92273 Knowledge Brief Health, Nutrition and Population Global Practice ACHIEVING MDGS 4 & 5: CHINA’S PROGRESS ON MATERNAL AND CHILD HEALTH Rafael Cortez, Seemeen Saadat, Intissar Sarker and Shuo Zhang August 2014 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. Introduction people—live under the poverty line; and over half (55 percent) live in rural areas. As of 2009, the adult literacy China has made great progress in improving maternal and rate was 94 percent, with near gender parity. Secondary child health (MCH). It reduced maternal deaths from 1,500 per 100,000 live births and over 200 infant deaths per school enrollment has increased significantly from 32 1,000 live births in 1949 to 120 per 100,000 live births and percent in 1990 to 83 percent in 2010 for girls and from 43 infant deaths to 42 per 1,000 by 1990. Currently China is percent to 80 percent for boys. on track to meet its MDG 5 target of 31 maternal deaths per 100,000 live births, and has already achieved its MDG MATERNAL AND CHILD HEALTH POLICIES 4 target of reducing child mortality to 16 deaths per 1,000 live births (figure 3). This note explores the actions China Provision of basic health services and prevention of illness has taken to reduce child and maternal mortality, focusing was the cornerstone of China’s early policy with special on key policies and programs since the 1990s. 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 context: China, a lower-middle-income country, had a per capita GNI (PPP) of US$ 7,917 in 2012 and an average GNI Law on Maternal and Infant Health Care (1994): This is growth rate of over 10 percent between 2000 and2012. As the most comprehensive law on maternal and infant health of 2010, China had a population of 1.3 billion with a growth in China. It helped to refocus attention on maternal and rate of 0.6 percent. Seventy-two percent of the population child health (MCH) after a decade of slow progress. is in the working-age group (15–64 years of age), with an age dependency ratio of 11 percent. According to national China’s One Child Policy (1979): This policy has had a data, 3 percent of the population—roughly 40 million profound influence on the Chinese society. It contributed to Page 1 HNPGP Knowledge Brief  the already declining fertility rate - reducing it from 2.8 to in the rural areas, the government created a three-tier 1.9 births per woman between 1978 and 1998. The one- health system serving both urban and rural areas. In rural child policy has also had some unintended negative areas where maternal mortality was highest, the consequences, including a skewed gender ratio. government established Maternal and Child Health (MCH) Stations to improve access and encourage facility-based MATERNAL AND CHILD HEALTH PROGRAMS clean deliveries. By mid-1990s, all counties were required to have MCH specialty hospitals, completing the three-tier Programs to manage MCH include the following: MCH structure from village to county level. This has Program to Reduce Maternal Mortality and Eliminate helped to create a chain of command, linking all levels of Neonatal Tetanus (2000): Also known as the Safe service provision. Motherhood Program, it promotes hospital-based Health Insurance: The New Rural Cooperative Medical deliveries. The program provides subsidies to mothers in Scheme (NCMS) was introduced in 2003 to reduce “national poverty counties” with higher than average financial barriers to inpatient care. Although rural maternal mortality and neonatal tetanus. Local capacity populations had previously been covered by the Rural building, health education and social mobilization are Cooperative System, which provided free health care, with important pillars of this program. It has also helped to the collapse of China’s commune system , rural i establish referral networks across all tiers of service populations lost this coverage. In the rural western delivery. In counties where the program was implemented, provinces of China where MCH components are available, facility-based births increased by 28 percent between 2000 NCMS is associated with an increase in institutional and 2006. During the same period, MMR declined from deliveries—from 45 percent in 2002 to 80 percent in 2007. roughly 120 to 60 deaths per 100,000 live births; and While it has been moderately successful in reducing neonatal mortality declined from 20 to 12 deaths per 1,000 catastrophic health expenditures, NCMS is criticized for its live births. The incidence of neonatal tetanus also declined high deductibles and focus on hospital care. from 0.5 cases to 0.1 cases for every 1,000 live births. China was declared free of maternal and neonatal tetanus Figure 1. Out-of-Pocket Health Expenditure in 2012 by the WHO. (% of total expenditure on health) 80 Expanded Program for Immunizations (1978): Established to provide integrated routine immunizations, 60 46 by 2007 the program covered vaccines for over 20 diseases. However, due to demand and supply side 40 factors, including cost, there were gaps in immunization coverage along socio-economic lines. To address this, in 20 34 2007, the Government began to centrally fund the program and made services free. These efforts have helped 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 increase immunizations to 99 percent for both DPT and measles. Control of Childhood Diseases : The National Children's Figure 2. Health expenditure per capita, PPP Respiratory Infection Control Program (1992–1995) and (constant 2005 international $) the Diarrheal Disease Control Program (1990 –1994) were 500 432.3 introduced to address acute respiratory infections and 400 chronic diarrheal disease, which were all major causes of child ill health and mortality in China in the 1990s. The 300 programs promoted use of appropriate technology, 200 systematic training, health education, management, and 100 52.6 monitoring to prevent and manage illnesses, especially in rural areas. More recently, China has also prioritized 0 prevention of mother-to-child transmission of HIV. 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 HEALTH SYSTEM China’s robust health system has contributed to improving Overall, out of pocket costs have declined (figure 1) and maternal and child health outcomes: with increased investment, and rising burden of non- communicable diseases there has been an increase in Service Delivery System: One of China’s most critical health expenditure per capita (figure 2). pillars in improving MCH has been its well-organized service delivery system, with wide geographic coverage. Monitoring and Accountability: China has one of the Beginning from a very weak base in the 1950s, especially largest networks of women’s and children's health Page 2 HNPGP Knowledge Brief  surveillance in the world. Among key sources of focuses on the EPI and prenatal care, while the target information, the MCH reports, produced since the early agreements focus on hospital level MCH services. 1980s, are most comprehensive and are collected from each county. Another key tool for accountability and Figure 3 provides a timeline of MDG 4 and 5 interventions decision making are Maternal death reviews which were in China. 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 CREATING AN ENABLING ENVIRONMENT agreements” to monitor and improve supply-side performance. The contract responsibility system primarily Improvements in women’s status and education are linked Figure 3. China: Timeline of MDG 4 and 5 Interventions MDG 4: Under 5 Mortality 120 70 deaths per 1,000 live births 99 60 100 61 50 80 78 40 % 60 58 30 40 20 20 10 14 0 0 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 DPT Measles U5MR MDG 5: Maternal Mortality 120 120 deaths per 100,000 live births 97 99.1 100 100 80 89.3 80 69.5 60 60 % 40 32 40 20 20 0 0 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 Contraceptive Prevalence Rate Skilled Birth Attendance Maternal Mortality Ratio 1960–1985 1985–1999 2000–2012 1960: Over 800,000 midwives trained. 1986: Ministries of Health and Labor co- 2000: Program to Reduce Maternal Focus on improving hygiene and mass formulate standards for MCH Mortality and Eliminate Neonatal immunizations Tetanus (“Two Reductions” or Safe 1990–94: Diarrheal Disease Control Motherhood Program) 1965: "June 26 Directive" calls for Program scientific methods in healthcare 2000: Maternal death reviews initiated 1992–95: National Children's Mid-1970s: Barefoot doctors in every Respiratory Infection Control Program 2003: NCMS to subsidize health care village costs in rural areas and extended to all 1994: Law on Maternal and Infant Health counties by 2010 1978: Expanded Program for Care Immunization (EPI) initiated 2011: Implementation Guidelines of the Mid-1990s: MCH department created; all Law on Maternal and Child Health 1979: One-Child Policy counties required having an MCH specialty hospital 1980s: Position of Maternal and Child Health (MCH) clinician created 1996: Integrated Health Information System for MCH through merger of 1984: Operational protocols to existing surveillance systems standardize maternal healthcare provision Page 3 HNPGP Knowledge Brief  to improved MCH outcomes. Key developments in China critical to improving MCH in this population group. related to education and women’s empowerment are the following:  While major strides have been made to reduce gender disparities, gaps remain. Most women still work in the  Early efforts focused on universal primary education agricultural sector as unpaid family workers. Wage and mass adult literacy campaigns. In 1986, free differentials and other practices such as forced early compulsory education for the first nine years of retirement due to pregnancy put women at a schooling was introduced, with particular focus on the disadvantage, affecting their insurance coverage and poor and ethnic minority areas. other benefits that depend on employment. Closing  The government also set a target of eliminating gender these socio-economic loopholes will help to strengthen inequities in primary and secondary education by women’s status further, and contribute to better health 2005. Data show near gender parity in schooling, with outcomes for all mothers and children in China. the ratio of girls to boys at the primary and secondary levels at 99.9 and 102, respectively. Note:  China legally recognizes men and women as equal. i. The economic model of collective production and ownership This is enshrined in the Constitution of the People’s (particularly in agriculture) that China used from 1950 to 1979. Republic of China (1954).  A number of key laws and regulations protect women’s References rights. These include the Marriage Law of the People’s Eggleston, Karen, L. Ling, M. Gingyue, M. Lindelow, and A. Wagstaff. 2008. “Health Republic of China (1949); the Electoral Law of the Service Delivery in China: A Literature Review.” Health Economics 17 (2): 149–65. People’s Republic of China (1953); Regulations Fang, P., S. Dong, J. Xiao, C. Liu, X. Feng, and Y. Wang. 2009. Regional Inequality Concerning the Labor Protection of Female Staff and in Health and its Determinants: Evidence from China. Health Policy 94: (1): 14–25. Workers (1988); and the Law of the People’s Republic Hesketh, T., and W. X. Zhu. 1997. “Maternal and Child Health in China.” BMJ 314: of China on the Protection of Woman’s Rights and 1898–1900. Interests (1992). 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 In the context of China’s one-party rule, political leadership Approach.” BMC Public Health 2010 10:566. has been important in identifying and prioritizing long term Long, Q., T. Zhang, L. Xu, S. Tang, and E. Hemminki. 2010. “Utilisation of Maternal policy directions for MCH. 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. Future Challenges Xie, Jipan, and William H. Dow. 2005. “Longitudinal Study of Child Immunization Determinants in China.” Social Science & Medicine 61 (3) (August): 601–11. Although considerable gains have been made in improving MCH, some challenges remain. These include the Short, S.E., and Z. Fengying. 1998. “Looking Locally at China’s One Child Policy. Studies in Family Planning 29 (4): 373-87. following: Wagstaff, A., M. Lindelow, G. Jun, X. Ling, and Q. Juncheng. 2009. “Extending  With the emphasis on facility based service delivery, Health Insurance to the Rural Population: An Impact Evaluation of China’s New Cooperative Medical Scheme.” Journal of Health Economics 28 (1): 1–19. China needs to address shortage of health personnel, especially in rural areas. The capacity of health World Bank. 2006. “Public Health: A Case Study of Two Chinese Counties.” World Bank, Washington, DC. workers also needs attention. Health sector reforms initiated in 2009 aim to address these issues. 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.  At 70 percent, China has a very high rate of cesarean sections. Addressing the demand and supply side World Development Indicators: www.worldbank.org/data factors associated with this will help to reduce unnecessary financial and health burden.  Migrant workers constitute a particular challenge This HNP Knowledge Brief highlights the key findings from a study by the since they do not have access to the urban medical World Bank on “Maternal and Child Survival: Findings from Five insurance system or other basic services. The Countries’ Experience in Addressing Maternal and Child Health Challenges” by Rafael Cortez, Seemeen Saadat, Sadia Chowdhury, and maternal mortality rate among permanent urban Intissar Sarker (forthcoming). residents is 25 compared to 71 per 100,000 among migrant workers. Improving access to services is 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. Page 4