ACHIEVING MDGS 4 & 5: CHINA’S PROGRESS ON MATERNAL AND CHILD HEALTH

August 2014

Rafael Cortez, Seemeen Saadat, Intissar Sarker and Shuo Zhang

Health, Nutrition and Population Global Practice

Page 1

Knowledge Brief

Introduction China has made great progress in improving maternal and child health (MCH). It reduced maternal deaths from 1,500 per 100,000 live births and over 200 infant deaths per 1,000 live births in 1949 to 120 per 100,000 live births and infant deaths to 42 per 1,000 by 1990. Currently China is on track to meet its MDG 5 target of 31 maternal deaths per 100,000 live births, and has already achieved its MDG 4 target of reducing child mortality to 16 deaths per 1,000 live births (figure 3). This note explores the actions China has taken to reduce child and maternal mortality, focusing on key policies and programs since the 1990s.

Context China, a lower-middle-income country, had a per capita GNI (PPP) of US$ 7,917 in 2012 and an average GNI growth rate of over 10 percent between 2000 and2012. As of 2010, China had a population of 1.3 billion with a growth rate of 0.6 percent. Seventy-two percent of the population is in the working-age group (15–64 years of age), with an age dependency ratio of 11 percent. According to national data, 3 percent of the population—roughly 40 million

people—live under the poverty line; and over half (55 percent) live in rural areas. As of 2009, the adult literacy rate was 94 percent, with near gender parity. Secondary school enrollment has increased significantly from 32 percent in 1990 to 83 percent in 2010 for girls and from 43 percent to 80 percent for boys.

MATERNAL AND CHILD HEALTH POLICIES

Provision of basic health services and prevention of illness was the cornerstone of China’s early policy with special attention to MCH. Standards and protocols for MCH services were established to address quality of care. Overall, two policies have been very important in China’s context:

Law on Maternal and Infant Health Care (1994): This is the most comprehensive law on maternal and infant health in China. It helped to refocus attention on maternal and child health (MCH) after a decade of slow progress.

China’s One Child Policy (1979): This policy has had a

profound influence on the Chinese society. It contributed to

KEY MESSAGES:

China is on track to achieve MDGs 4 and 5. Early investment in “low-cost, high-impact” services led to considerable gains in reducing maternal and child mortality in the 1960s and 70s.

The 1994 Law on Maternal and Infant Health Care and the Safe Motherhood ”Two Reductions” Program were pivotal in focusing attention on, and improving maternal and neonatal health. Where it covers maternal and child health, the New Cooperative Medical Scheme has helped to reduce gaps in utilization of services.

Ensuring adequate and high quality human resources for health, focusing on improving quality of care, integrated service delivery, and reducing remaining gaps in social services for vulnerable populations are some of the issues China has to address to maintain gains.

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Page 2

HNPGP Knowledge Brief

the already declining fertility rate - reducing it from 2.8 to 1.9 births per woman between 1978 and 1998. The one-child policy has also had some unintended negative consequences, including a skewed gender ratio.

MATERNAL AND CHILD HEALTH PROGRAMS

Programs to manage MCH include the following:

Program to Reduce Maternal Mortality and Eliminate Neonatal Tetanus (2000): Also known as the Safe

Motherhood Program, it promotes hospital-based deliveries. The program provides subsidies to mothers in “national poverty counties” with higher than average maternal mortality and neonatal tetanus. Local capacity building, health education and social mobilization are important pillars of this program. It has also helped to establish referral networks across all tiers of service delivery. In counties where the program was implemented, facility-based births increased by 28 percent between 2000 and 2006. During the same period, MMR declined from roughly 120 to 60 deaths per 100,000 live births; and neonatal mortality declined from 20 to 12 deaths per 1,000 live births. The incidence of neonatal tetanus also declined from 0.5 cases to 0.1 cases for every 1,000 live births. China was declared free of maternal and neonatal tetanus in 2012 by the WHO.

Expanded Program for Immunizations (1978): Established to provide integrated routine immunizations, by 2007 the program covered vaccines for over 20 diseases. However, due to demand and supply side factors, including cost, there were gaps in immunization coverage along socio-economic lines. To address this, in 2007, the Government began to centrally fund the program and made services free. These efforts have helped increase immunizations to 99 percent for both DPT and measles.

Control of Childhood Diseases: The National Children's Respiratory Infection Control Program (1992–1995) and the Diarrheal Disease Control Program (1990–1994) were introduced to address acute respiratory infections and chronic diarrheal disease, which were all major causes of child ill health and mortality in China in the 1990s. The programs promoted use of appropriate technology, systematic training, health education, management, and monitoring to prevent and manage illnesses, especially in rural areas. More recently, China has also prioritized prevention of mother-to-child transmission of HIV.

HEALTH SYSTEM

China’s robust health system has contributed to improving maternal and child health outcomes:

Service Delivery System: One of China’s most critical

pillars in improving MCH has been its well-organized service delivery system, with wide geographic coverage. Beginning from a very weak base in the 1950s, especially

in the rural areas, the government created a three-tier health system serving both urban and rural areas. In rural areas where maternal mortality was highest, the government established Maternal and Child Health (MCH) Stations to improve access and encourage facility-based clean deliveries. By mid-1990s, all counties were required to have MCH specialty hospitals, completing the three-tier MCH structure from village to county level. This has helped to create a chain of command, linking all levels of service provision.

Health Insurance: The New Rural Cooperative Medical

Scheme (NCMS) was introduced in 2003 to reduce financial barriers to inpatient care. Although rural populations had previously been covered by the Rural Cooperative System, which provided free health care, with the collapse of China’s commune system

i, rural

populations lost this coverage. In the rural western provinces of China where MCH components are available, NCMS is associated with an increase in institutional deliveries—from 45 percent in 2002 to 80 percent in 2007. While it has been moderately successful in reducing catastrophic health expenditures, NCMS is criticized for its high deductibles and focus on hospital care.

Overall, out of pocket costs have declined (figure 1) and with increased investment, and rising burden of non-communicable diseases there has been an increase in health expenditure per capita (figure 2).

Monitoring and Accountability: China has one of the

largest networks of women’s and children's health

46

34

0

20

40

60

80

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Figure 1. Out-of-Pocket Health Expenditure (% of total expenditure on health)

52.6

432.3

0

100

200

300

400

500

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Figure 2. Health expenditure per capita, PPP (constant 2005 international $)

HNPGP Knowledge Brief

Page 3

surveillance in the world. Among key sources of information, the MCH reports, produced since the early 1980s, are most comprehensive and are collected from each county. Another key tool for accountability and decision making are Maternal death reviews which were initiated in 2000 with the strong support and involvement of local governments. In the 1990s, China also introduced the “contract responsibility system” and “target responsibility agreements” to monitor and improve supply-side performance. The contract responsibility system primarily

focuses on the EPI and prenatal care, while the target agreements focus on hospital level MCH services.

Figure 3 provides a timeline of MDG 4 and 5 interventions in China.

CREATING AN ENABLING ENVIRONMENT

Improvements in women’s status and education are linked

Figure 3. China: Timeline of MDG 4 and 5 Interventions

58

99

78

61

14 0

10

20

30

40

50

60

70

0

20

40

60

80

100

120

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

de

ath

s p

er

1,0

00

liv

e b

irth

s

%

MDG 4: Under 5 Mortality

DPT Measles U5MR

69.5

89.3

99.1 97

32

0

20

40

60

80

100

120

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

0

20

40

60

80

100

120

death

s p

er

100,0

00 liv

e b

irth

s

%

MDG 5: Maternal Mortality

Contraceptive Prevalence Rate Skilled Birth Attendance Maternal Mortality Ratio

1960–1985

1960: Over 800,000 midwives trained.

Focus on improving hygiene and mass immunizations

1965: "June 26 Directive" calls for

scientific methods in healthcare

Mid-1970s: Barefoot doctors in every

village

1978: Expanded Program for

Immunization (EPI) initiated

1979: One-Child Policy

1980s: Position of Maternal and Child

Health (MCH) clinician created

1984: Operational protocols to

standardize maternal healthcare provision

1985–1999

1986: Ministries of Health and Labor co-

formulate standards for MCH

1990–94: Diarrheal Disease Control

Program

1992–95: National Children's

Respiratory Infection Control Program

1994: Law on Maternal and Infant Health

Care

Mid-1990s: MCH department created; all

counties required having an MCH specialty hospital

1996: Integrated Health Information

System for MCH through merger of existing surveillance systems

2000–2012

2000: Program to Reduce Maternal

Mortality and Eliminate Neonatal Tetanus (“Two Reductions” or Safe Motherhood Program)

2000: Maternal death reviews initiated

2003: NCMS to subsidize health care

costs in rural areas and extended to all counties by 2010

2011: Implementation Guidelines of the Law on Maternal and Child Health

Page 4

HNPGP Knowledge Brief

to improved MCH outcomes. Key developments in China related to education and women’s empowerment are the following:

Early efforts focused on universal primary education and mass adult literacy campaigns. In 1986, free compulsory education for the first nine years of schooling was introduced, with particular focus on the poor and ethnic minority areas.

The government also set a target of eliminating gender inequities in primary and secondary education by 2005. Data show near gender parity in schooling, with the ratio of girls to boys at the primary and secondary levels at 99.9 and 102, respectively.

China legally recognizes men and women as equal. This is enshrined in the Constitution of the People’s Republic of China (1954).

A number of key laws and regulations protect women’s rights. These include the Marriage Law of the People’s Republic of China (1949); the Electoral Law of the People’s Republic of China (1953); Regulations Concerning the Labor Protection of Female Staff and Workers (1988); and the Law of the People’s Republic of China on the Protection of Woman’s Rights and Interests (1992).

In the context of China’s one-party rule, political leadership has been important in identifying and prioritizing long term policy directions for MCH.

Future Challenges

Although considerable gains have been made in improving MCH, some challenges remain. These include the following:

With the emphasis on facility based service delivery, China needs to address shortage of health personnel, especially in rural areas. The capacity of health workers also needs attention. Health sector reforms initiated in 2009 aim to address these issues.

At 70 percent, China has a very high rate of cesarean sections. Addressing the demand and supply side factors associated with this will help to reduce unnecessary financial and health burden.

Migrant workers constitute a particular challenge since they do not have access to the urban medical insurance system or other basic services. The maternal mortality rate among permanent urban residents is 25 compared to 71 per 100,000 among migrant workers. Improving access to services is

critical to improving MCH in this population group.

While major strides have been made to reduce gender disparities, gaps remain. Most women still work in the agricultural sector as unpaid family workers. Wage differentials and other practices such as forced early retirement due to pregnancy put women at a disadvantage, affecting their insurance coverage and other benefits that depend on employment. Closing these socio-economic loopholes will help to strengthen women’s status further, and contribute to better health outcomes for all mothers and children in China.

Note: i. The economic model of collective production and ownership

(particularly in agriculture) that China used from 1950 to 1979.

References Eggleston, Karen, L. Ling, M. Gingyue, M. Lindelow, and A. Wagstaff. 2008. “Health Service Delivery in China: A Literature Review.” Health Economics 17 (2): 149–65. Fang, P., S. Dong, J. Xiao, C. Liu, X. Feng, and Y. Wang. 2009. Regional Inequality in Health and its Determinants: Evidence from China. Health Policy 94: (1): 14–25. Hesketh, T., and W. X. Zhu. 1997. “Maternal and Child Health in China.” BMJ 314: 1898–1900. Liu, X, H. Yan, and D. Wang. 2010. “The Evaluation of ‘Safe Motherhood’ Program on Maternal Care Utilization in Rural Western China: A Difference in Difference Approach.” BMC Public Health 2010 10:566. Long, Q., T. Zhang, L. Xu, S. Tang, and E. Hemminki. 2010. “Utilisation of Maternal Health Care in Western Rural China under a New Rural Health Insurance System (New Co-operative Medical System).” Tropical Medicine & International Health 15 (10): 1365–3156. Xie, Jipan, and William H. Dow. 2005. “Longitudinal Study of Child Immunization Determinants in China.” Social Science & Medicine 61 (3) (August): 601–11.

Short, S.E., and Z. Fengying. 1998. “Looking Locally at China’s One Child Policy. Studies in Family Planning 29 (4): 373-87. Wagstaff, A., M. Lindelow, G. Jun, X. Ling, and Q. Juncheng. 2009. “Extending Health Insurance to the Rural Population: An Impact Evaluation of China’s New Cooperative Medical Scheme.” Journal of Health Economics 28 (1): 1–19. World Bank. 2006. “Public Health: A Case Study of Two Chinese Counties.” World Bank, Washington, DC. Yip, W., and W.C. Hsiao. 2009. “Non-evidence-based Policy: How Effective is China’s New Cooperative Medical Scheme in Reducing Medical Impoverishment?” Social Science & Medicine 68 (2): 201–9. World Development Indicators: www.worldbank.org/data

This HNP Knowledge Brief highlights the key findings from a study by the World Bank on “Maternal and Child Survival: Findings from Five Countries’ Experience in Addressing Maternal and Child Health Challenges” by Rafael Cortez, Seemeen Saadat, Sadia Chowdhury, and Intissar Sarker (forthcoming).

The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health.