the Maoist period, but previous studies have used the CHNS data on heights, as an indicator of health. They show a similar trend to the final conclusions of this study, that is, of improvements in health and health resources nationwide, but with great inequality between provinces and at different political stages during the period under study. 19 Finally, the provincial gazetteers provide valuable information on developments in the supply of health resources, described in Section 4.
This article is divided into five sections. Section 2 describes the different policies and health institutions that were introduced in China during the Maoist period, based on the four different stages listed above. Section 3 analyzes the data at both the national and provincial levels. Section 4 focuses on the development of the health system in Henan Province specifically. Section 5 offers some final conclusions. health-care system based on the communist ideals developed during the revolutionary era , in defence of a public health system governed by policies concerned with the control of epidemics. In November of that year, the Ministry of Health (MOH) was established as the organisation responsible for health, with subnational local branches. Labour insurance and government health insurance were introduced in the early 1950s, with free health care being provided to industrial workers and families, government employees, teachers, and students. However, because of financial constraints, the central government allocated only 1.2 per cent of the national budget to the health-care sector, rapidly creating congested health services demand and limitations on state finance. Ironically, this situation widened the gap between the urban and rural areas, leaving the peasants behind.
The central government was aware of the precarious situation in the rural areas and its own financial constraints. As a result, it became important to concentrate on the prevention first policy, which insisted on averting the spread of infectious diseases, thus allowing the state to 'gain political capital by reducing human suffering' . 21 The means to accomplish this objective relied on the state's control of society, especially in the countryside, by launching patriotic health and mass mobilisation campaigns to increase health awareness. While at the beginning of the 1950s private health facilities still existed, by the mid 1950s the healthcare system had become mostly an activity of the state. The MOH identified 20 communicable diseases, but due to the financial and institutional constrains, only cholera, smallpox, and the plague were targeted as priorities. 22 In addition, by 1957 the fight against schistosomiasis and venereal diseases had become a central goal. At the end of this stage, two thirds of all the counties in China had an epidemic prevention station (EPS) applying communicable disease control (CDC) programs, vaccination, and environmental sanitation and hygiene. 23 While the prevention first policy was successful in the long run (eg, the last outbreak of smallpox was in 1960, 20 years before its global eradication), 24 the health-care system had a long way to go in providing the rural population, with curative treatments and tackling infectious diseases not targeted by the CDC programs, which remained a latent problem. Nevertheless, by the end of the initial stage of implementing the health-care system, Mao had won popularity among peasants and local officials, to the extent that he felt powerful enough to weaken the intervention of the MOH bureaucracy, as he understood it, thus acquiring complete authority to supervise health activities in the years that followed. 25

The Great Leap Forward (GLF) (1958-61)
Policies during the GLF were basically concentrated on collectivizing China's socioeconomic structure. The establishment of a commune system in rural areas, controlled politically, clearly changed the social and economic structure of the system and also had an impact on healthcare. Already in the mid 1950s some communes in Central China, including Henan, adopted the so-called Cooperative Medical Schemes (CMS), which provided free health-care for the whole of the rural population. By the end of 1958, all cooperatives had adopted the CMS. Mostly decentralised, free medical services, financed by county and commune budgets, provided peasants with an incentive to adopt the system of collectivisation in its entirety. The rural public health-care system was supported by two main sources of funding: the commune members' annual fees, and the revenues collected from agricultural production. The former provided only very low revenues and ultimately became practically non-existent, while the later was only likely to be effective if the primary sector of the economy at the provincial level was successful; this proved not to be the case, and three years after the GLF's policies had been implemented, the system had reached a state of collapse.
The prevention first policy nonetheless remained the focal domain in the public health system during the GLF. One of the most emblematic hygiene campaigns was the so-called Four Pests, which made the wiping out of mosquitoes, flies, rats, and sparrows a top state priority in order to eliminate schistosomiasis. Avoiding most of the technical and professional leaders of the MOH, Mao proclaimed the mobilisation of rural labour to catch and kill the four pests. 26 By the end of 1959, 50 per cent of patients suffering from schistosomiasis disease had been cured. 27 However, the Hundred Flowers Campaign in 1956 and the Anti-Rightist Campaign in 1957 'set in motion a bandwagon effect with localities competing for rapid elimination of schistosomiasis' . 28 The same pattern was evident in the setbacks to agricultural production during this period, one of the main reasons for the famine in the GLF. 29 Low nutritional intake and the unprecedented consumption of non-edible goods during the subsistence crisis increased disease levels, especially in the rural areas. By 1961, the decrease in the amount of revenue allocated to health resources could not support the increased demand for medical provision, leading to greater fiscal constrains with clear negative effects for maintaining an efficient health-care system. The national budget also fell during the period due to the increased investment in the secondary sector in urban areas, meaning that the communes and counties could not turn to the central government for financial assistance. To confront the problems of welfare funding, local cadres considered increasing peasants' fees for access to health, but levels of poverty at the commune level had reached their peak. In addition, contrary to Mao's initial objectives, the health gap between the urban and rural areas widened due to intensification of the industrial sector.

The Adjustment Stage (1962-65)
After the GLF Famine, the state and local governments worked to improve the agricultural system in order to increase food production based on more bureaucratically oriented policies. This was the beginning of the modernisation of the primary sector, which would be pursued with greater force in the mid 1960s. Collectivisation was relaxed; but the setbacks during the GLF met their response in Mao's silence on healthcare issues from July 1960 to August 1964. 30 The subsistence crisis at the previous stage weakened the rural population's ability to engage in mass mobilisation on preventive health issues, and patriotic hygiene campaigns were discouraged until 1964. During this new stage, commune health centers declined in all respects, and the gap between rural and urban areas increased. By 1964, 30 per cent of government health-care funding was being allocated to urban areas, and only 16 per cent to rural areas. In addition, 90 per cent of senior health workers were appointed at or above the county level, leaving behind residents in the communes, which constituted the greater part of the Chinese population. 31

The Cultural Revolution (1966-76)
By the mid 1960s, Chairman Mao felt he was losing political control after leaders such as Liu Shaoqi and Deng Xiaoping had gained political influence with revisionist policies during the adjustment period to overcome the failures of the GLF. In 1964, the coup against Nikita Khrushchev in the USSR alerted Mao that a similar outcome could take place in China. At this point, loyalty towards party personnel became more important than its policies, and Mao concentrated all his power on preserving its leadership. 32 This political environment produced a new stage in China that lasted for 10 years: the Cultural Revolution (CR). During this decade, major changes took place in the country that involved political repression, which also affected the health-care system. By the mid 1960s the confrontation between Mao's revolutionary views and the MOH's bureaucratic practices returned to the situation of the mid 1950s. At this point, Mao's major concern regarding health issues was the existing inequalities, between the rural and urban areas, and he referred to the MOH as the 'Ministry of Urban Lords' . 33 Mao's political agenda had two main policies for the health system. The first was to transfer a large number of professional doctors from urban to rural areas. The second was to restructure the education of medical technical personnel by reducing the number of years of training from six-and eight-year programs to three-year programs. 34 These measures faced great opposition from the MOH. However, between 1968 and 1973, after the fall of Liu Shaoqi and Deng Xiaoping in 1967, the MHO lost all its influence in the policy-making process. Mao's most engaging health program at the time was the barefoot doctor (BFD) program, established as national policy in 1968 and regarded as an effective measure solving the problem of the scarcity of doctors in rural areas and minimizing costs. 35 The typical BFD was actually a peasant who provided basic health care, sanitation, health education, and preventive medicine at the brigade and working team levels. Many BFDs, who received credits for work points in health and agriculture, were urban medical personnel transferred to rural areas. In 1965, fewer than 19,000 medical personnel were sent to the countryside; at the end of the period, the figure peaked at 1.8 million. 36 The package, mainly founded by brigades, provided a more continuous service and achieved a higher population reach than the preventive campaigns of the 1950s. 37 Together with midwives and physicians, the new system adopted a bottom-up rather than top-down approach and responded to the failures of the GLF, using fees and other market mechanisms to prevent overuse and unnecessary use of health services. 38 The BFD program remained in existence until the 1980s.

National statistics
During the Maoist period, great achievements in health were related to the improvement of health institutions dating from the previous Republican era and the construction of new ones. From the establishment of the PRC in 1949 to 1976, the number of health institutions increased by 23.2 per cent (see Graph 1). These institutions included major investment in hospitals and clinics, and to a lesser extent also in sanitary and epidemic stations, sanatoriums, specialized prevention and treatment centers and stations, and maternity and child-care centers.
Maternity and child-care centers represented a low proportion of total health bodies, but they experienced the greatest increase during the period, reaching at 36 per cent.  . Source: Author's elaboration from the Comprehensive statistical data and materials on 50 years of new China (1950China ( -1998.

Graph 1. Health institutions in China
Nearly one million midwives were re-trained, reducing newborn and puerperal infection rates, including the rate of neonatal tetanus. 39 The increase in women's enrolment in education was also positive for the reducing infant mortality, as it not only contributed to the provision of health information, but also increased the age at marriage for females from 17.5 years in 1952 to 22.3 years in 1980. 40 Sanitation and anti-epidemic stations and specialized prevention and treatment centers also experienced representative increases, reaching 26.3 per cent and 25.7 per cent, respectively. As previously mentioned in Section 2, the prevention first policy played a major role in reducing infectious diseases.
Medicine and chemical test laboratories and medical science research institutes, not shown in Graph 1 due to their low representation in the total figures for health institutions, also increased by 38.6 and 34.8 per cent respectively. These figures are not representative in the whole picture for two main reasons. First, even though Western medicine started to play a greater role in the health system during the Maoist period, Chinese traditional practices still had greater representation. Statistical records show that until 1970 more doctors were practicing traditional Chinese medicine than Western medicine. 41 This situation was reversed in 1971, when there were 206,000 doctors of traditional Chinese medicines and 241,000 doctors of Western medicine. By 1976, the figures had reached 236,000 and 308,000 respectively. The second explanation is related to the intellectual and scientific setbacks experienced during the Cultural Revolution. The limits placed on the MOH in the process of policy-making had a great negative impact on the developments in this particular area. It was not until 1978, with the new economic reforms of Deng Xiaoping, that medical research would win a representative share of the health system.
Despite the remarkable increase in the number of health institutions during the Maoist period, the pace of growth at each stage of the health system differed greatly. The most outstanding increase came at the initial stage, with a 55 per cent growth rate; no other stage was to reach such a representative rate. In fact, after 1958, the growth in health institutions not only slowed to 8 per cent during the GLF, but also suffered stagnation and a decline in growth after 1962 (0.7 per cent growth during the adjustment stage and 2.4 per cent decline during the Cultural Revolution). Such percentages show the fiscal defaults since the beginning of the 1960s, previously explained. However, in Graph 1 we can see that that in any case the figures were lower than in the achievements of 1957. Even in 1971, with fewer health institutions being registered since 1959, the figures are higher than in 1957. It should also be noted that the decrease in the number of health institutions after the mid 1960s is to be explained by a decline in the number of clinics, despite which the number of hospitals almost doubled, from 35,500 in 1959 to 65,000 in 1970.
The number of beds in health institutions is another indicator of improvements to the health system. From 1949 to 1976, the number of beds available increased by 18.7 per cent. Graph 2 shows that, despite the increase in the number of beds in health facilities in the initial stage, the figures are not representative when taking the total population into account. In addition, in light of the clear inequalities between rural and urban areas, we should stress that figures did not exist for the countryside. Even during the Cultural Revolution, when a great effort was made to reduce the gap between rural and urban areas, two thirds of these resources were allocated to the latter. During the GLF there was a clear increase in the number of beds per ten thousand persons, which can be attributed to the change in the population structure, given that this particular period is characterized by high mortality rates (the levels of mortality and infant mortality in China increased to 15 per thousand and 66 per thousand respectively). The situation remained one of stagnation until the early 1970s, when there was a constant increase in the number of beds. By the end of the Maoist period, records give a figure of twenty beds per ten thousand persons.

Provincial differences in health endowments
Health policies were implemented nationwide during the Maoist period. Yet, the decentralized system translated into provincial differences in fiscal revenues and, therefore, investment in local health-care systems. 42 Records show that the adoption and construction of health institutions remained very low in Western China (especially Qinghai, Ningxia, Xinjiang) (see Table 1). Qinghai and Ningxia provinces did not reach 1 per cent share of the total healthcare facilities in the country for the whole period. A similar pattern is shown for Xinjiang and the southern region of Hainan until the decade of the 1960s. Even then, the share remained lower than 2 per cent. Table 2 shows a similar picture when the share of total hospitals in China is examined. Several features may explain this pattern. First, the western regions were, as they still are today, low-income provinces with high levels of poverty. Secondly, although these provinces constitute a great proportion of China's total geographical area, most of its land is infertile and cannot be used for agriculture. Given that, at some stages in the Maoist period the communes based partially on agricultural production funded the health system in rural areas, it is understandable that the budget for health-care would be lower in these regions. Thirdly, the western provinces are not only less populated, but a greater proportion of minority populations are settled in these regions. Unbiased political mechanisms might be used in these cases. In Section 2, I mentioned how during the GLF requiring the different localities to compete in the areas of health and agriculture allegedly led to actual socioeconomic achievements being exaggerated. Figures for the total number of health institutions and hospitals recorded during the GLF prove to be misleading when the share by province is computed. Such estimations suggest that provinces such as Henan, Anhui, Shandong, Hunan and Shaanxi may indeed have exaggerated their statistics regarding the number of hospitals each had (see Table 1). Many of the figures in these regions are exaggerated by as much as a factor of ten, going back to the same records as at the initial stage during the adjustment period.
A similar pattern is observed in Table 2, which focuses on all health institutions. While the increases in these figures are not as evident as when the figures for hospitals alone are examined, there is a general and representative increase in the proportions of institutions in almost all regions. The absolute figures indicate that the total number of hospitals during the GLF increased to 247,000 units from 52,000 in the previous stage. It has proved difficult to determine the reasons why these figures increased at such great rates during the GLF and with such variations across provinces. In any case, the alleged over-reporting during the GLF shown in Tables 1 and 2 suggests that the number of health institutions had had a representative increase since the beginning of the 1960s and that the number of hospitals reached its peak during the Cultural Revolution. All through this 27 years period, Hunan and Hebei Provinces seem to have had the greatest shares of the total of health institutions and of hospitals respectively. Yet both regions had high infant mortality rates during this period. From 1949 to 1976, the number of medical technical personnel and doctors increased by 8.5 per cent and 5.4 per cent, respectively. Even though the highest figures are recorded after the 1960s, the growth rate is higher in the initial stage (4.7 per cent) and the GLF (4.6 per cent), when compared to the remaining two stages (2.6 per cent). While the increase was representative, the allocation of doctors was not equally distributed nationwide.
Map 3 illustrates the development of the allocation of doctors in China from 1949 to 1985. It is notable that during the initial stage (Map 3(a)) there is a low share of doctors per ten thousand inhabitants in most regions, with the exception of Shaanxi, Hubei, Shanghai, and Beijing. During the GLF Shanxi and Shaanxi increased the rate to 27 and 20 doctors per ten thousand inhabitants respectively. While there was a general increase in the allocation of doctors nationwide, Liaoning and Guangdong reduced their share of doctors, while Tibet and Gansu Provinces remained with the same proportion (see Map 3(b)).
Map 3(c) and (d) show a clear decline in the allocation of doctors during the Cultural Revolution. While the share of doctors is greater during this period than at the initial stage and during the GLF, the adjustment stage seems to have had a greater allocation of this type of medical resources. However, while we notice an increase in the share of doctors at the recovery stage, previous publications indicate that the allocation was distributed mainly in urban areas, thus widening the gap between them and the rural areas.
During the Cultural Revolution 20 out of 28 provinces decreased the share of doctors, by between 2 per cent in Zhejiang Province and 41 per cent in Henan Province. During the initial years of the reform stage, the allocation of doctors per ten thousand persons increased to as high as 18 per cent in Ningxia and 154 per cent in Tibet. Note that only Anhui (2 per cent increase), Fujian (1 per cent increase), and Gansu (no increase) remained stagnant in terms of health allocation. Indeed, Gansu Province had very low share of doctors (0,1 doctors per ten thousand inhabitants) and a high infant mortality rate (70 per thousand) throughout the Maoist period.
Annual figures show that the number of medical personnel and doctors per ten thousand persons declined during the initial stage of the Cultural Revolution, but recovered again at the beginning of the 1970s to the end of the Maoist period (see Graph 3). There are no specific notes in the official statistics showing whether the BFDs were included in the category of doctors or in some other category of medical personnel. In any case, while a great emphasis was placed on the BFD program covering rural areas, there was also a strong campaign to reduce the number of years of training, leading to the shutting down of a great number of medical universities nationwide. Indeed, the number of medical personnel per ten thousand persons, including doctors, in the early 1970s dropped to rates very close to those of 1957. This decline, which started in 1966, was reversed after 1972, and by 1976 the number of medical personnel per ten thousand persons exceeded all figures registered in any previous year.

Henan province
During the Republican era, most practitioners of traditional Chinese medicine (TCM) were working in the private sector, either in self-owned offices or in private hospitals that combined TCM with Western medicine. Based on Henan Province's gazetteers, nearly 2,700 private practitioners were located in the province, though only 154 had been approved and registered by the Provincial Health Department. With the establishment of the People's Republic of China, one of the main focuses of the new government was to promote the practice of TCM once again. Henan Province concentrated on the production of medical herbs and established a state-owned pharmaceutical industry open to the local and national market.
By 1954 the local government had already invested in the construction and spread of different hospitals and clinics within the province that concentrated on the practice of TCM, many of which were combined with Western medicine. While this practice developed during the 1950s and early 1960s, during the Cultural Revolution the work was paralyzed. Indeed, one third of the TCM hospitals closed down, many clinics had their licenses revoked, and about 150,000 practitioners in the sector were relocated. TCM policies were implemented again in 1978, in circumstances of their rapid development, which spread to different prefectures in the region and acquired greater importance in the 1980s.
While several studies define the BFD program as a positive system established during the Cultural Revolution, statistical data show that Henan Province lagged behind during this period in health levels. Graph 4 shows a representative decrease of the number of doctors per 10,000 inhabitants. The decline started at the beginning of the Cultural Revolution and did not recover to the levels of the mid 1960s until the early 1980s. During this period the share of doctors declined from 9.5 doctors per 10,000 inhabitants in 1965 to 5.8 per 10,000 inhabitants in 1976, reaching its lowest point in 1971 with 4.8 doctors for every 10,000 inhabitants. Indeed, during this time many hospitals in the province closed down, and all the progress made in preventive medicine in previous years was wiped out. The provincial gazetteers show that during the Cultural Revolution, thirteen hospitals were either merged or closed down. 43 Also, the development of medical technology stagnated until the beginning of the 1970s.
The provincial health and epidemic stations were reduced from 153 units in 1965 to 62 units in 1969. Therefore, prevention of tuberculosis and other parasitic diseases ended until the beginning of the 1970s. Between 1956 and 1962 a "seven year plan to eliminate malaria' was implemented, but it failed in Henan due to the GLF. However, by 1964 the province had become one of the greatest successes nationwide in malaria eradication, reducing the cases to 1.3 per cent. Nonetheless, the interruption of malaria treatments during the Cultural Revolution increased the rate of malaria cases and gastrointestinal diseases increased by more than 40 per cent in some prefectures. At this point, Henan Province became one of the worst provinces in China.
While during the initial stage of the Maoist period great stress was placed on maternal health care, during the Cultural Revolution maternal and child health-care institutions also suffered a substantial decline, with nearly 70 per cent of stations closing down between 1965 and 1969. Most women lost their labour protection, which had been introduced at the beginning of the Maoist period by the local Health Department and the Provincial Women's Federation: pre-natal and post-natal leave was abolished, and female health rooms and nursing rooms in factories and mines were closed down. These developments contributed to an increase in the incidence of common disease among women and a greater deterioration in child health-care. By 1975, child mortality and maternal morbidity had increased to figures higher than the national average. Between 1976 and 1978, Henan Pediatric Medical College conducted a survey of 100,000 children between 0 and 14 years old in eighteen brigade teams and three cities. The results showed increased death rate among children between 0 and 12 months of 25.7 per cent. The death rates for cohorts aged 1 to 3 years old, 4 to 7 years old, and 8 to 14 years old were 2.9 per cent, 1.3 per cent, and 0.6 per cent respectively. The recovery begun in 1978, when provincial health bureaus developed new standards for women's and children's health-care, with a greater focus on the rural areas.

Conclusions
The Maoist period is characterized by improvements in health indicators nationally, leading to the demographic transition in China and increased life expectancy. However, between 0 2 4 6 8 10 12 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 Number of doctors (per 10000 persons) Graph 4. number of doctors per ten thousand inhabitants in Henan province  1949 and 1976, institutional changes can be divided into four different stages in the healthcare system. The GLF (1958-61) was by far one of the greatest setbacks in China from every perspective, including health and welfare. In terms of health institutions there were representative increases, but there are irregularities in the data, a problem noted in subsection 3.2. Also, while health institutions increased nationally during the Cultural Revolution , the number of medical personnel per ten thousand persons declined from 1966 to 1972, reaching the same levels as in 1957. The decade of the Cultural Revolution is divided into two stages: a first period, from 1966 to 1971, when allocation of health resources suffered a decline; and a second period, from 1972 to 1976, when the distribution of health resources increased at an accelerated rate. During the Maoist period, improvements in the health-care system were not positive in all provinces. Indeed, allocations of health infrastructure in the western regions, such as hospitals and clinics, were not representative nationwide. This is a problem, given that the population of the western regions is sparser than in other Chinese regions and therefore a greater number of hospitals and beds per person in such regions should reduce inequality nationally, a setback that still has to be solved in China. 44 Still, the allocation of doctors per ten thousand inhabitants was representative in comparison to other provinces located in the southeast of the country, especially after the adjustment stage .
In order to acquire a better understanding of existing health inequalities and the development of the health system in China, the case of Henan Province has been analyzed in this article, based on provincial gazetteers and statistical yearbooks. This province was chosen due to its middle position in China regarding well-being and its high population density. Official sources show that the Cultural Revolution represented a great leap backwards in terms of health, as denoted by the representative increase in infectious diseases and infant mortality. This was mainly due to the restrictions on the development of the sector. Therefore, in the case of Henan Province, this particular decade was a backward stage not only for education, as previous studies have invariably indicated, but also for the structure and efficiency of the health system. Yet other regions such as Gansu Province had a lower share of health resources and higher rates of infant mortality. Such conclusions prompt a new question, namely whether the BFD system implemented in the mid 1960s was indeed a well-functioning system in all-Chinese provinces, as past studies have indicated.
There are some limitations to this article that must be mentioned. First, the data it uses give no information about exactly where the health resources were allocated within each province, making impossible to determine whether the health inputs were equally distributed between the urban and rural areas, nor which counties and/or districts were better provisioned. Therefore, it cannot be determined whether access to health resources was equal throughout the local population. Secondly, there are no specific figures about the number of barefoot doctors during the Cultural Revolution. While this might prevent the figures during this period being clearly interpreted, it must be remembered that not only did the number of doctors and medical personnel per ten thousand inhabitants decline at this stage, so did the quality of the health inputs because of the fewer years spent in medical education and research. Finally, so far, it has not been possible to make a clear correlation between the inequalities of health inputs and the health outputs; further study is needed in this regard. In any case, we have found a relationship between the increase in allocations of health resources and the decline in the rate of infant mortality nationwide.
Despite these limitations, it has proved possible to answer the questions set out in the introduction to this article. First, contrary to Mao's aim, to reduce health inequalities in China, variation was indeed found in the distribution of health resources among the provinces before the spread of the economic reforms at the end of the 1970s. Secondly, using Henan Province as a case study, it can be concluded that, while health inputs increased from 1950 to 1976, the health policies implemented during the GLF and, especially, the Cultural Revolution simply produced a deterioration of the health system in the region. Future research must be carried out to determine whether the inequality of health inputs in China during the Maoist period had a positive correlation with the inequality of the health outputs nationwide.