Regional Disparities of Under-Five Mortality in China: Issues and Challenges for Improving Child Survival

Abstract

Background: Over the past decade in the Millennium Development Goal Era, China has made great progress at the national level in decreasing the under-five mortality rate, but the progress has varied across China’s regions with different socioeconomic development levels. These regional disparities in the under-five mortality rate (U5MR) raises concerns for improving child survival in the Sustainable Development Goal Era, especially when in depth studies on this particular indicator is absent. This study aimed to examine disparities in child survival and identify factors explaining the regional disparities in the U5MR in China, key lessons, and future priority areas for improving child survival. Methods: This is a mixed methods study using quantitative data from secondary sources, mainly the National Chinese Statistical Yearbooks with some additional quantitative data from the Institute of Health Metrics and grey and peer-reviewed literature. The qualitative data collection involved key informant interviews of maternal and child health (MCH) administrators and practitioners in urban and rural MCH institutions in Yunnan province in China’s western region and Hubei province in the central region. In Yunnan and Hubei we conducted interviews at institutions both at the city level in the capital cities, Kunming and Wuhan respectively, and at the county/district level in Shaungbai and Caidian respectively.Results: Socioeconomic, health-system related, and cultural factors were found to explain the regional disparities of U5MR in China. First was the regional income inequality, with Yunnan’s rural population earning about 50% less than Hubei’s rural population and its U5MR was more than one-third higher than Hubei’s U5MR. The greatest gap of the U5MR existed between the urban and rural areas within regions and also across rural areas in different regions, where the human resources for MCH were unevenly distributed. From 2004 to 2017 Yunnan had 32% increase in human resources for MCH whereas Hubei saw an almost 50% increase. The third factor was caregiver-related in which key informants reported parental awareness and taking preventative measures when taking care of children as reason for regional disparities. Secondary data revealed a disparity amongst children left behind in rural areas compared to their urban counterparts in terms of parental presence which can affect the parental awareness. Key lessons in improving child survival in the MDG era came from health financing with the three main social public health insurance schemes and health service delivery with strict management for mothers with increasing rate of systematic maternal management nationally and regionally. Future priority areas for improving child survival were addressing the health workforce shortage in pediatric and neonatal departments and health promotion and education for all caregivers, including mothers, parents and other family members. Conclusion: Regional disparities in the U5MR revealed rural populations in the western region of China at a great disadvantage in regards to determinants of child survival. Key factors explaining these disparities are clear barriers to improving child survival and highlight the inequities persisting in child health and survival in China. From a human rights perspective, reducing child health disparities and improving child survival in rural areas across and within regions in China will reflect China’s pursuit for health equity in the Sustainable Development Goal era.