The prognosis is bad for China's health- care system, the World Health Organisation (WHO) concludes in its World Health Report 2000, a mass of facts and figures ranking each nation by performance. Out of 191 countries, China stands 188th in terms of fairness in the way its health system operates. It placed 144th for overall performance and 139th in health expenditure per capita. China's health system attainment is ranked below such countries as India, Bangladesh, Indonesia and Egypt, but above most African countries. In overall performance, China's health system is far below India's at 112th. In the top 50 are other countries from the region including Malaysia, Thailand and Singapore. On the other hand, China does well in terms of the level of health achieved. The WHO ranks it in 61st position, well ahead of richer countries. Life expectancy at birth is 61 years, higher than former Soviet states such as Latvia or Belarus. China reports low infant mortality rates, far better than those of most other developing countries. In terms of 'responsiveness of the health system', China is ranked 88th, equal with Turkmenistan and ahead of India, the country with which comparison is most apt. The United States is ranked first. When it comes to the distribution of health services, China is ranked 105th, also ahead of India at 125th. According to estimates of the 'fairness of financial contribution to health system', China ranks just above the bottom country, Sierra Leone, while India is in the top 50. This reflects the fact that most health spending in China is lavished, in part, on the urban elite out of revenues extracted from the population as a whole. The rural population hardly benefits from state health spending at all. Most strikingly, China spends only 2.7 per cent of gross domestic product (GDP) on health, compared with 6.3 per cent in Cuba and 3.2 per cent in Afghanistan. In fact China appears to spend less of its GDP than any other country listed. The same is true for education, where as a percentage of GDP, China's spending puts it close to the bottom. Even measured as a percentage of public expenditure, health accounts for 5.5 per cent, less than most countries but still more than India at 3.9 per cent. However, India devotes five per cent of its GDP to the health of its estimated one billion-plus inhabitants. The picture that emerges is likely to be viewed as contradictory. China seems to do quite well devoting, as it does, smaller resources to health but achieving impressive results in terms of infant mortality and life expectancy. Equally, spending also seems to be unequal, with the country apparently maintaining a poor and unresponsive health-care system, the report states. Part of the explanation may be the fact that generalisations about such a huge population are not informative. And secondly, that in the Mao Zedong era, China reported good progress in delivering primary public health services such as inoculation or clean drinking water, while since 1980, health spending has been increasingly diverted towards an elite that leans heavily on drugs and expensive equipment. The vast majority have been neglected. The statistics also show up unexpected anomalies. Last year, for instance, 10 per cent of China's population was aged over 60, almost twice as high as in most other developing countries, while the fertility rate was as low as developed countries such as Denmark. This, of course, assumes that China's population data is reliable, while many observers think there is a large under-estimation of the number of children. A peculiarity of the data reported is that under the age of five, Chinese females are much less likely to survive than males, but after 15, the situation is reversed. Thus the life expectancy of Chinese females is around 71.3 years while men live to an average 68.1 years.