Strategies for Survival and Development of Chinese Children

Strategies for Survival and Development of Children Aged 0–6 in China 中 Acquisitions Editor: Dong Caixuan( 董采萱）国 Executive Editor: Liu Yan（刘燕） Jin Yi（靳奕）

6岁儿童生存中国 0~6 岁儿童生存发展策略发展策 —从证据到行动（英文版）略 — Strategies for Survival and Development 从证 of Children Aged 0–6 in China: 据到 from Evidence to Action 行动︵英文版︶

（金曦）（罗荣）（曹彬） : from Evidence to Action Chief Editors: Jin Xi Luo Rong Cao Bin Robert Scherpbier Guo Sufang（郭素芳）

Department of Maternal and Child Health of the NHC UNICEF China 北京大学医学出版社 National Center for Women and Children’s Health, China CDC

北京大学医学出版社

Peking University Medical Press 中国 0 ~ 6 岁儿童生存发展策略 —从证据到行动（英文版）

Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

Chief Editors: Jin Xi（金曦）, Luo Rong（罗荣）, Cao Bin（曹彬）, Robert Scherpbier, Guo Sufang（郭素芳） Chief Proofreaders: Qin Geng（秦耕）, Song L（i 宋莉）, Zhang Tong（张彤）, Xu Xiaochao（徐晓超）

Department of Maternal and Child Health of the NHC UNICEF China National Center for Women and Children’s Health, China CDC

北京大学医学出版社 Peking University Medical Press ZHONGGUO 0 ~ 6 SUI ERTONG SHENGCUN FAZHAN CELÜE—CONG ZHENGJU DAO XINGDONG(YING WEN BAN)

图书在版编目（CIP）数据

中国0 ~ 6岁儿童生存发展策略：从证据到行动(英文版)＝Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action/ 金曦等主编. - 北京 : 北京大学医学出版社, 2019.3 ISBN 978-7-5659-1956-5

Ⅰ. ①中… Ⅱ. ①金… Ⅲ. ①儿童－保健－英文 Ⅳ. ①R179

中国版本图书馆CIP数据核字(2019)第042195号

Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the publisher, except for brief quotations embodied in critical articles and reviews.

To request permission, please contract Peking University Medical Press at 38 Xueyuan Rd, Haidian District, Beijing 100191, P.R. China, via email at [email protected], or via our website at http://www.pumpress.com.cn

Printed in the People’s Republic of China

中国0~6岁儿童生存发展策略—从证据到行动（英文版）（Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action）主编：金曦罗荣曹彬 Robert Scherpbier 郭素芳出版发行：北京大学医学出版社地址：（100191）北京市海淀区学院路38号北京大学医学部院内电话：发行部 010-82802230；图书邮购 010-82802495 网址：http：//www.pumpress.com.cn E - m a i l ：[email protected] 印刷：北京强华印刷厂经销：新华书店责任编辑：刘燕靳奕责任校对：靳新强责任印制：李啸开本：889 mm×1194 mm 1/16 印张：7.25 字数：185千字版次： 2019年3月第1版 2019年3月第1次印刷书号：ISBN 978-7-5659-1956-5 版权所有，违者必究（凡属质量问题请与本社发行部联系退换） Editorial Board

Chief Editors Jin Xi National Center for Women and Children’s Health, China CDC Luo Rong National Center for Women and Children’s Health, China CDC Cao Bin Department of Maternal and Child Health of the NHC Robert Scherpbier UNICEF China Guo Sufang UNICEF ROSA Office

Chief Proofreaders Qin Geng Department of Maternal and Child Health of the NHC Song Li Department of Maternal and Child Health of the NHC Zhang Tong National Center for Women and Children’s Health, China CDC Xu Xiaochao Department of Maternal and Child Health of the NHC

Board Members (in the alphabetic order) Cao Bin Department of Maternal and Child Health of the NHC Chang Suying UNICEF China Fan Fucheng National Center for Rural Water Supply Technical Guidance, China CDC Gong Limin National Center for Women and Children’s Health, China CDC Guo Sufang UNICEF ROSA Office He Chunhua National Office for Maternal and Child Health Surveillance of China He Zhimin National Center for Women and Children’s Health, China CDC Hu Wenling National Center for Women and Children’s Health, China CDC Huang Xiaona UNICEF China Jin Xi National Center for Women and Children’s Health, China CDC Lai Jianqiang National Institute for Nutrition and Health, China CDC Li Hong Department of Maternal and Child Health of the NHC Liu Yanmin National Immunization Program, China CDC Luo Rong National Center for Women and Children’s Health, China CDC Pan Xiaoping National Center for Women and Children’s Health, China CDC Pang Xuehong National Institute for Nutrition and Health, China CDC Qin Geng Department of Maternal and Child Health of the NHC Qiu Yingpeng China National Health Development Research Center Robert Scherpbier UNICEF China Song Li Department of Maternal and Child Health of the NHC Tao Yong National Center for Rural Water Supply Technical Guidance, China CDC Tian Xiaobo UNICEF China Wang Fang National Center for Women and Children’s Health, China CDC Wang Huaqing National Immunization Program, China CDC Wang Huishan National Center for Women and Children’s Health, China CDC Wang Kun National Center for Women and Children’s Health, China CDC Wang Yanping National Office for Maternal and Child Health Surveillance of China Wu Jing Office of NCD and Community Health, China CDC Wu Jiuling National Center for Women and Children’s Health, China CDC Xiao Yue China National Health Development Research Center Xu Xiaochao Department of Maternal and Child Health of the NHC Yang Yuning UNICEF China Yang Zhenbo UNICEF China Ye Jianli National Center for Women and Children’s Health, China CDC Zhang Tong National Center for Women and Children’s Health, China CDC Zhang Yuhui China National Health Development Research Center Zhao Chunxia UNICEF China Zhao Kun China National Health Development Research Center Zheng Ruimin National Center for Women and Children’s Health, China CDC Zhu Xu UNICEF China Preface

Children are a nation’s hope and future. Childhood is a critical period in a person’s life. Good opportunities and conditions for survival, development, protection and participation are necessary to meet the needs of children and provide them with a solid foundation on which to grow and ultimately realize their potentials. The Government of P. R. China attaches great importance to women and children’s survival and health status, and it has achieved outstanding results in securing women and children’s survival and development, improving the health of women and children, and reducing maternal and child mortality across China. However, every year, China’s child mortality statistic is still a considerable figure given the country’s large population base, and the level of health for China’s children varies between regions of the country, between urban and rural areas, and between communities of the population. The Fifth Plenary Session of the 18th CPC Central Committee decided and approved to allow all couples to have two children. The initiation of the two-child policy has enabled a sharp increase in cumulative birth demand. As a result, the number of live births also has increased, the proportion of advanced maternal age pregnancies has risen, and the risks of maternal comorbidities/complications during pregnancy and birth have grown. All these situations bring new challenges to further reducing the maternal and child mortality and ensuring maternal and child safety.

Under the leadership of the Department of Maternal and Child Health of the National Health Commission of the PRC (NHC) and the support of the China Office of the United Nations Children's Fund (UNICEF), the National Center for Women and Children’s Health of Chinese Center for Disease Control and Prevention (China CDC) set up a study team in 2013 to work on the strategies for survival and development of children aged 0–6 in China. The study team is composed of dozens of experts and researchers in the disciplines of maternal and child health care, nutrition, water and environment, chronic disease prevention, immunization, epidemiology and health statistics, health management, health economics, policy research, and administrative management. The study team comprehensively analyzed the health status of children, provision and utilization of child health care services, key diseases and health issues that may affect children’s survival and health and main factors therein, and the governmental support to child health for children aged 0-6 in China. Referring to leading international experience while maintaining China’s reality at the forefront, the study team analyzed globally-advocated, evidence- based, well-performed and cost-effective strategies and measures for reducing child mortality, protecting children and promoting child development to create the maternal and child health care intervention package, including core interventions aligned particularly to the situations in China. After discussing the cost-effectiveness, drivers and barriers for implementation, and necessary support of environment and resources for the interventions, the study team proposed the strategies and measures for survival and development of children aged 0–6 across China in the coming period. The major seven strategies proposed include: strengthening the training of special personnel, building a sound service network, increasing the child health cost-effectiveness ratio, improving the basic medical care system for children, promoting the maternal and child health care intervention package, accelerating and improving the formulation of relevant policies, and enhancing multi-sector cooperation. This report fully illustrates the idea, methodology and results of study on strategies for survival and development of children aged 0–6 in China. The study results can provide a reference for local governments at all levels to define their respective strategies for enhancing survival and development of children aged 0–6 depending on their particular situations while using the national strategy as a foundation.

Editors December 2017 Contents

Executive Summary...... 1

Background...... 5

Purpose...... 7

Methodology ...... 8

Results...... 10 1 Current Status...... 10 1.1 Child health...... 10 1.2 Provision and utilization of child health care services...... 22 1.3 Factors influencing children’s health...... 24 1.4 Equity analysis ...... 34 1.5 Supportive environment...... 42 2 Interventions and Cost-effectiveness...... 54 2.1 Maternal and child health care intervention package...... 54 2.2 Intervention bottleneck analysis...... 57 2.3 Cost-effectiveness analysis ...... 59 3 Monitoring and Evaluation Indicators...... 65

Strategies and Measures...... 66 • Strategy 1: Strengthen the Capacity Building of Child Medical and Health Care Service Personnel...... 66 • Strategy 2: Reinforce the Construction and Management of the Obstetrics Department and Neonatology Department, and Build a Sound Maternal and Neonatal Service Network...... 67 • Strategy 3: Increase the Input in Child Disease Prevention and Improve the Child Health Input- Benefit Ratio...... 68 • Strategy 4: Further Improve the Basic Medical Care System...... 69 • Strategy 5: Take Step-by-Step Actions to Gradually Extend the Categories and Coverage of Key Services/Measures...... 70 • Strategy 6: Accelerate and Improve the Formulation and Implementation of Relevant Policies...... 71 • Strategy 7: Enhance Multi-sector Cooperation to Ensure the Policies are Effectively Implemented...... 71

Annexes...... 73 Annex 1: Maternal and Child Health Care Intervention Package...... 73 Annex 2: Implementation Channels for Maternal and Child Health Care Interventions...... 77 Annex 3: Maternal and Child Health Care Interventions by Periods...... 85 Annex 4: Bottleneck Analysis for the Maternal and Child Health Care Intervention package...... 89 Annex 5: Evaluation Indicators of the Maternal and Child Health Care Intervention Package...... 95 References...... 103 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

Executive Summary

1 Purpose Executive Summary This report aligns globally-advocated, well-performed and cost-effective strategies and measures for reducing child mortality, protecting children and promoting child development with China’s reality in order to elucidate effective interventions for reducing under-five mortality, preventing child diseases and promoting child development in line with the situations across China. This report also deeply analyzes the drivers and barriers and necessary environment and resources for the implementation of such interventions, and evaluates the implementation results employing the monitoring indicators defined.

2 Methodology Through literature review, expert workshop/consultation, cost-effectiveness analysis and other methods, the status and challenges of child survival and development in China were analyzed, and relevant interventions (or strategies/measures) were summarized. Then, according to the successful practices around the world, the maternal and child health care service package and core interventions were determined, and the strategies for child survival and development in China were generated.

3 Findings and Conclusions 3.1 Child health In the past decade, the health status of children in China improved greatly, but some issues have remained prominent. The mortality statistics of mothers, newborns, infants and children under 5 years of age have declined year after year. However, newborns accounted for the highest proportion in under-five mortality – up to 50.5% in 2015. In 2015, the top three causes for neonatal mortality in China were preterm birth/low birth weight, asphyxia/birth injury, and congenital malformation, and the key five birth defects of perinatal babies included congenital heart disease, toe/finger deformity, cleft lip and palate, talipes equinovarus, and congenital hydrocephalus. In 2014, China’s injury mortality rate was 61.5/100,000 for children aged 0 and 32.2/100,000 for children aged 1–4; moreover, the child injury mortality rate was higher in rural areas than in urban areas and higher for males than for females.

Acute respiratory infection (ARI) and diarrhoea have been the most prevalent infectious diseases threatening children under 5 in China. The incidences of child hepatitis B and epidemic cerebrospinal meningitis (ECM) have decreased year after year. In 2013, the incidence and mortality rate of child measles increased. The rate of stunting among children under 5 has greatly improved, but noticeable differences remain between urban and rural areas. Moreover, the issues of overweight and obesity have become increasingly prominent for children in China. 3.2 Child health care services From 2000 to 2015, China’s postnatal care coverage for children within 28 days of birth climbed from 85.6% to 94.3%. In 2015, the neonatal disease and hearing screening rates were 93.5% and 83.9%, respectively. In 2011, the coverage of “four vaccines” (OPV3, BCG1, DPT3 and MCV1) and “five vaccines” (OPV3, BCG1, DPT3, MCV1 and HepB3) for infants were 98.9% and 98.7%, respectively. In 2015, the inpatient care coverage for under-five deaths was 79.4% nationally, with 82.8% and 77.8% in

1 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

urban and rural areas, respectively. In some remote areas, good quality neonatal health care services and child health care services were less accessible for pregnant women and newborns. 3.3 Factors influencing child health The influencing factors of child health include child nutrition; maternal health status; water, sanitation and hygiene; and women and children’s health literacy. Child malnutrition involves iodine, vitamin-A and zinc deficiencies. In 2006, China’s prevalence of vitamin-A deficiency among children under-five was about 9.1%. In 2012, China’s prevalence of maternal anaemia was 17.2%. By the end of 2015, China’s central water supply coverage and tap water supply coverage in rural areas climbed to 82.0% and 76.0%, respectively. At the end of 2014, China’s proportion of sanitary latrines in rural areas reached 76.1%. The prevalence of endemic diseases, lead poisoning, parasitosis, trachoma or indoor air pollution may be affecting children’s health, growth and development to a certain extent. Health literacy may directly impact children’s health, as demonstrated by pregnant women’s recognition of warning signs for themselves or their children as well as caretakers’ knowledge of optimal infant and young child feeding practices, incorporation of appropriate hygiene behaviours, and recognition of risk factors for child injury. 3.4 Equity analysis The maternal and neonatal mortality rates vary in different areas – higher in rural areas than in urban areas and higher in economically underdeveloped areas than in economically developed areas. From 2000 to 2013, China’s nutritional status of children under 5 was noticeably different between rural areas and urban areas; the child stunting prevalence in rural areas was nearly 2.6 times of that in urban areas, while the child stunting prevalence in rural areas in poverty-stricken areas was 1.7 times of that in ordinary rural areas. Generally, the levels of safe drilling water and proportion of sanitary latrines were lower in rural areas than in urban areas. Certain indicators were higher for migrant than for resident children, like the two-week prevalence of children under 3 with diarrhoea, two-week prevalence of children under 3 with suspected pneumonia, prevalence of children under 3 with stunted growth and prevalence of children at 6–35 months with anaemia. Rural left-behind children have a much higher stunting prevalence than non- left-behind children, and these rural children have lower growth and development conditions compared to urban children. 3.5 Supportive environment At present, China has a relatively complete policy and law system which covers the national macro health policy and special laws and regulations concerning the protection of women and children’s health, as seen in the Maternal and Infant Health Care Law of the PRC, the National Program for Women’s Development in China and the National Program for Child Development in China. Moreover, China has implemented substantial reforms of the medical and health care systems, and carried out major maternal and child public health programs and basic public health care service programs, thereby further enhancing the work of maternal and child health activities. The maternal and child health care service system is improving day by day. The health and infectious disease reporting and injury surveillance systems concerning women and children are developing steadily, thus they are contributing to a stronger capability to survey birth defects, maternal mortality and under-five mortality and report on surveillance of child infectious diseases and child injuries. The government also supports managing the purchase, storage, transportation and distribution of relevant medicines, vaccines and nutritional packages. The government also manages related funds within this and other sectors so as to ensure the provision of material security for maternal and child health care activities. In 2014, the average recurrent health expenditure per child in China was

2 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

RMB2525.5, which was higher than RMB2348.9, the recurrent health expenditure per capita. In addition, health commissions at all levels supervise and assess maternal and child health activities to ensure that all national policies are effectively implemented at local levels. 3.6 Maternal and child health care intervention package and cost-effectiveness analysis Executive Summary A maternal and child health care intervention package was developed. It includes a total of 106 interventions involving six periods, i.e. adolescence period. preconception/pre-marriage period, fetus/ gestation period, birth/delivery period, neonatal/postnatal period, babyhood and childhood period, and the interventions are mainly implemented via eight levels of care, specifically: households; village clinics/ community health care service stations; township hospitals and community health care service centers; medical facilities at the county level or above; communities; schools/nurseries and kindergartens; media; and enterprises, including water, agriculture, environment and transport sectors.

Through screenings, 14 interventions with high effectiveness or cost-effectiveness were selected. The cost and cost-effectiveness of the high-impact interventions were estimated. Promotion and implementation of 14 high-impact interventions across the country during the period of the 13th Five-Year Plan are expected to reduce maternal and child mortality and improve women and children’s health status significantly in China.

4 Strategies and Measures Strategy 1 Strengthen the training of child medical and health care service personnel Measure 1: Strengthen the training of personnel specialized in midwifery, neonatal care and treatment, and child health care services, and establish a long-term training mechanism.

Measure 2: Perform thorough and stepwise training as well as expand the training coverage in order to improve the professional capabilities of service personnel, especially the first-line personnel.

Measure 3: Strengthen the development of neonate-related professional skill training bases.

Strategy 2 Reinforce the construction and management of obstetrics departments and neonatology departments, and build a sound maternal and neonatal service network Measure 1: Reinforce the construction of obstetrics departments and neonatology departments, and improve the capacities of maternal health care, midwifery services and basic neonatal care.

Measure 2: Increase the effort to improve the capacities of prenatal screening, prenatal diagnosis of birth defects and neonatal disease screening.

Measure 3: Enhance capacity building for treatment of maternal and neonatal emergencies and severe cases.

Measure 4: Establish and improve regional maternal and neonatal emergency transfer systems, and create sound green channels for emergencies and severe cases that are able to transfer pregnant women and newborns.

Strategy 3 Increase the input in child disease prevention and improve the child health input-benefit ratio Measure 1: Increase the input in child disease prevention services, especially those provided to poverty-

3 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

stricken areas and low-income people.

Measure 2: Extend the coverage of free child-disease-prevention services, and incorporate more basic child health care services under national free policies.

Strategy 4 Further improve the basic medical care system Measure 1: Establish a basic reproductive service guarantee mechanism for urban and rural residents, and gradually introduce free basic reproductive services throughout the country.

Measure 2: Further improve children’s medical insurance and assistance policies: ensure newborns enjoy basic medical security from birth; improve the insurance compensation policy for children with a serious disease; increase and properly adjust the proportion of reimbursement for child diseases; improve adolescence (out of school) medical insurance policies.

Measure 3: Improve the list of essential drugs for children by incorporating essential medicines for child health care and disease prevention and treatment, such as zinc (for diarrhoea treatment).

Strategy 5 Take step-by-step actions to gradually extend the categories and coverage of key services/ measures Measure 1: Define core interventions for maternal and child health care, specify the contents and implementation standards for the interventions, and promote and implement the interventions in all provinces/municipalities/ autonomous regions across the country during the period of the 13th Five-Year Plan.

Measure 2: Gradually promote the maternal and child health care intervention package, and extend the coverage of interventions; place emphasis on the areas with high mortality and absolute deaths as well as migrant pregnant women and newborns.

Measure 3: Enhance the supervision and management, and regularly supervise and evaluate the implementation of interventions.

Measure 4: Offer extensive health education to improve the continued use of maternal and child health services by clients.

Strategy 6 Accelerate and improve the formulation and implementation of relevant policies Measure 1: Accelerate and improve the formulation of policies to promote early childhood development, adolescent health care, adolescence and adult vaccination, maternal health care, puerperal mental health care, drinking water and lavatory improvement, and other aspects. Measure 2: Implement relevant policies for child injury prevention.

Strategy 7 Enhance multi-sector cooperation to ensure policies are effectively implemented Measure 1: Strengthen stratified and multi-sectoral cooperation by establishing coordination mechanisms between health care facilities at all levels within the health and family planning system as well as between the health and family planning departments and the various sectors including the government, education, media, enterprises, environmental protection, water, community and many others.

Measure 2: Establish a multi-sectoral collaborative prevention and control mechanism for child injuries, and explore the feasibility of the “four-in-one” intervention, which integrates family, school, road and community.

4 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

Background

China has 880 million women and children, comprising two-thirds of the country’s total population. The health of women and children is related to the prosperity and future of the nation, and also the premise and foundation for the population’s sustainability. Childhood is a critical period in a person’s life. Accordingly, providing children with the necessary opportunities and conditions for survival, development, protection and participation will lay a solid foundation for children to grow; enabling their needs to be met so

that they may reach their potentials. Protecting children’s health and reducing child mortality are an Background embodiment of children’s rights.

Since the establishment of the People’s Republic of China, the Chinese Communist Party and the Central Government have attached great importance to the health of women and children by taking a series of actions to improve the level of women and children’s health. For example, the maternal and child health care service system was improved; special national funds were allocated to promote the implementation of effective health interventions with regard to hospital delivery, prenatal care, child health care and immunization for children; programs were carried out to improve child nutrition in poverty-stricken areas; and particular focus was given to children with special needs. During the period of the 12th Five-Year Plan, with progress from the medical and health system reform, China’s overall health level of women and children has improved quickly. According to the 2016 Analysis of Women and Children’s Health in China Report issued by National Health Commission of the PRC (NHC), China’s maternal mortality ratio dropped by 33.8% from 30.0/100,000 in 2010 to 20.1/100,000 in 2015; the neonatal mortality rate and under-five mortality rate fell by 34.9% and 34.8%, from 8.3‰ and 16.4‰ in 2010 to 5.4‰ and 10.7‰ in 2015, respectively. Nevertheless, every year, China’s child mortality statistic is still a considerable figure given the country’s large population base, and the level of health for China’s children varies between regions of the country, between urban and rural areas, and between communities of the population. In particular, 40 million children concentrated in special hardship areas reflect health and education levels much lower than the national average. According to the statistics, in 2015, the neonatal mortality rate and under-five mortality rate in rural areas were 6.4‰ and 12.9‰, respectively, demonstrating 1.9 and 2.2 times the neonatal mortality rate and under-five mortality rate than in urban areas, which were 3.3‰ and 5.8‰, respectively. The comparison of under-five mortality rate among provinces/municipalities/autonomous regions shows that the under-five mortality rate of the province/ municipality/autonomous region with the highest rate is more than 8 times that of the province/municipality/ autonomous region with the lowest rate. If the lowest under-five mortality rate is attained throughout the country, about 268,000 children would be saved every year. In 2015, the deaths of children under-five were primarily caused by preterm birth/low birth weight, asphyxia/birth injury, congenital malformation and pneumonia, and newborns accounted for 50.5% of the deaths for children under-five. In fact, 75% of maternal and child deaths were attributed to causes or diseases that can be prevented or cured.

According to the Child Health Expenditure Accounting in China Study completed by China National Health Development Research Center (CNHDRC), due to health financing limitations, the total health expenditures for children comprise 40% or more of a family’s health expenses. Furthermore, a fairly significant number of basic medical and health care services for women and children are self-paying items, which exacerbate the financial burden on households. Meanwhile, in some areas (especially central and

5 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

western, rural, and former revolutionary base areas), the social and economic development level, medical service capacity, health financing model, cultural customs and other factors hinder the implementation of some effective interventions, thereby impeding the improvement of maternal and child health [1].

The World Health Organization (WHO) is always concerned with the promotion of effective interventions for maternal and child health. In A Global Review of the Key Interventions Related to Reproductive, Maternal, Newborn and Child Health (RMNCH) issued by WHO in 2011, sixty proven-effective interventions were proposed. These pertinent and instructive interventions were designed to further seek a global consensus in order to realize effective allocation of resources and advance the promotion and popularization of high-impact interventions. The RMNCH interventions include low-cost and high- benefit interventions related to neonatal resuscitation, kangaroo mother care, breastfeeding, early initiation of breastfeeding and oral rehydration salts (ORS) therapy as well as some effective interventions for reducing maternal and child mortality, which are widely applicable in China. Currently, relevant measures to improve maternal and child health outcomes are not implemented adequately and evenly across all areas of China, especially in the poverty-stricken and underdeveloped areas; therefore, it is necessary to promote the aforementioned interventions throughout China, especially in the poverty-stricken areas with high maternal and child mortality rates.

In September 2015, the United Nations (UN) announced the Sustainable Development Goals (2015–2030), which include ensuring the health of women and children as a critical task. As one of the main initiating countries, China made a solemn commitment to the international community to fulfill the 2030 Agenda for Sustainable Development. In 2015, the Fifth Plenary Session of the 18th CPC Central Committee proposed the new goal of “Healthy China”, which holds the people’s health at its core and aims to greatly improve health and health equity nationally. In 2014, the General Office of the State Council issued the “National Child Development Plan for Poverty-Stricken Areas (2014-2020)”, which aims for the overall child development level in special hardship areas to be at or near the national average by 2020.

Accordingly, in the next five years, the medical and health systems are committed to reducing the maternal mortality ratio and child mortality rate, promoting child development in poverty-stricken areas, ending the intergenerational transmission of poverty, improving the health of women and children, and encouraging the sustainable development of population health. At present, China is planning and establishing goals related to all national economic and social development sectors for the period during the 13th Five-Year Plan. This research is of practical significance because it presents strategies for improving the survival and development of children in China while aligning with internationally-recommended cost-effective interventions to reduce maternal and child mortalities and taking into account China’s circumstances to promote appropriate healthy child development.

6 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

Purpose

To align globally-advocated, well-performed and cost-effective strategies and measures for reducing child mortality, protecting children and promoting child development with China’s circumstances in order to assess the appropriate interventions for reducing under-five mortality, preventing child diseases and promoting child development across the country; create an in-depth analysis on the drivers and barriers as well as necessary environment and resources needed for the implementation of such interventions; and evaluate the implementation results with the defined monitoring indicators of aforementioned interventions. Purpose

7 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

Methodology

1 Data and Literature Sources Data use in this study were sourced from the websites of China National Maternal and Child Health Surveillance System, UNICEF, WHO, NHC and other organizations, as well as China Health and Family Planning Statistical Yearbook, China Statistical Yearbook, Regional Statistical Yearbook and other health publications. Literature was sourced from databases in Chinese (e.g. China Academic Journal Network Publishing Database (CNKI), VIP Journal Integration Platform (VJIP), and Wanfang Data Knowledge Service Platform), databases in English (e.g. EBSCO, ProQuest, and PubMed), as well as some major Chinese research reports. The information about the surveillance and evaluation indicators for the indicators and the child health expenditures were quoted from the Maternal and Child Health Indicator System Research Report issued by the National Center for Women and Children’s Health and the Expenditure Accounting of Health for Children in China Study issued by the China National Health Development Research Center.

2 Methodology 2.1 Literature review The status and challenges of survival and development of children in China were investigated by reviewing available Chinese and foreign literature as well as Chinese policy documents, projects and specific study reports concerning women and children’s health. China’s current strategies and measures for child survival and development were summarized and compared with other countries’ practices. Using this foundation in combination with relevant international study results, a preliminarily intervention package suitable for China was proposed. 2.2 Expert workshops At each workshop, ten to fifteen maternal and child health experts gathered to test and discuss the study program, the framework of the study report, the intervention and high-impact intervention packages, the intervention bottleneck analysis, and other periodic study results. 2.3 Expert consultation By consulting experts in clinical medicine, public health, maternal and child health care, sexually transmitted infections/AIDS, and other domains, cost estimations related to the target population, population in need, coverage of the intervention package, and medicine and examination items needed for the interventions were determined. 2.4 Methods of cost estimation for the high-impact intervention package (1) Costing. The OneHealth Tool (OHT) was used to build the costing model for the maternal and child health care high-impact intervention package, and the model was developed and operated using parameters obtained through expert consultation.

(2) Effect analysis. OHT was used to analyze the effects of the maternal and child health care high-impact intervention package in reducing child mortality rate and maternal mortality ratio, with the number of preventable deaths as the unit of analysis.

(3) Cost-effectiveness analysis. The cost-effectiveness ratio was analyzed to estimate the cost per

8 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

preventable death.

(4) Scenario analysis. Using the assessed effectiveness and cost-effectiveness, the different implementation levels of the high-impact intervention package were divided. Then, the cost-effectiveness of each implementation level was analyzed in order to provide the basis for actual decision-making. Methodology

9 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

Results

1 Current Status 1.1 Child health 1.1.1 Child mortality rate During 2000 to 2015, China’s neonatal mortality rate declined by 76.3%, from 22.8‰ to 5.4‰, representing an average annual reduction rate of 9.2%, and the under-five mortality rate dropped by 73.0%, from 39.7‰ to 10.7‰, representing an average annual reduction rate of 8.4% (Table 1-1, Figure 1-1). In 2008, China met the 2015 UN Millennium Development Goal for under-five mortality rate. In 2012, China’s under-five mortality rate was lower than the UNICEF-estimated 14‰. In the ranking of under-five mortality rate, from highest to lowest, for 195 countries with relevant traceable data, China ranked 120th; however, due to China’s large population base, China’s under-five mortality rate in 2012 accounted for 4% in the world and 42% in the East Asia-Pacific region[2], and China shared, together with four other countries including India, about half of the world’s under-five deaths. In 2013, China accomplished the goal of lowering the under-five mortality rate below 13‰, as referenced in theNational Program for Child Development in China (2011–2020).

Table 1-1 China’s neonatal and under-five mortality rates in 2000–2015 (‰)

Age 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Neonatal 22.8 21.4 20.7 18.0 15.4 13.2 12.0 10.7 10.2 9.0 8.3 7.8 6.9 6.3 5.9 5.4 Under-five 39.7 35.9 34.9 29.9 25.0 22.5 20.6 18.1 18.5 17.2 16.4 15.6 13.2 12.0 11.7 10.7

Neonatal Under-five Mortality rate (‰)

Year

ழၷЈ neonatal and֗ under-fiveࡧ̿ʾЈቨ൫̒ဋԫӑᡖҹ mortality rates in 2000–2015ڎVariation of China’sࣲЛ ڏFigure 1-1

ݤࣷӼၷᄣ฾ጇፒ Maternal and Child Health Surveillance SystemڎSource: China National஝૶౏ູ὘Л

10 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

1.1.2 Child deaths: by age and cause 1.1.2.1 Under-five deaths by age During 2000 to 2015, China’s neonatal mortality rate dropped continuously at an annual average rate of 9.2%, but the proportion of newborn deaths included in the under-five mortality rate was 50.5%, noticeably higher than 44%, the world’s proportion of newborn deaths in the under-five mortality rate in 2012. Thus, the UN Millennium Development Goals Countdown Committee included China as one of the 35 priority intervention countries with its proportion of newborn deaths in the under-five mortality rate exceeding 40%[3] (Table 1-2).

Table 1-2 China’s distribution of child under-five deaths by age, 2000 and 2015 (%)

Age 2000 2015

Infants* 84.0 75.8 Newborns 62.5 50.5 12–59 months 16.0 24.2 Total 100.0 100.0 * Including newborns. Source: China National Maternal and Child Health Surveillance System

1.1.2.2 Child under-five deaths by cause 1.1.2.2.1 Newborn deaths In the past 15 years, the main killers of newborns in China included preterm birth/low birth weight and asphyxia/birth injury. In 2015, the main causes of newborn deaths were preterm birth/low birth weight

(30.8%), asphyxia/birth injury (25.5%), congenital malformation (15.2%) and pneumonia (8.6%), as Results shown in Table 1-3 and Figure 1-2. Over the past 15 years, the proportions of deaths caused by preterm birth/low birth weight and congenital malformation slightly increased, while the proportions of deaths caused by asphyxia/birth injury and infectious diseases (e.g. pneumonia, diarrhoea and tetanus) decreased. Compared with the global distribution of newborn deaths by cause in 2012, China showed a lower proportion due to meningitis/septicemia and a higher proportion due to congenital malformation and similar other causes (Figure 1-3)[2].

Table 1-3 China’s distribution of newborn deaths by cause, 2000 and 2015 (%)

Cause of death 2000 2015 Whole country Urban areas Rural areas Whole country Urban areas Rural areas

Preterm birth/low birth weight 29.1 28.9 29.1 30.8 28.6 31.3 Asphyxia/birth injury 26.7 31.5 26.2 25.5 24.6 25.7 Congenital malformation 12.6 21.6 11.8 15.2 19.7 14.1 Pneumonia 14.8 8.5 15.3 8.6 8.0 8.7 Diarrhoea 1.4 0.5 1.5 0.5 0.2 0.6 Meningitis/septicemia 1.7 1.2 1.8 2.6 3.9 2.4 Tetanus 0.8 0.0 0.9 0.0 0.0 0.0 Other infectious diseases in newborns 0.0 0.0 0.0 0.2 0.6 0.1 Other diseases 12.9 7.8 13.3 16.6 14.4 17.1 Total 100.0 100.0 100.0 100.0 100.0 100.0

11 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

Other infectious diseases in newborns 0.2%

Other diseases Meningitis/septicemia 2.6% 16.6% Preterm birth/low Diarrhoea 0.5% birth weight 30.8% Pneumonia 8.6%

Congenital malformation 15.2% Asphyxia/birth injury 25.5%

౞ੇڂழၷЈ൫ڎ˗ࣲ ڏ

ݤࣷӼၷᄣ฾ጇፒ distribution of newborn deaths by cause, 2015ڎFigure 1-2 China’s஝૶౏ູ὘Л ౞ੇڂழၷЈ൫ڎ˗ࣲ ڏ Source: China National Maternal and Child Health Surveillance System ݤࣷӼၷᄣ฾ጇፒڎ஝૶౏ູ὘Л

Diarrhoea 2.0% Tetanus 2.0% Other causes 6.0% Congenital malformation 9.0%

Preterm birth 34% Pneumonia 10.0%

Sepsis/meningitis 12.0% Labor complications 24.0%

౞ੇ of newborn deaths by cause, 2012ڂdistributionࣲЛုழၷЈ൫ ڏFigure 1-3 Global

஝૶౏ູ὘"1SPNJTF3FOFXFE1SPHSFTT3FQPSU6/*$&'Source: Promise Renewed Progress Report 2013 UNICEF ౞ੇڂࣲЛုழၷЈ൫ ڏ

஝૶౏ູ὘"1SPNJTF3FOFXFE1SPHSFTT3FQPSU6/*$&'

12 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

According to WHO’s “Born Too Soon: The Global Action Report on Preterm Birth, 2012” [4], about 15 million babies were born too early worldwide, representing a preterm birth rate of 11.1%, and more than 1 million died due to complications. In China, there are no available data providing an extensive epidemiological survey on preterm births, but multiple studies have revealed that China’s incidence of preterm births is rising year by year. Studies also have shown that preterm birth is the leading cause of child death in China, in urban and rural areas. In 2010 to 2011, the incidence of preterm births reached 9.9% according to a survey conducted in 52 hospitals in 23 provinces/municipalities/autonomous regions[5]. The higher preterm birth rate in recent years has been closely linked to social factors, environmental exposure, application of assisted reproductive technology, increase of multiple births, higher number of obstetric interventions, and the development of perinatal medical technology. Therefore, it is necessary to further expand the coverage of interventions for preterm births. On one hand, the provision and utilization of maternal health care services should be improved. In order to reduce the incidence of preterm births, periodic antenatal care services should be provided to pregnant women, especially older pregnant women, and proactive actions should be taken to prevent complications and comorbidities of pregnancy. On the other hand, the level of treatment and care for preterm births should be improved in order to end complications like asphyxia, neonatal respiratory distress syndrome and infectious pneumonia that may result in death of the newborns. To reduce preterm-specific mortality, proper efforts should be made to guarantee the implementation of basic newborn health care interventions for preterm infants, such as early initiation of breastfeeding, exclusive breastfeeding and kangaroo mother care.

Since 2002, China has implemented the “Reducing Maternal Mortality and Eliminating Neonatal Tetanus Project” in rural areas and achieved remarkable results. In 2012, WHO announced that China eliminated neonatal tetanus. Since 2004, the former Ministry of Health of the PRC has implemented the Neonatal Results Resuscitation Programme in 20 provinces where the aforementioned program was performed in order to promote the appropriate neonatal resuscitation techniques. As a result, birth asphyxia has fallen from the first to the second cause of death of newborns in urban areas and the whole country. In China in 2014, newborn deaths caused by birth asphyxia declined by 7.1% from 2000; however, due to China’s large population base with a newborn population of 16.87 million in 2014, newborn deaths from birth asphyxia reached 24,684, indicating that there is still room for a significant reduction in mortality from birth asphyxia. 1.1.2.2.2 Deaths among infants at 1–11 months In 2015, the main causes of death of infants from 1–11 months in China included congenital malformation (24.4%), pneumonia (27.7%), injury (14.6%) and diarrhoea (8.1%). As compared with the data in 2000, the proportions of deaths from congenital malformation and injury increased, and the injury-specific deaths mainly occurred in rural areas; the proportions of deaths from pneumonia and diarrhoea decreased (Table 1-4, Figure 1-4).

13 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

Table 1-4 China’s distribution of deaths among infants at 1–11 months by cause, 2000 and 2015 (%)

2000 2015 Cause of death Whole country Urban areas Rural areas Whole country Urban areas Rural areas

Congenital malformation 13.0 40.0 11.5 24.4 29.4 23.3 Pneumonia 35.6 21.9 36.3 27.7 18.5 29.5 Diarrhoea 15.2 2.9 15.9 8.1 1.6 9.4 Injury 11.5 6.7 11.8 14.6 14.5 14.6 Meningitis/cerebritis 3.0 1.0 3.1 1.4 0.8 1.5 Measles 0.2 0.0 0.3 0.3 0.8 0.2 Tetanus 0.2 0.0 0.3 0.0 0.0 0.0 Other infectious diseases 3.5 6.7 3.3 3.1 4.8 2.8 NCD 12.8 17.1 12.5 12.6 17.7 11.6 Other diseases 5.0 3.8 5.1 7.9 11.7 7.1 Total 100.0 100.0 100.0 100.0 100.0 100.0

Other diseases 7.9% NCD 12.6%

Congenital Other infectious diseases 3.1% malformation 24.4%

Measles 0.3% Injury 14.6% Pneumonia Meningitis/cerebritis1.4% 27.7% Diarrhoea 8.1%

Figure 1-4 China’s distribution of deaths among infants at 1–11 months by cause, 2015

౞ੇ Surveillance Systemڂand Child HealthథᴔޯЈ൫ ڎ˗Maternalࣲ ڏSource: China National ݤࣷӼၷᄣ฾ጇፒڎ஝૶౏ູ὘Л

1.1.2.2.3 Deaths among children aged 1–4 In 2015, the main causes of death for children aged 1–4 in China included injury (50.9%), noninfectious chronic diseases (NCDs) (19.2%), congenital malformation (9.2%) and pneumonia (9.2%), as shown in Table 1-5 and Figure 1-5. In recent years, injury has been the top cause of death among children aged 1–4, and its proportion has increased slightly to 50.9% from its level in 2000, suggesting the urgency of implementing child injury interventions. Meanwhile, the proportion of deaths caused by NCDs increased, especially in urban areas where NCDs have become the leading cause of child death. Although the proportion of deaths caused by infectious diseases, such as pneumonia and diarrhoea, has declined, they still remain a leading cause of death for children age 1 year and older.

14 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

Table 1-5 China’s distribution of deaths among children aged 1–4 by cause, 2000 and 2015 (%)

2000 2015 Cause of death Whole country Urban areas Rural areas Whole country Urban areas Rural areas

Injury 45.4 32.9 46.0 50.9 41.7 52.3 Pneumonia 16.8 2.6 17.5 9.2 7.7 9.5 Diarrhoea 8.6 2.6 8.9 2.6 1.8 2.7 Congenital malformation 7.8 19.7 7.2 9.2 10.7 8.9 Meningitis 4.1 3.9 4.1 2.1 1.2 2.2 Measles 0.0 0.0 0.0 0.0 0.0 0.0 Other infectious diseases 2.2 3.9 2.1 3.7 6.5 3.3 NCD 14.4 34.2 13.4 19.2 26.2 18.2 Other diseases 0.7 0.0 0.7 3.1 4.2 2.9 Total 100.0 100.0 100.0 100.0 100.0 100.0

Other diseases 3.1% NCD 19.2% Results

Other infectious diseases 3.7%

Injury 50.9%

Congenital malformation Meningitis 2.1% 9.2%

Pneumonia Diarrhoea 9.2% 2.6%

Figure 1-5 China’s distribution of deaths among children aged 1–4 by cause, 2015 ౞ੇڂࡧЈቨ൫ ڎ˗ࣲ ڏ Source: China National Maternal and Child Health Surveillance System ݤࣷӼၷᄣ฾ጇፒڎ஝૶౏ູ὘Л

15 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

1.1.3 Birth defects In 2015, congenital heart disease (CHD), toe/finger deformity, cleft lip and palate, talipes equinovarus and congenital hydrocephalus were the top five most prevalent birth defects among perinatal babies, with incidences of 66.5/10,000, 18.1/10,000, 7.4/10,000, 6.2/10,000, and 5.3/10,000, respectively. Since 2005, CHD has been the most prevalent birth defect among perinatal babies in China, and its incidence in 2015 was 27.7% higher than that in 2014. 1.1.4 Child injuries 1.1.4.1 Total injury mortality rate In 2014, China’s injury mortality rate among children aged 1-11 months and among children aged 1–4 was 61.5/100,000 and 32.2/100,000, respectively. Based on the number of infants aged 1–11 months and children aged 1–4 reported in the population census in 2010 in China, it is estimated that 8,479 infants aged 1–11 months and 19,882 children aged 1–4 die annually from injuries. The child injury mortality rate was much higher in rural areas than in urban areas and higher for males than for females (Figure 1-6 and Figure 1-7).

100.0 90.0 80.0 ᶴ 70.0 ᡀ 60.0 82.9 80.2 ∄ 50.0 40.0

%Proportion (%) 30.0 20.0 10.0 17.1 19.8 0.0 01-4 Age group

Urban areas Rural areas

Figure 1-6 China’s distribution of injury mortality among children under-five in urban areas and rural ࡧ̿ʾЈቨ͞ࠏ൫̒ۢ˹౞ੇڎ˗ࣲ ڏ areas, 2014 ᄣ฾ጇፒڂ൫ڎ஝૶౏ູ὘ ࣲЛ Source: National Cause of Death Surveillance System 2014

16 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action Proportion (%)

Age group ࡧ̿ʾЈቨ͞ࠏ൫̒ভѿ౞ੇMale Femaleڎ˗ࣲ ڏ

ᄣ฾ጇፒڂ൫ڎ஝૶౏ູ὘ ࣲЛ ࡧ̿ʾЈቨ͞ࠏ൫̒ভѿ౞ੇ mortality among children under-five by gender, 2014ڎdistribution ࣲ˗ of injury ڏFigure 1-7 China’s

ᄣ฾ጇፒ Surveillance System 2014ڂ൫ڎSource: National஝૶౏ູ὘ Cause of DeathࣲЛ

1.1.4.2 Causes of child injury mortality According to the 2014 National Cause of Death Surveillance System, the top five causes of injury mortality among children aged 0, in descending order of severity, included: unintentional asphyxia, road injury, falling, drowning and poisoning; unintentional asphyxia accounted for 67.0% of all deaths in the 0 age group (Figure 1-8). Moreover, the top five causes of injury mortality among children aged 1–4, in Results descending order of severity, included: drowning, road injury, falling, poisoning and fire (Figure 1-9). Drowning was the leading cause of injury mortality among children aged 1–4, with a mortality rate of 13.0/100,000. Based on the number of children aged 1–4 in 2010 in China, it is estimated that 8,008 children aged 1–4 die from drowning every year.

Intentional injury 1.7% Others 5.4% Accidental poisoning Road 2.5% Accidental falling 5.4% accident 13.0%

Fire 0.8% Drowning 4.2%

Unintentional asphyxia 67.0%

౞ੇ injury mortality among children aged 0 by cause, 2014ڂЈ͞ࠏ൫ޯڎofࣲЛ ڏFigure 1-8 China’s distribution

ᄣ฾ጇፒڂ൫ڎ஝૶౏ູ὘ ࣲЛ ౞ੇ of Death Surveillance System 2014ڂЈ͞ࠏ൫ޯڎNational CauseࣲЛ ڏ:Source ᄣ฾ጇፒڂ൫ڎ஝૶౏ູ὘ ࣲЛ 17 ࡧЈቨၷߛԧ࡙ኖ႕úṵ́᝽૶҂ᛡүStrategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Actionڎ˗ƾ

Others 16.6% Intentional injury 0.9%

Road accident 27.6%

Accidental poisoning 3.5% Drowning 40.3% Accidental falling 9.6%

Fire 1.5%

౞ੇ among children aged 1–4 by cause, 2014ڂof injury mortalityࡧЈቨ͞ࠏ൫ ڎdistribution ࣲЛ ڏFigure 1-9 China’s

ᄣ฾ጇፒ of Death Surveillance System 2014ڂ൫ڎSource:஝૶౏ູ὘ National CauseࣲЛ

1.1.5 Child diseases 1.1.5.1 Acute respiratory infection (ARI) and diarrhoea ARI and diarrhoea are the leading infectious diseases among children under age five in China. According to the China National Health Services Survey (2013) [6], the total two-week prevalence of diseases among children under age five was 10.6%, with 11.5% in urban areas and 9.9% in rural areas. To be specific, the prevalence of these infectious diseases in the one-year-old age group was the highest – up to 12.5%. The prevalence of these diseases in the zero-year-old age group was higher in rural areas than in urban areas, while the prevalence of these diseases in other age groups was the opposite: higher in urban areas than in rural areas (Table 1-6).

The two-week prevalence of ARI among children under age five was 8.6%. Specifically, the prevalence of the one-year-old age group was the highest – up to 10.0%, and it was similar in both urban areas and rural areas, being 10.0% and 10.1%, respectively. Therefore, in either urban or rural areas, children aged 1–2 should be considered as the key group for prevention and control of ARI. The two-week prevalence of diarrhoea among children under age five was 0.6%, and it was slightly higher in rural areas than in urban areas (Table 1-7).

Table 1-6 Two-week prevalence of diseases among children under 5 in the survey areas (%)

Urban areas Rural areas Age Total Subtotal Eastern Central Western Subtotal Eastern Central Western

0 9.6 8.7 6.2 7.8 11.5 10.4 10.6 12.0 9.0 1 12.5 12.9 11.7 11.2 15.6 12.2 17.0 13.0 7.4 2 11.0 13.4 11.5 9.8 18.1 9.3 12.3 9.0 7.3 3 11.1 13.1 10.6 10.9 17.0 9.6 12.3 9.6 7.6 4 8.4 9.4 9.8 5.8 12.7 7.7 10.8 8.1 4.7 Total 10.6 11.5 9.9 9.1 14.9 9.9 12.7 10.3 7.2 Source: Analysis Report of the National Health Services Survey in China (2013)

18 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

Table 1-7 Two-week prevalence of ARI and diarrhoea among children under 5 in the survey areas (%)

Urban areas Rural areas Age Total Subtotal Eastern Central Western Subtotal Eastern Central Western ARI 8.6 9.7 7.8 8.2 12.5 7.9 10.5 8.1 5.5 0 7.2 6.8 4.5 6.5 9.1 7.5 7.1 8.4 7.2 1 10.0 10.0 7.8 9.6 12.0 10.1 14.6 10.5 5.9 2 9.3 11.7 10.3 8.4 15.8 7.7 11.3 6.9 5.7 3 9.3 11.9 9.2 10.9 14.9 7.5 9.8 8.0 5.3 4 7.0 8.0 7.7 5.4 10.9 6.3 9.1 6.7 3.6 Diarrhoea 0.6 0.5 0.7 0.3 0.7 0.6 0.6 0.6 0.7 Source: Analysis Report of the National Health Services Survey in China (2013)

1.1.5.2 Infectious diseases China has made great achievements in the reduction of preventable infectious disease. There has been no local wild-type poliovirus case found in China since September 1994, when the last case occurred. 1.1.5.2.1 Hepatitis B, measles and epidemic cerebrospinal meningitis (ECM) According to the 2006 HBV Sero-epidemiological Survey Report for People in China [7], the HBSAg prevalence among people in China dropped from 9.8% in 1992 to 7.2% in 2006, and the HBSAg prevalence among children aged 1–4 and 5–14 decreased from 9.7% and 10.2% in 1992 to 1.1% and 2.1% in 2006, respectively. According to the analysis of the HBV epidemiological survey reported on the website of the China Information System for Disease Control and Prevention in 2010, the acute hepatitis B incidence in China for the whole population declined from 7.5/100,000 in 2005 to 5.6/100,000 in 2010; the proportion of reported cases from children under 15 years old fell from 5.6% to 1.9% [8], and the Results incidence of acute hepatitis B among children under 15 years old declined from 1.2/100,000 in 2005 to 0.5/100,000 in 2010.

According to the Nine Provinces’ Measles Surveillance System Report, the incidence of measles across China in 2000 was 6/100,000 [9]. In 2010, the measles vaccine intensive immunization activities were conducted throughout the country, and a total of 103 million children were vaccinated. In 2011, the reported measles incidence across the country was 0.7/100,000 [10], which was 87.7% lower than that in 2000. Children under one year old and aged 2–6 accounted for 53.9% and 13.4% of the total cases, respectively. In 2013, however, the reported national measles morbidity and mortality increased by 344.9% and 200.0%, respectively, suggesting it is a great challenge to eliminate measles. Since the 1980s when nationwide coverage of Group A meningococcal polysaccharide vaccine (MPV) was first promoted, ECM incidence has declined year after year[11] – below 0.2/100,000 in 2000 and below 0.05/100,000 in 2009.

All these achievements are closely related to the continuous improvement of China’s child immunization policies. In 2000, China proposed the goal of universal child immunizations to control and eliminate infectious diseases while also working towards consolidating and maintaining high immunization coverage nationally. China has achieved this goal in provinces, counties and townships by reaching 85% coverage for child immunizations. In December 2001, the State Council approved the incorporation of the hepatitis B vaccine into the immunization programme for children. As a critical part to deepen the reform of the medical and health system and achieve equity of public health care services nationally, hepatitis B

19 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

vaccination was performed in three consecutive years from 2009 to 2011 for the nonimmunized population born between 1994 and 2001, namely, the population under 15 years of age. In 2010, the program of prevention of mother to child transmission (PMTCT) was initiated to prevent transmission of the human immunodeficiency virus (HIV), syphilis and/or hepatitis B from mother to child. In addition to hepatitis B vaccination for newborns, the hepatitis B immunoglobulin immunization was promoted throughout the country, thus further enhancing the PMTCT of hepatitis B. 1.1.5.2.2 Mother to child transmission (MTCT) of HIV and syphilis In recent years, China’s PMTCT of HIV and syphilis was not ideal. Due to the large population coupled with the rapid expansion of work coverage and the impact of disease outbreaks, the number of infected pregnant women was significant and increasing year after year. Despite this, the MTCT rate of HIV dropped from 34.8% before the initiation of PMTCT to 6.1% after the initiation of PMTCT in 2014. Since the integrated PMTCT of HIV, syphilis and hepatitis B was started in 2010, the increasing trend of reported congenital syphilis cases has turned around and has been decreasing consistently over the past three years. In 2014, the reported incidence of congenital syphilis was 61.6 per 100,000 live births, down from 22.0% in 2011. 1.1.5.2.3 Other infectious diseases In 2012, the outbreak of hand-foot-and-mouth disease (HFMD) led to 2,168,737 children being infected and 567 deaths, yielding a case fatality rate of 2.6/10,000. This outbreak caused HFMD to be recorded as a Class-C infectious disease causing many deaths; therefore, it is essential to create HFMD immunization and prevention strategies. 1.1.5.3 Newborn phenylketonuria (PKU) and congenital hypothyroidism (CH) The national neonatal disease screening in 2012 revealed 879 PKU-affected babies, with an incidence of 0.7/10,000, and 5,004 CH-affected babies, with an incidence of 3.8/10,000. The high incidence of PKU occurred mainly in northwestern China, including Qinghai, Ningxia, Gansu and Inner Mongolia; among which, Qinghai had the highest prevalence with up to 3.7/10,000. The high incidence of CH was concentrated in southern China and eastern coastal areas; especially, with Zhejiang and Fujian provinces having the highest incidence, being 6.2/10,000 and 5.8/10,000, respectively. 1.1.5.4 Child disabilities The Second National Sampling Survey of Disability demonstrated that, in 2006, there were 1,678,000 disabled children aged 0–6, with a prevalence of 1.7%. The number of children with disabled eyesight, hearing, speaking, body, intelligence and mentality was 97,000, 137,000, 540,000, 314,000, 1,188,000 and 111,000, respectively. 1.1.6 Nutritional status 1.1.6.1 Prevalence of stunting among children under five years old In recent years, the prevalence of stunting among children under five years old dropped greatly in China, especially in rural areas. In 2013, the prevalence of stunting was 8.1%, dropping from 20.0% in 2000. Specifically in urban areas, stunting was 4.3% and remained relatively stable from 2000 to 2013. In rural areas, a substantial drop in stunting prevalence was seen, changing from 25.3% in 2000 to 11.2% in 2013. In poor rural areas, prevalence of stunting also decreased substantiallg, from 36.9% in 2000 to 18.7% in 2013[12], as shown in Figure 1-10.

20 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

40 36.9 35 ⭏ 30 25.3 䮯 4025 36.9 䘏 20.0 20.9 20.3 35 18.7 㕃 20 16.3 30 13.0

⭏⦷( 15 25.3 12.1 11.2 䮯 9.9 %) 2510 8.1 䘏Prevalence of stunting(%) 20.0 20.9 20.3 4.1 3.4 4.3 18.7 㕃 205 3.16.31 13.0 ⦷( 150 12.1 9.9 11.2 Year 2000 2005 2010 2013 %) 10 8.1 4.1 4.3 5 Whole country Urban3.1 areas Rural 3.areas4 Poor rural areas Figure 1-10 Prevalence0 of stunting among children under 5 in urban areas and rural areas by years 2000 2005 2010 2013 andˀՏࣲएۢ Nutrition Surveillance˹ Systemࡧ̿ʾЈቨၷ᫂ᤍᎁဋඋᣗ and Chinese Resident Nutrition and Health Surveillance ڏSource: Chinese Food

ࡐඟᖹЩˁϤक࿄цᄣ฾ڎ˗ࠒᮼྭˁᖹЩᄣ฾ጇፒ֗ڎ஝૶౏ູ὘

ˀՏࣲएۢ˹ࡧ̿ʾЈቨၷ᫂ᤍᎁဋඋᣗ ڏ

ࡐඟᖹЩˁϤक࿄цᄣ฾ of overweight/obesity among children under five years oldڎ˗ࠒᮼྭˁᖹЩᄣ฾ጇፒ֗ڎPrevalence஝૶౏ູ὘ 1.1.6.2 From 2000 to 2010, the prevalence of overweight children under 5 grew quickly in China. In urban areas, the issue of overweight and obese children became increasingly severe, and the prevalence of overweight children among those who are under 5 climbed from 3.6% to 8.5%. Meanwhile, in rural areas, overweight Results and obese children also gradually emerged as serious problems, and the prevalence of overweight children among those under five years old increased from 2.9% to 6.5%[13] , as shown in Figure 1-11.

10 8.5 8 6.5 䎵 106 5.4 䟽 8.5 ⦷ 4.0 ( 8 3.6 4 2.9 %) 6.5 䎵 5.4 䟽 62 ⦷ 4.0 ( 3.6 40 2.9

%) 2000 2005 2010 2 Prevalence of overwerght(%) 0 Year 20ˀՏࣲएۢ00 ˹ࡧ̿ʾЈቨᡔ᧘ဋඋᣗ2005 2010 ڏ

ࠒᮼྭˁᖹЩᄣ฾ጇፒ Urban areas Rural areasڎ஝૶౏ູ὘ Figure 1-11 Prevalence of overweight among children under 5 in urban areas and rural areas by years ˀՏࣲएۢ˹ࡧ̿ʾЈቨᡔ᧘ဋඋᣗ ڏ Source: Chinese Food and Nutrition Surveillance System ࠒᮼྭˁᖹЩᄣ฾ጇፒڎ஝૶౏ູ὘

21 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

1.1.6.3 Anaemia Anaemia, especially iron-deficiency anaemia, is a common nutritional deficiency disease affecting children in China. It is more prevalent in rural areas than in urban areas. Anaemia prevalence is the highest for children at 6–24 months, sees a plateau for children aged 2–3, and decreases gradually for children over 3 [14]. From 2000 to 2005, the prevalence of anaemia among children under 5 in China lingered between 19% and 23%. Since 2005, the prevalence has dropped – from 19.3% to 12.6% in 2010, falling by 8.8% from 11.3% to 10.3% in urban areas and by 39.3% from 21.9% to 13.3% in rural areas (Figure 1-12).

30 25.8 25 22.6 21.9 䍛 20.8 19.3 㹰 20 18.8 ᛓ 13.3 ⯵ 15 12.9 12.7 12.6 11.3 10.3

⦷( 10

%) 5 Prevalence of anaemia(%) 0 Year 2000 2002 2005 2010 ᒤ

Urban areas Rural areas Whole country

Figure 1-12 Prevalence of anaemia among children under 5 in urban areas and rural areas by years ˀՏࣲएۢ˹ࡧ̿ʾЈቨ᠒ᛞ৤Ⴡဋඋᣗ ڏ Source: Chinese Food and Nutrition Surveillance System and China’s Resident Nutrition and Health Surveillance ࡐඟᖹЩˁϤक࿄цڎ˗ࠒᮼྭˁᖹЩᄣ฾ጇፒ֗ڎ஝૶౏ູ὘

1.2 Provision and utilization of child health care services 1.2.1 Coverage of child health care services 1.2.1.1 Postnatal care for newborns within 28 days and neonatal disease screening From 2000 to 2015, the postnatal care coverage for newborns within 28 days in China rose from 85.6% to 94.3% (95.2% in urban areas and 93.6% in rural areas). In 2014, the screening rate for phenylketonuria, congenital hypothyroidism and neonatal hearing in China was 89.7%, 89.6% and 77.4%, respectively. 1.2.1.2 Infant and young child feeding According to the 5th National Health Services Survey in China (2013), the breastfeeding rate in survey areas was 84.6% in 2013.

In addition to breastfeeding, solid, semisolid or soft foods are often introduced to babies at 6–8 months. In 2013, 49.2% of children were properly introduced to solid, semisolid or soft foods at 6–8 months; the proportion was higher in rural areas (51.1%) than in urban areas (46.6%), and the highest proportion was observed in rural areas in central China, being 56.6% (Table 1-8).

22 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

Table 1-8 Infant and young child feeding in survey areas (%)

Urban areas Rural areas Indicator Total Subtotal Eastern Central Western Subtotal Eastern Central Western China China China China China China

Breastfeeding 84.6 83.5 86.2 79.6 85.0 85.4 87.0 79.4 89.7 Introduction of solid, semisolid or soft foods at 6–8 months 49.2 46.6 40.6 48.8 49.2 51.1 45.0 56.6 51.2

1.2.1.3 Childhood immunization According to the National Immunization Coverage Survey in China after the integration of more vaccines (Type I Vaccines) into the EPI was carried out in 2011 [15], the immunization coverage of 3 doses of oral poliomyelitis attenuated live vaccine (OPV3), 1 dose of bacillus calmette guerin (BCG1), 3 doses of combined diphtheria-pertussis-tetanus (DPT3), 1 dose of measles containing vaccine (MCV1) and 3 doses of hepatitis B vaccine (HepB3) (the former four vaccines are referred to as “Four Vaccines”, and all five vaccines are referred to as “Five Vaccines” hereinafter) were 99.7%, 99.8%, 99.4%, 99.4% and 99.5%, respectively, and the immunization coverage of the Four Vaccines and Five Vaccines were 98.9% and 98.7%, respectively.

Based on the above-mentioned survey, the household survey [16] was completed for 4,681 children aged 1–2. The results indicated that 61.4% of these children were vaccinated with Type II vaccines like varicella (live) vaccine, 46.9% with the varicella (live) vaccine, 45.3% with the Haemophilus influenzae Type B conjugate vaccine, 23.7% with the oral live rotavirus vaccine, and 9.9% with the seven-valent

pneumococcal conjugate vaccine. Results 1.2.2 Utilization of child health care services 1.2.2.1 Two-week medical consultation for children under age five According to the 5th National Health Services Survey in China (2013), the treatment rate of children under age five under the guidance of doctors was 86.2% (84.2% in urban areas and 87.9% in rural areas). 1.2.2.2 Antemortem medical consultation of children under age five According to the 2016 Report on Analysis of Women and Children’s Health in China, in 2015, the antemortem medical consultation coverage (including inpatients and visits) of children under age five in the whole country, urban areas and rural areas were 79.4%, 82.8% and 77.8%, respectively. The proportion of children under age five with antemortem medical consultation across the whole country increased from 83.1% in 2000 to 87.8% in 2015, but there still remained 12.2% of children under age five without antemortem medical consultation in 2015. 1.2.3 Accessibility to health care services According to the 5th National Health Services Survey in China (2013), 63.9% of households were less than 1,000 m away from the nearest medical and health facilities, and 3.4% of households were more than 5,000 m away from the nearest medical and health facilities. The proportion of urban residents with a distance to the nearest medical and health facilities less than 1,000 m was 71.0%, higher than 56.7% in rural areas. China’s medical insurance coverage reached 88% and 96% in 2008 and 2011, respectively; however, in 2008, the medical insurance coverage among infants and young children was only 50%, and the hospital reimbursement ratio was lower than 50%. The proportion of medical expense in a family’s total expenditure grew from 12% in 2008 to 12.9% in 2011; the proportion of medical expense for pregnant

23 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

women in a poor family climbed to 35%, while that in a rich family reduced to 20%. Due to direct or indirect expenses (e.g. delivery cost, travelling expense and accommodation fee), the hospital delivery rate in Tibet and Liangshan of Sichuan province remained below 50%.

In some ethnic minority areas and remote mountainous areas, many pregnant women rejected antenatal care and hospital delivery due consideration of their customs and local culture. 1.2.4 Quality of neonatal health care services The National Centre for Women and Children’s Health, China CDC, made a survey on midwifery facilities within China in 2010. The results showed that, among the facilities surveyed, 59.9% could offer essential neonatology services, 30% could offer comprehensive neonatology services, 15.1% could offer both essential obstetrics services and essential neonatology services, and 24.5% could offer comprehensive obstetrics services and comprehensive neonatology services.

1.3 Factors influencing children’s health 1.3.1 Malnutrition 1.3.1.1 Iodine deficiency Iodine deficiency of pregnant women, lactating women or infants will lead to severe threats to children’s birth and survival, such as abortion, stillbirth, congenital malformation, high perinatal mortality, goitre, congenital hypothyroidism, cretinism, intellectual dysplasia, and physical dysplasia. China started to implement universal salt iodization (USI) in 1995. Throughout the country, the coverage of iodized salt increased from 39.9% in 1995 [17] to 96.6% in 2010 [18], and the goitre rate among children aged 8–10 dropped continuously – from 20.4% in 1995 to 4.4% in 2010. Thus, the goal of ending iodine deficiency disorders (IDD) has been realized at the country level.

Since 2009, emergent iodine fortification measures were duly taken for such key populations as newly married women at reproductive ages, women planing for pregnancy, pregnant women and lactating women in the areas with high risk of IDD. Thus, the iodine deficiency harms were blocked effectively and the health of populations in high-risk areas was protected to the maximum [19]. 1.3.1.2 Vitamin-A deficiency As one of the four world-leading nutrition deficiency diseases, vitamin-A deficiency may make children suffer from nyctalopia, failure of eyesight or even blindness, and it is also a cause making children vulnerable to exposure to severe infectious diseases or even death. The prevalence of vitamin-A deficiency among children under age five dropped from 11.9% in 2000 [20] to 9.1% in 2006 [21], indicating only a slight reduction. The prevalence of marginal vitamin-A deficiency among children under age five in China has always been high – 39.2% in 2000 and 41.8% in 2006. Relevant survey results indicate that rural areas and remote areas are prominent for child vitamin-A deficiency, and thus should have a targeted intervention. A relevant study [22] revealed that current situations of child vitamin-A deficiency can be improved by supplementing vitamin-A agents, consuming vitamin-A fortified foods, eating more vitamin-A-rich foods, and enhancing the nutritional education and publicity in relation to vitamin-A deficiency. Thus far, China has not introduced any standard for child vitamin-A supplementation and relevant policies, and China has not implemented any interventions for vitamin-A supplementation throughout the country.

24 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

1.3.1.3 Zinc deficiency Zinc deficiency may lead to such child diseases as delayed nervous system development, stagnated growth and development, delayed sexual development, anaemia, anabrosis, and alopecia; it especially affects the growth and development of infants and young children, and even causes zinc deficiency dwarfism (also known as the Iranian villagers’ disease). According to the Report on the Nutrition and Health Status of the Chinese People released by the Child Work Department of All-China Women’s Federation, the prevalence of zinc deficiency among children aged 2–6 in China was 39.0%; among the 31 provinces/municipalities/ autonomous regions investigated, 60.0% of children were found with a daily zinc intake less than half of WHO’s recommended intake. Zinc deficiency of an infant may be due to the lower zinc content in the breast milk of his/her mother who was zinc-deficient during pregnancy or the lower zinc content in the foods fed to the baby. 1.3.2 Maternal health status 1.3.2.1 Coverage of maternal health care services 1.3.2.1.1 Hospital delivery rate In 2015, the hospital delivery rate in China was 99.7%, with 99.9% in urban areas and 99.5% in rural areas (Figure 1-13), meeting the target provided in the Program for Women’s Development in China (2011–2020), namely, 98.0% or higher hospital delivery rate of pregnant women in the country. ဋԫӑᡖҹޠͱᬓѬڎࣲЛ ڏ Results

Whole country Urban areas

Hospital delivery rate (%) Rural areas

Year

ݤࣷӼၷᄣ฾ጇፒ1-13 Hospital delivery rate in China, 2000–2015ڎFigure ஝૶౏ູ὘Л

Source: China National Maternal and Child Health Surveillance System

1.3.2.1.2 Antenatal care visits Antenatal care coverage refers to the proportion of postnatal women who received at least one antenatal care visit during pregnancy as compared to the total number of postnatal women. According to the 5th National Health Services Survey in China (2013), the antenatal care coverage was 97.8% throughout the country (98.4% in urban areas and 97.3% in rural areas). The antenatal care coverage did not vary greatly between urban areas and rural areas and among eastern, central and western China regions, and stayed at a high level in all of these areas (Table 1-9).

25 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

Table 1-9 Antenatal care visits and antenatal care coverage (%) in the survey areas

Urban areas Rural areas Antenatal care visit/coverage Total Subtotal Eastern Central Western Subtotal Eastern Central Western China China China China China China

Average number of visits 6.3 7.4 8.4 6.5 7.4 5.4 6.3 4.8 5.2 Antenatal care ≥1 visit (%) 97.8 98.4 99.2 97.9 98.2 97.3 98.4 97.4 96.4 Antenatal care ≥5 visits (%) 69.1 77.4 85.8 68.6 78.3 61.9 74.0 55.2 57.1

According to the 5th National Health Services Survey in China (2013), among the women who delivered a baby/many babies in the past five years, the average number of visits for antenatal care was 6.3 throughout the country, with 7.4 and 5.4 in urban areas and rural areas, respectively. As specified in China’s systematic health management for pregnant women, a pregnant woman should receive at least five antenatal care visits. The survey results revealed that the antenatal care coverage of at least five visits was 69.1% throughout the whole country, with 77.4% in urban areas and 61.9% in rural areas. The average antenatal care coverage and the antenatal care coverage of at least five visits were significantly different between urban areas and rural areas and across regions – higher in urban areas than in rural areas, and higher in eastern China than in western and central China (Table 1-9). 1.3.2.1.3 Items of antenatal care In antenatal care, routine blood test, blood pressure, routine urine test and ultrasound are obligatory items that must be checked. According to the 5th National Health Services Survey in China (2013), ultrasound coverage was the highest – up to 98.5%, and it did not vary greatly between urban areas and rural areas and between eastern China and central China. The blood pressure coverage was 97.1%. The routine blood test coverage was the lowest, at 92.4%, and it was variable between urban areas and rural areas and among eastern China, central China and western China. To be specific, the routine blood test coverage was higher in urban areas than in rural areas, and higher in eastern China than in central China and western China. The coverage of routine blood test, blood pressure, routine urine test and ultrasound was 90.7% throughout the country, and it varied greatly across areas/regions. As shown in Table 1-10, multi-item coverage was much higher in urban areas (94.4%) than in rural areas (87.4%). In terms of coverage in urban areas separated by region, it was highest in eastern China, followed by western China and central China. In terms of coverage in rural areas separated by region, it was highest in eastern China, and similar in central China and western China (Table 1-10).

Table 1-10 Single-item coverage and multi-item coverage of antenatal care (%)

Urban areas Rural areas Items of antenatal care Total Subtotal Eastern Central Western Subtotal Eastern Central Western China China China China China China

Routine blood test 92.4 95.7 97.7 93.3 96.1 89.5 92.6 88.6 87.7 Blood pressure 97.1 98.0 98.9 97.2 97.9 96.3 96.9 95.6 96.3 Routine urine test 94.1 96.2 98.1 94.1 96.7 92.1 93.1 91.6 91.7 Ultrasound 98.5 98.9 99.5 98.1 99.1 98.2 98.7 98.2 97.7 Routine blood test + blood pressure + 90.7 94.4 97.3 91.3 94.8 87.4 90.8 85.9 85.6 routine urine test + ultrasound

26 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

1.3.2.1.4 Coverage of folic acid supplementation In 2009, NHC initiated the folic acid supplementation program to prevent neural tube defects thus reducing the incidence of neural tube defects across China. Essentially, special subsidies from the central government were allocated for women who were planning to give birth in rural areas to receive free folic acid supplementation. In 2015, the program reached 10,837,000 pregnant women in rural areas. According to the 2011 Assessment of National Health Care Reform Report, 61.5% of married women aged 15–49 had taken folic acid, specifically 72.7% in urban areas and 58.4% in rural areas. In view of intake time, 51.5% took folic acid for 3 months before pregnancy and 36.4% for 3 months during early pregnancy. Such intake time was almost identical in urban areas and rural areas. As the program was implemented, the incidence of neural tube defects among newborns dropped substantially – from 11.96/10,000 in 2000 to 2.18/10,000 in 2015, according to relevant sources. 1.3.2.1.5 HIV, syphilis and hepatitis B testing rates among pregnant women and coverage of interventions for PMTCT Since the integrated PMTCT program was initiated in 2010, HIV, syphilis and hepatitis B testing rates among pregnant women throughout the country has soared quickly. As of 2015, the program had spread to all provinces/municipalities/autonomous regions, cities and counties of China. In 2015, HIV, syphilis and hepatitis B testing rates among pregnant women increased to 98.6%, 98.9% and 99.1%, respectively. At the same time, comprehensive interventions for PMTCT were fully implemented, triggering the indicators to improve notably. From 2005 to 2014, the antiretroviral therapy coverage among HIV-infected pregnant women increased from 64.6% to 82.6%; the antiretroviral therapy coverage among HIV-exposed children rose from 77.2% to 91.7%; the hospital delivery rate of HIV-infected pregnant women rose from 93.7% to 97.4%; and the proportion of HIV-exposed children under 6 months of age fed with artificial feeding Results increased from 87.3% to 97.5%. From 2011 to 2014, the rate of maternal treatment for syphilis infection increased from 48.0% to 68.1% nationally, and the treatment rate in some provinces reached more than 80.0%. The hepatitis B immunoglobulin immunization coverage among hepatitis B-exposed children remained at a high level, which was 98.7% in 2014. 1.3.2.2 Maternal diseases 1.3.2.2.1 Prevalence of maternal anaemia Anaemia during pregnancy constitutes a high-risk pregnancy and it’s the most common complication during pregnancy. According to relevant studies [23], iron deficiency in pregnancy is related to preterm birth, low birth weight and insufficient pregnancy weight gain. In 2012, the prevalence of maternal anaemia (with Hb <110 g/L) nationally was 17.2% (17.0% in urban areas and 17.5% in rural areas), which was 11.7% lower than the level reported in 2002. 1.3.2.2.2 Prevalence of HIV, hepatitis B and syphilis among pregnant women The situation of HIV, syphilis and hepatitis B in China is very serious. In recent years, there has been no significant change in the prevalence of HIV, syphilis and hepatitis B among pregnant women. Since China is a country with a large population, as the testing rates of HIV, syphilis and hepatitis B among pregnant women quickly grow, the number of pregnant women testing positive for these diseases is substantial and increases year after year.

According to the Report on HIV/ADIS in China (2011), the HIV prevalence among pregnant women was 0.31%–1.86%. Generally, the pregnant women with HIV were 25 to 35 years of age, less educated, of low

27 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

socioeconomic status, usually farmers or unemployed, and concentrated in certain geographic regions. Most were infected with HIV through sexual transmission. 1.3.2.2.3 Rubella prevalence among pregnant women Rubella is an acute respiratory infection (ARI) caused by the rubella virus. Infection of rubella during early pregnancy may lead to stillbirth, abortion or congenital rubella syndrome, thereby threatening the birth and future development of children [24]. In 2004, a serological survey of rubella virus was conducted among the women at reproductive ages in Shandong, Guizhou, Inner Mongolia, Qinghai, Beijing, Shenzhen, and Xi’an, revealing that 17.1% of women at reproductive ages in China were not immune to the rubella virus [25]. According to the random sampling survey on rubella immunoglobulin G (IgG) antibody titre of women at reproductive ages (20–40) in Shanxi province in 2006, the rubella antibody lowered with age, reflecting that such rubella antibody titre will not increase along with the accumulation of exposure to natural sources of this infection year after year [26]. In Shandong province, the rubella prevalence recently among married women at reproductive ages was 2.7% [27]. In Gansu province, the rubella prevalence among women before pregnancy was 88.8% [28]. 1.3.2.3 Intrapartum care services In 2010, among the 3,201 midwifery organizations in China investigated by the National Centre for Women and Children’s Health of the China CDC, 20.1% could only provide basic obstetric services while 48.5% could offer comprehensive obstetric services. 1.3.3 Water, sanitation and hygiene 1.3.3.1 Drinking water According to China’s 4th National Health Services Survey Analysis Report (2008) [29], tap water supplied the water for more than 90% of large and medium cities, while tap water supplied 42.0% of water coverage in rural areas, with unsafe water types (e.g. rivers, lakes, ponds, and ditches) accounting for an additional 14.2% of the water supply. Along with the rapid growth of the population and industrial/ agricultural production, massive amounts of wastewater have been discharged polluting water throughout the country and threatening the safety of drinking water. The Patriotic Health Campaign Committee of China and the former Ministry of Health of the PRC conducted a survey on drinking water and sanitation throughout rural areas of the country from 2006 to 2007 [30], which revealed that rural residents mainly collected drinking water from underground water sources. The rural population relying on underground water and ground water accounted for 74.9% and 25.1%, respectively. Moreover, in rural areas, 44.4% of drinking water failed to meet basic quality standards, and 25.9% of drinking water exceeded the mandatory microbiological indicator of water with respect to aerobic and coliform bacteria. The main reason for the excessive microbial indicators of drinking water is due to the low disinfection rate.

By the end of 2015, the central water supply had benefited 82.0% of the rural population, and the tap water supply coverage had reached 76.0% of rural areas; the water quality also had improved significantly. During the period of the 13th Five-Year Plan, China will launch a programme to ensure drinking water safety consolidation and improvement in rural areas, with the goal to supply more than 80% of the country with tap water and to provide more than 85.0% of the country with a central water supply by 2020. 1.3.3.2 Sanitation and hygiene Basic sanitation facilities and good hygiene behaviours are extremely important to children’s health, safety and development. According to the 4th National Health Services Survey in China Analysis Report (2008),

28 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

85.9% of residents in urban areas used flush toilets that are connected to the sewage system. In rural areas, however, the sanitary latrine coverage was only 43.3%. In general, lavatory improvement in rural areas, especially underdeveloped rural areas, is a really challenging task. An investigation in 2007 [31] uncovered serious problems in sanitation facilities in rural schools, among which only 32% had sanitary latrines, and most lacked handwashing facilities. Another survey in 2010 revealed that only 31% of township hospitals had indoor lavatories, of which only 55% were equipped with handwashing facilities.

Since 2000, China has been increasing the funds for lavatory improvement in rural areas. In 2004, China’s Central Government launched local health subsidies specifically for rural lavatory improvement. In 2009,

80.0 74.1 76.1 75.0 72.0 67.4 69.2 70.0 63.2 65.0 Პ 59.7 ৺ 60.0 55.3 55.0 57.0 ⦷ 55.0 50.0 % 45.0 40.0 35.0 Proportion of sanitary latrines (%)

30.0 Year Results 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

кేӼၷԐਫ਼௿ԣဋԫӑᡖҹ latrines in rural areas of China, 2005–2014ڎ˗Proportion of sanitaryࣲ ڏFigure 1-14

Ӽၷ֗ᝠѳၷᐲፒᝠࣲ᧝ Planning Statistical Yearbook - 2015ڎ˗Source: China஝૶౏ູ὘ Health and Familyࣲ

China deepened the reform of the medical and health system to incorporate rural lavatory improvement as a major public health care service by allocating more funds. By the end of 2014, the proportion of sanitary latrines in rural areas had increased to 76.1% [32] (Figure 1-14).

Both adults and children should have good hygiene habits, which are conducive to preventing diseases. Relevant studies suggest [33] that midwives’ handwashing before midwifery can help reduce the neonatal

29 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

mortality by 19%, and women’s handwashing before touching their newborn babies can help mitigate neonatal mortality risk by 44%. However, as indicated in the 2011 White Book of Chinese Handwashing Behaviour, only 4% of residents surveyed in five provinces/municipalities (including Beijing, Liaoning and Zhejiang) could wash their hands correctly. 1.3.3.3 Impacts of water, sanitation and hygiene on child health 1.3.3.3.1 Endemic diseases 1.3.3.3.1.1 Arsenicosis In recent years, the harms to human health of excessive arsenic in drinking water are of increasing concern to the international community. Over 20 countries, including China, India, Bangladesh, Chile and Argentina, have reported arsenic poisoning from drinking water. Excessive arsenic in drinking water may cause various harms. On one hand, arsenic in drinking water may lead to typical arsenic skin damage, such as palmoplantar keratosis, chromatosis and depigmentation. On the other hand, the arsenic may damage human organs and systems (e.g. respiratory system, digestive system, cardiovascular system, and neural system), making pregnant women at higher risk of abortion and enabling children to suffer from mental retardation and inattention to class. What’s more, from the long-term prospective, arsenic may cause cancers.

In China mainland, since 1983 when the arsenic poisoning from drinking water was found in Xinjiang, this endemic disease has occurred in Inner Mongolia, Shanxi, Ningxia, Jilin, Qinghai, and other provinces. The endemic areas are broad and involve a large population and a high severity. Thus far, the population exposed to arsenic has exceeded 2 million, and the number of patients with confirmed exposure have approached 10,000. Surveys in recent years have revealed more and more areas with arsenicosis. In the areas under arsenic removal, the arsenicosis is restrained to a certain extent, but not stopped locally even if the drinking water has been improved. Instead, the arsenicosis patients are increasing. 1.3.3.3.1.2 Endemic fluorosis and dental decay Fluoride is an indispensable microelement in the human body, but it has dual effects. Fluoride at a low concentration has beneficial effects on bones and prevention of caries. On the contrary, fluoride at high concentration is often associated with dental fluorosis or even skeletal fluorosis in severe cases, which may make people lose working capability entirely and especially will have greater impacts on growing infants and children. Many countries have decided to add fluoride in drinking water for preventing dental decay, especially children’s dental decay. Additionally, the prevalence of dental fluorosis has increased substantially.

As of the end of 2010, 87,000 villages in China’s 28 provinces/municipalities/autonomous regions (including Xinjiang Production and Construction Group) were affected by fluoride poisoning from drinking water, involving 77.13 million people, and reflecting a coverage of water improvement of 81.9%. According to surveillance from 2010 to 2011, a high proportion of dental fluorosis was detected in villages as part of a water improvement programme in Tianjin, Sichuan, Henan and Shandong, whereas a high proportion of dental fluorosis detected in villages where a programme for water improvement was not implemented was mainly observed in Shaanxi, Hebei, Tianjin and Jiangsu. In all villages where a water improvement programme was implemented smoothly and the fluoride content in the water was quantified, the proportion of dental fluorosis detected among children declined, suggesting that water improvement with fluoride reduction is an effective measure to prevent fluoride poisoning from drinking water.

30 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

1.3.3.3.2 Lead poisoning According to Wang Shunqin et al. (2004)[34], in China, the average blood lead level of children aged 0–6 is 92.9 mg/L, and the prevalence of lead poisoning is 33.8%, much higher than that in the United States, Canada and other countries. For children, the blood lead level and prevalence of lead poisoning tend to rise with age, typically for 0 age group and 1-year-old age group. Some scholars indicate that the 1-year- old age group has higher blood lead levels and prevalence of lead poisoning than the 0 age group. On one hand, the children in the 1-year-old age group demonstrated a higher lead content in hand dust caused by their exploratory behaviours like crawling on the ground. On the other hand, the children in the 1-year-old age group reveal a higher lead uptake, which is caused by their frequent hand-mouth interactions before they have conscious health habits and adequate protective barriers in their digestive tracts. As children grow older, they are increasingly involved in outdoor activities and ingesting lead-containing goods/ foods, making them have a higher exposure to lead contaminations. As a result, their blood lead levels grow gradually and peak when they are 5 or 6 years of age. This coincides with the study results of some developing countries.

Environmental lead pollution is also a major contributor to the higher blood lead level in children. It is mainly sourced from the extensive utilization of lead in modern industries and gasoline. The blood lead level of children varies greatly across areas – it is much higher in industrial areas and urban areas than in suburban areas and rural areas. 1.3.3.3.3 Parasitosis The survey by the former Ministry of Health of the PRC suggests that, in China, parasitosis is most prevalent among women and children. Typically, the prevalence of roundworm, whipworm and pinworm

and the seroprevalence of paragonimiasis and kala-azar are higher among children aged 0–14. The survey Results also demonstrated that the prevalence of pinworm among children under 12 reaches 10.3%; and the child’s infection often leads to their mothers’ infection. Moreover, the highest prevalence of a soil-transmitted nematode in China is found in two age groups: 5–9 and 10–14. It is estimated that at least 1 million infants in China are malformed due to infection with toxoplasmosis during pregnancy. 1.3.3.3.4 Trachoma Trachoma, a chronic infectious conjunctivitis caused by the chlamydia infection, is a common chronic infectious eye disease among young children and adolescents. Globally, there are approximately 450 million trachoma patients, about 1/10 of the world population; about 2–5 million people are suffering from trachoma blindness. Trachoma is mainly endemic in some countries/regions with a poor economy and poor hygiene. In China, multiple rounds of general surveys and treatments of trachoma have been conducted. In addition, living conditions have improved, so that the prevalence of trachoma has dropped significantly. In large cities, the prevalence of trachoma among students in primary and secondary schools has declined to about 10% and declined to about 20% in suburban areas. 1.3.3.3.5 Indoor air pollution Relevant sources [35-36] indicate that the indoor air pollution in China’s rural areas is primarily generated by fuel combustion and smoking. Heating and cooking in rural areas are mainly fuelled by coal and biomass (e.g. crop stalks, hay, wood and animal dung), or by gas fuels (e.g. LPG and methane). There are numerous people who smoke in rural areas, but the impact of smoking to indoor air quality has yet to be reported.

31 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

Under an intervention program for indoor air pollution in China’s rural poverty-stricken areas sponsored by the World Bank, two rounds of a survey were conducted about the respiratory system symptoms and signs of women, infants and young children in Guizhou, Shaanxi, Gansu and selected areas of Inner Mongolia. The results revealed that the symptoms and signs of the respiratory system are related to coal consumption. It was proven that indoor coal-fire air pollution was the leading cause for a high incidence of lung cancer among women in Xuanwei of Yunnan, so the incidence of lung cancer has declined dramatically due to improved indoor air quality from stove transformations.

Since 2009, China has initiated a program to end fluoride poisoning from coal burning in six provinces, including Guizhou and Yunnan. Fluoride poisoning from coal burning is a unique challenge in China, affecting 1,354 townships of 199 counties in 13 provinces, each to a different extent with more than 16 million dental fluorosis patients and about 2 million skeletal fluorosis patients. 1.3.4 Women and child health literacy 1.3.4.1 Identification of warning signs for pregnant women According to the baseline survey conducted in 2011 under the Integrated Maternal and Child Health Program jointly initiated by the former Ministry of Health of the PRC and UNICEF, 26.7% of pregnant women surveyed were able to identify at least three warning signs in pregnancy, like colporrhagia, convulsions, dyspnoea, fever, severe headache, blurred vision, palpebral oedema/hand oedema or hyposarca, decreased foetal movement and vaginal leaking. Also, among the pregnant women surveyed, only 17.0% could identify three postnatal warning signs, like abnormal vaginal bleeding, convulsions, faster breathing/dyspnea, fever, severe stomach-ache, severe headache and bad vaginal odour. 1.3.4.2 Identification of warning signs for a child According to the aforementioned baseline survey, 27.9% of caretakers surveyed were able to identify at least three warning signs/symptoms of newborns, including ineffectual sucking; weak/abnormal/stagnant crying; somnolence or coma; fever; local skin infection; faster, difficult or slower breathing; convulsions; severe vomiting; abnormally cold body temperature; umbilical haemorrhage/reddening which spreads to surrounding skin or is associated with purulent secretion; yellow eyes/skin; and purulent secretion from the eyes. Moreover, 28.7% of caretakers surveyed knew at least 3 warning signs/symptoms of young children, including ineffectual drinking/sucking, aggravated symptoms, fever, faster or difficult breathing, blood in the stool, less drinking, vomiting of any food ingested, and convulsions. These data suggest that caretakers are less than competent in identifying warning signs/symptoms of newborns and young children. 1.3.4.3 Caretakers’ knowledge of infant and young child feeding Breastfeeding and complementary feeding are integral to infant and young child feeding, and they may have direct impacts on a child’s growth and intelligence. Much research and evidence show that feeding knowledge and attitudes are two major factors for breastfeeding [37]. Providing a systematic breastfeeding educational curriculum for mothers can help dramatically increase the breastfeeding success rate in communities[38], thus improving the exclusive breastfeeding rate of infants 0–6 months old [39] and promoting optimal breastfeeding. During the Resident Nutrition and Health Surveillance of China (2010- 2012), more than 6,000 infants and young children aged 0–18 months and their parents in 16 cities/ regions, such as Beijing (typically Haidian and Shunyi districts), Qiqihar, Daqing and Jiujiang, were surveyed. The results revealed that nearly half of the parents did not choose iron-fortified rice cereal as the

32 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

first non-dairy complementary food for their babies, and one-third of infants and young children were not provided with daily vitamin-D supplementation; the rationale behind these decisions is attributed to the lack of scientific knowledge on child nutrition and correct feeding recommendations. 1.3.4.4 Identification of risk factors of child injuries Currently in China, there are no applicable standards for child injury prevention, and few investigations have been conducted with respect to the perception and attitudes towards child injury prevention. In 2003, the National Center for Chronic and Noncommunicable Disease Control and Prevention of the China CDC and Safe Kids carried out the Survey on the Perception of Unintentional Injuries among Children and Parents in Beijing, Shanghai and Guangzhou [40]. The survey results showed that the parents in the developed areas of China were knowledgeable about unintentional child injuries: they achieved above an 85% on the knowledge of unintentional child injuries, and more than 70% of parents knew the correct measures to prevent their child from sustaining an injury. However, a considerable proportion of parents, even in developed cities, were not as knowledgeable and less capable of dealing with certain aspects related to unintentional child injuries. For example, 27.1% of parents deemed it safest for babies to sleep with their parents; 13.2% of parents thought it acceptable to ride a bike with a passenger(s); 30.0% of parents failed to recognize the need to treat sharp edges and corners of furniture with proper protective measures; about 25.0% of parents failed to recognize the need to keep a knife, scissors, hot water, lighter or other dangerous goods in places inaccessible to a child. 1.3.4.5 Caretakers’ hygiene behaviours According to the baseline survey in 2011 under the Integrated Maternal and Child Health Program, the rate of hand washing by caretakers and the rate of using soap to wash their hands at critical moments, like before food preparation, before child feeding, after cleaning a child’s faeces, after the caretaker defecates, Results and before the caretaker eats, were lower than 70% (Figure 1-15) and 80%, respectively.

100

50 % 40

30 Rate of hand washing (%) 20

10 Hand washing 0 moment Before߶༷伏⢙ࡽ food 㔉ᆙᆀல依ࡽBefore child ༴⨶ᆙᆀⲴ㋚ׯAfter cleaning ਾ ⴻᣔӪк৅ᡰਾAfter caretaker̓s BeforeⴻᣔӪਲ਼依ࡽ caretaker̓s preparation feeding child’s faeces defecation eating Јቨᄺઐ̡Т᪄௑҉ฤ੤ဋ ڏ Figure 1-15 Rate of caretaker̓s hand washing at critical moments

33 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

1.3.5 Household possession of books and toys for children According to UNICEF’s 2013 Baseline Survey under the Integrated Early Childhood Development Programme for Poor Areas, among the households surveyed, 48.3% had one book or more, 51.7% had no book, and 42.4% had no toy for a child (Figure 1-16).

100% ≥ 90% 3 books 80% Yes 29.9% 48.3% Yes 70% ᤕ 57.6% ᴹ 60% ⦷ 50%

% 40% 0–2 books 30% No 70.1% No Proportion of households (%) 20% 51.7% 42.4% 10% 0% HouseholdᇦᓝᤕᴹമҖ possession of HouseholdᇦᓝᤕᴹമҖ possession of books ᇦᓝᤕᴹ⧙ާHousehold books (Yes vs. No) (0–2 books vs. ≥3 books) possession of toys

(%) ǌနЦવదဋ὆὇ of households possessing books and toys for children˺ڏЈቨࠒऑ ڏFigure 1-16 Proportion

ӝЈቨொర፬Ռԧ࡙តགᮊᄬ۳ጳូಊ Early Childhood Development Programme for Poor AreasྟڈЈቨ۳᧛͘ UNICEF’s 2013 Baseline Survey underࣲ᠒ڎSource:஝૶౏ູ὘ᐏՌ

1.4 Equity analysis 1.4.1 Outcome indicators 1.4.1.1 Neonatal mortality rate 1.4.1.1.1 Difference between urban areas and rural areas In 2000–2015, the neonatal mortality rate throughout the whole country and rural areas dropped significantly, and varied greatly among regions – much higher in rural areas than in urban areas. In 2015, the neonatal mortality rate in rural areas was 1.9 times that of urban areas (Table 1-11, Figure 1-17).

Table 1-11 Neonatal mortality rate (‰) in China, 2000 and 2015

Region 2000 2015 Average annual rate of reduction (%)

Whole country 22.8 5.4 9.1 Urban areas 9.5 3.3 6.8 Rural areas 25.8 6.4 8.9

34 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action 30

25 ᯠ ⭏30 ݯ 20 25 ᯠ↫ 15 ⭏ӑ ޘഭ ⦷20 ݯ ෾ᐲ ↫ 10 ‰15 ߌᶁ ӑ ޘഭWhole country ⦷ 5 ෾ᐲ 10 Urban areas ‰ 0 ߌᶁRural areas Neonatal mortality rate (‰) 5

0 Year ழၷЈ൫̒ဋԫӑԣۢ˹ࣀपڎࣲЛ ڏ

ݤࣷӼၷᄣ฾ጇፒڎ஝૶౏ູ὘Л Figure 1-17 Neonatal mortality rate in China, 2000–2015 ழၷЈ൫̒ဋԫӑԣۢ˹ࣀपڎࣲЛ ڏ Source: China National Maternal and Child Health Surveillance System ݤࣷӼၷᄣ฾ጇፒڎ஝૶౏ູ὘Л 1.4.1.1.2 Difference among regions In 2000–2015, the neonatal mortality rate in all regions reduced year by year, with a higher amplitude in eastern and central China than in western China (Table 1-12, Figure 1-18).

Table 1-12 Neonatal mortality rate (‰) in China, 2000 and 2015

Region 2000 2015 Average annual rate of reduction (%) Results Eastern China 13.0 2.6 10.2 Central China 24.4 3.9 11.5 Western China 31.7 8.2 8.6

Eastern China Central China Western China Neonatal mortality rate (‰)

Year

ӝᫎࣀप mortality rate in China, 2000–2015ڡழၷЈ൫̒ဋԫӑԣڎFigure 1-18 NeonatalࣲЛ ڏ ݤࣷӼၷᄣ฾ጇፒڎ஝૶౏ູ὘Л Source: China National Maternal and Child Health Surveillance System ӝᫎࣀपڡழၷЈ൫̒ဋԫӑԣڎࣲЛ ڏ ݤࣷӼၷᄣ฾ጇፒ 35ڎ஝૶౏ູ὘Л Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

1.4.1.1.3 Provinces with high neonatal mortality rate and number of newborn deaths Based on the data of the National Women and Children’s Health Surveillance in 2012, 30 provinces/ municipalities/autonomous regions (excluding Tibet) of China were ranked in descending order of neonatal mortality rate and number of newborn deaths. Thus, the top ten provinces/municipalities (where the mortality was most severe) and bottom ten provinces/municipalities (where the mortality was least severe) were determined.

According to the absolute data from 2012, Qinghai and Ningxia have a small number of newborn deaths, which may be related to the small population in these two provinces; nevertheless, efforts are still needed to improve the capability of preventing and treating neonatal diseases to further reduce the neonatal mortality rate in these provinces. The top ten provinces/municipalities/autonomous regions with respect to neonatal mortality rate include Xinjiang, Qinghai, Gansu, Inner Mongolia, Ningxia, Yunnan, Shanxi, Sichuan, Hainan, and Hebei. The top ten provinces/municipalities/autonomous regions in terms of absolute number of newborn deaths are Jiangsu, Xinjiang, Inner Mongolia, Zhejiang, Shanghai, Liaoning, Shandong, Chongqing, Yunnan, and Hebei. The provinces/municipalities/autonomous regions among the top ten in terms of both neonatal mortality rate and number of newborn deaths include Xinjiang, Inner Mongolia, Yunnan, and Hebei, where great efforts should be made to reduce neonatal mortality (Table 1-13).

Table 1-13 Ranking of provinces/municipalities/autonomous regions of China by neonatal mortality in 2012

By neonatal mortality rate By number of newborn deaths Rank Province/municipality/ Neonatal mortality rate (‰) Province/municipality/ Number of newborn deaths autonomous region autonomous region

1 Xinjiang 14.43 Jiangsu 1762 2 Qinghai 11.63 Xinjiang 992 3 Gansu 10.25 Inner Mongolia 702 4 Inner Mongolia 9.50 Zhejiang 698 5 Ningxia 7.60 Shanghai 617 6 Yunnan 7.52 Liaoning 550 7 Shanxi 7.51 Shandong 525 8 Sichuan 7.21 Chongqing 323 9 Hainan 6.77 Yunnan 322 10 Hebei 6.70 Hebei 304

21 Liaoning 4.20 Guangdong 155 22 Tianjin 3.98 Guizhou 149 23 Guangxi 3.48 Jilin 145 24 Jilin 3.45 Hainan 144 25 Hunan 3.17 Hunan 143 26 Zhejiang 3.13 Ningxia 137 27 Shanghai 2.75 Tianjin 135 28 Guangdong 2.19 Heilongjiang 121 29 Jiangsu 1.98 Qinghai 97 30 Beijing 1.91 Shaanxi 78

36 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

1.4.1.1.4 Correlation between rural per capita net income and neonatal mortality rate in provinces/ municipalities/autonomous region In 2012, the rural per capita net income was negatively correlated with neonatal mortality rate in the provinces/municipalities/autonomous regions of China (Table 1-14, Figure 1-19), implying that the economic development level may have an impact on neonatal mortality rate. The growth rate of rural per capita net income from 2002 to 2012 was compared with the average rate of reduction of neonatal mortality rate from 2000 to 2012 in 30 provinces/municipalities/autonomous regions (excluding Tibet), indicating that there is no apparent relationship between the growth rate of rural per capita net income and the rate of reduction of neonatal mortality rate in that 10-year period (Table 1-15).

Table 1-14 Correlation between rural per capita net income and neonatal mortality rate in provinces/municipalities/ autonomous regions, 2012

Province/municipality/autonomous Rural per capita net income (RMB1,000) Neonatal mortality rate (‰) region

Shanghai 17.8 2.8 Beijing 16.5 1.9 Zhejiang 14.6 3.1 Tianjin 14.0 4.0 Jiangsu 12.2 2.0 Guangdong 10.5 2.2 Fujian 10.0 4.4 Shandong 9.5 4.5 Results Liaoning 9.4 4.2 Heilongjiang 8.6 5.2 Jilin 8.6 3.5 Hebei 8.1 6.7 Hubei 7.9 5.8 Jiangxi 7.8 6.6 Inner Mongolia 7.6 9.5 Henan 7.5 4.4 Hunan 7.4 3.2 Hainan 7.4 6.8 Chongqing 7.4 4.6 Anhui 7.2 6.1 Sichuan 7.0 7.2 Xinjiang 6.4 7.5 Shanxi 6.4 14.4 Ningxia 6.2 7.6 Guangxi 6.0 3.5 Shaanxi 5.8 5.6 Yunnan 5.4 7.5 Qinghai 5.4 11.6 Guizhou 4.8 5.9 Gansu 4.5 10.3

37 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action Neonatal mortality rate (‰) Rural per capita net income (RMB1,000) Shanghai Beijing Zhejiang Tianjin Jiangsu Guangdong Fujian Shandong Liaoning Heilongjiang Jilin Hebei Hubei Jiangxi Inner Mongolia Henan Hunan Hainan Chongqing Anhui Sichuan Xinjiang Shanxi Ningxia Guangxi Shaanxi Yunnan Qinghai Guizhou Gansu Provinceⴱ˄ᐲǃ४˅ (Municipality/ Autonomous Region) ⴱ˄ᐲǃ४˅ⴱ˄ᐲǃ४˅

(‰) ጦஆКˁழၷЈ൫̒ဋᄊТጇ net income (RMB1,000) Neonatal mortality rateکRural per capitaࣲՊᄵкඟ̡ڏ

Figure 1-19 Correlation between rural per capita net income and neonatal mortality rate in provinces/ ጦஆКˁழၷЈ൫̒ဋᄊТጇکጦஆКˁழၷЈ൫̒ဋᄊТጇ ࣲՊᄵкඟ̡کࣲՊᄵкඟ̡ڏ ڏ municipalities/autonomous regions, 2012

Table 1-15 Growth rate of rural per capita net income (%) from 2002 to 2012 and rate of reduction of neonatal mortality rate from 2000 to 2012 (%) in provinces/municipalities/autonomous regions of China

Province/municipality/ Growth rate of rural per capita net income (%) Average rate of reduction of neonatal mortality rate (%) autonomous region

Jilin 14.1 10.0 Inner Mongolia 13.8 7.2 Shaanxi 13.7 11.8 Heilongjiang 13.6 5.6 Chongqing 13.4 9.2 Liaoning 13.1 9.2 Xinjiang 13.1 2.7 Anhui 13.0 6.6 Jiangxi 13.0 10.3 Henan 13.0 13.1 Yunnan 12.9 8.5 Sichuan 12.8 4.5 Tianjin 12.6 5.3 Shandong 12.4 9.6 Hubei 12.4 8.2 Qinghai 12.4 8.1 Ningxia 12.4 7.1 Guizhou 12.3 11.5 Hunan 12.0 11.4 Jiangsu 11.9 14.2

(coutinued)

38 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

Province/municipality/ Growth rate of rural per capita net income (%) Average rate of reduction of neonatal mortality rate (%) autonomous region

Beijing 11.8 7.5 Hainan 11.8 9.6 Hebei 11.6 5.8 Guangxi 11.6 13.5 Shanxi 11.5 6.6 Zhejiang 11.4 7.7 Shanghai 11.1 1.0 Gansu 11.0 6.6 Fujian 10.9 10.4 Guangdong 10.4 10.3 Note: The 2002 and 2012 data of rural per capita net income were sourced from the National Bureau of Statistics of PRC website.

1.4.1.2 Difference between urban-rural and inter-regional of child stunting prevalence In China, the nutritional status of children under age 5 is different between urban areas and rural areas. In 2013, the prevalence of stunting among children under age 5 in impoverished rural areas was 18.7%. The child stunting prevalence in rural areas was 2.6 times that of urban areas, while the child stunting prevalence in poverty-stricken rural areas was 1.7 times that of non-poverty-stricken rural areas. Moreover, the nutritional status of children under age 5 varies greatly among regions. According to the survey of the former Ministry of Health of the PRC, in 2006, the prevalence of child stunting in central and western China was about two to three times that of eastern China. 1.4.1.3 Difference between urban-rural and inter-regional of water and sanitation facilities (latrines) In China, the financial health subsidies given to households are higher for the lower-income population; Results however, for historical reasons, the safe drilling water coverage and the proportion of sanitary latrines available are much lower in rural areas than in urban areas.

It can be seen from Table 1-16 that, in economically-developed areas, the tap water supply and safe drinking water coverage are high, while in economically-underdeveloped areas, the proportion of residents accessing unsafe drinking water is higher. This can be especially noted in 2008, in Class-4 rural areas where the proportion of residents accessing unsafe drinking water reached 25.4%. By regions, the safe drinking water coverage is high in rural areas in eastern China but low in rural areas in western China. In the large, medium and small urban areas of China, the safe drinking water coverage is stable at a high level. In rural areas, the safe drinking water coverage is the highest in Class-1 (close to that in urban areas), followed by Class-2 and Class-3, and lowest in Class-4 with a significant improvement from 2003 to 2008.

Table 1-16 Safe drinking water coverage (%) in various regions, 2003 and 2008

Large urban Medium urban Small urban Class-1 rural Class-2 rural Class-3 rural Class-4 rural Year areas areas areas areas areas areas areas

2003 99.6 99.9 98.1 92.2 84.2 79.1 49.6 2008 99.8 99.9 94.8 93.9 89.8 80.4 74.6 Source: National Health Services Survey in China (2003 & 2008)

39 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

It can be seen from Table 1-17 that the percentage of sanitary latrines is the highest in medium urban areas, followed by large and small urban areas, and it is much lower in rural areas than in urban areas. The percentage of sanitary latrines is the lowest in Class-3 and Class-4 rural areas. The percentage has grown at the highest rate in Class-4 rural areas, with a level in 2008 higher than that of Class-3 rural areas.

Table 1-17 Proportion of sanitary latrines (%) in various regions, 2003 and 2008

Large urban Medium urban Small urban Class-1 rural Class-2 rural Class-3 rural Class-4 rural ar Year areas areas areas areas areas areas eas

2003 87.7 95.5 77.1 32.7 25.7 12.2 8.7 2008 94.8 97.4 89.5 56.0 46.5 32.1 40.8 Source: National Health Services Survey in China (2003 & 2008)

1.4.2 Utilization of services 1.4.2.1 Equity analysis of some health indicators In general, from 2003 to 2011, the gap between the rich and the poor with respect to accessibility to and utilization of health care services reduced gradually – to basically zero by 2011. However, in terms of the proportion of households with accrued medical expenses for serious diseases, the poor were 2 times that of the rich [41] (Table 1-18).

Table 1-18 Ratio of the lowest-income households to the highest-income households in terms of some health indicators (2003, 2008 and 2011)

Health indicator 2003 2008 2011

Physical accessibility to health care services 0.95 0.94 0.95 Prenatal care coverage (at least 5 visits) 0.74 0.79 0.94 Hospital delivery rate 0.91 0.97 1.01 Medical insurance coverage 0.63 0.93 0.98 Outpatient service utilization rate 0.86 0.94 0.98 Hospitalization reimbursement ratio 0.37 0.85 0.97 Proportion of households with medical expense accrued for serious diseases (an inverse 0.54 0.50 0.49 indicator, referring to the reciprocal)

1.4.2.2 Immunization program According to the National Immunization Coverage Survey in China, after the integration of more vaccines (Type Ⅰ Vaccines) into the EPI in 2011 [15], the zero-to-twelve-months basic (primary) immunization coverage of the national immunization program vaccines (NIP Vaccines) among children aged 1–2 was higher than 95% in all eastern, central and western China regions. Moreover, the immunization coverage of Four Vaccines and Five Vaccines among children aged 1 and 2 were much lower in western China than in eastern and central China regions.

During the above-mentioned survey, a household survey was conducted for a total of 4,681 children aged 1–2, of which 61.4% were vaccinated with Type Ⅱ Vaccines including varicella vaccine. The coverage of Type Ⅱ Vaccines was variable across regions: 82.5%, 64.9% and 43.2% in eastern, central and western China regions, respectively. It was the highest in eastern China where the economy has grown the fastest, followed by central China and western China.

40 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

1.4.2.3 Equity of utilization of maternal and child health care services in poverty-stricken areas During the baseline survey under the Integrated Maternal and Child Health Program, the following indicators were investigated: prenatal care (PNC), hospital delivery rate (HDR), antenatal care coverage - at least 4 visits (ANC4), measles vaccines immunization coverage (MSL), antenatal care coverage - at least 5 visits (ANC5), early initiation of breastfeeding (EIBF), oral poliomyelitis attenuated live vaccine (OPV), exclusive breastfeeding (EBF) and others. It was found that the HDR and ANC4 coverage was different between the poor and the rich in poverty-stricken areas, and the former was about 25% lower than the latter; the EBF rate of the rich was 7% lower than that of the poor; and other indicators remained basically identical (Figure 1-20).

PNC HDR ANC4 MSL ANC5 EIBF Coverage (%) OPV EBF ORS

The poorest 20% The richest 20% Results

ӝߙ̗ݤ֗ЈቨδϤ఩ҬѾၹᄊНࣱভ maternal and child health care services in poverty-stricken areasڡڈof᠒ ڏFigure 1-20 Equity of utilization

1.4.3 Nutrition and health of migrant children The UNICEF’s 2012 survey in Pinghu of Zhejiang province showed that the stunting prevalence among migrant children under age 3 was approximately 2.2 times that among resident children under age 3. Moreover, the two-week prevalence of diarrhoea among children under 3, two-week prevalence of suspected pneumonia among children under 3, stunting prevalence among children under 3 and prevalence of anaemia among children aged 6–35 months were all higher for migrant children than resident children in Pinghu, and the differences thereto are meaningful statistically (except for the two-week prevalence of suspected pneumonia), as shown in Table 1-19.

Table 1-19 Comparison of disease prevalence (%) between migrant children and resident children in Pinghu, Zhejiang province

Migrant children Resident children Prevalence Survey size Rate (%) Survey size Rate (%)

Two-week prevalence of diarrhoea among children under 3 1,188 15.9 631 10.3 Two-week prevalence of suspected pneumonia among 1,186 9.7 631 7.8 children under 3 Stunting prevalence among children under 3 1,188 3.5 635 1.6 Prevalence of anaemia among children aged 6–35 months 1,022 28.2 538 14.9 Source: Baseline survey under UNICEF Migrant Children Program

41 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

1.4.4 Nutrition and health of left-behind children In 2010, migration in China reached 221 million, leading to a large number (>15 million) of left-behind children under age 5 in rural areas, as well as numerous unaccounted migrant children who accompanied their parents. Both migrant children and left-behind children suffer from malnutrition to an extent due to poor living conditions, less-educated caretakers and other factors. The study indicated that, in rural areas, the stunting prevalence among left-behind children is much higher than that among non-left-behind children, and the left-behind children in rural areas demonstrate decreased growth and development status compared to the children in urban areas. Furthermore, the left-behind children usually have not received appropriate care and health education related to injury prevention. Relevant data show that the child injury mortality rate in rural areas is significantly higher than that of urban areas.

1.5 Supportive environment 1.5.1 National policies 1.5.1.1 Improvement of laws and regulations 1.5.1.1.1 Relevant laws and regulations on women and children’s health The NPC Standing Committee reviewed and approved the Maternal and Infant Health Care Law of the PRC in October 1994, and the State Council launched the Measures for the Implementation of Maternal and Infant Health Care Law of the PRC in August 2001, ushering a new stage for legal management of maternal and child health activities in China. The Maternal and Infant Health Care Law of the PRC, formulated on the basis of the Constitution of the PRC, is the first specific legislation in China that protects women and children’s health rights and interests. It, in conjunction with the Law of the PRC on the Protection of Rights and Interests of Women, the Law of the PRC on the Protection of Minors, the Special Provisions on Labour Protection of Female Employees and other applicable laws and regulations, provides legal safeguards for women and children’s health.

To fulfil their solemn commitments to the World Summit for Children and the international community, the Chinese government successively prepared and implemented the Program for Women’s Development in China (1995–2000), the National Program of Action for Child Development in China in the 1990s, the Program for Women’s Development in China (2001–2010), the Program for Children’s Development in China (2001–2010), the Program for Women’s Development in China (2011–2020), and the Program for Children’s Development in China (2011–2020) in order to incorporate women and children’s health into their plan for national economic and social development as a priority. In 2000, the Chinese government promised to meet the UN Millennium Development Goals, specifically and importantly by reducing the maternal and child mortality rates.

In order to efficiently comply with theMaternal and Infant Health Care Law of the PRC, the National Program for Women’s Development in China, and the National Program for Child Development in China, and to accomplish the targets set in the aforementioned two programs and the UN Millennium Development Goals, the former Ministry of Health of the PRC formulated a series of supporting regulations and documents, like the Administrative Measures for Permits for Specific Maternal and Child Health Care Services and Personnel Qualifications, the Basic Standards for Maternal and Child Health Care Services, the Standards for Premarital Health Care Services (Revised), the Standards for Pre-pregnancy Health Care Services (Trial), the Regulations for Prenatal Diagnosis Techniques, the

42 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

Regulations for Neonatal Disease Screening, the Guidelines on Further Enhancing Women and Children’s Health Care Activities, the Rules for Management of Maternal and Child Health Care Facilities, the National Regulations for Child Health Care Activities (Trial), and the Administrative Measures for Hygiene and Health Care in Nurseries and Kindergartens. The former Ministry of Health of the PRC also formulated applicable specifications and guidelines on maternal and child health care. Thus, the legal basis for all aspects of maternal and child health care services is kept available, such as administrative management, supervision and inspection, and professional specifications. 1.5.1.1.2 Relevant laws and regulations on infectious disease prevention and treatment In order to prevent, control and eliminate the occurrence and spread of infectious diseases, and ensure personal health and public health, the Law of the PRC on the Prevention and Treatment of Infectious Diseases was adopted at the sixth meeting of the Standing Committee of the Seventh National People’s Congress on February 21, 1989, and was revised at the eleventh meeting of the Standing Committee of the Tenth National People’s Congress on August 28, 2004. Under this Law, infectious diseases are divided into Class A (incl. 2 diseases), Class B (incl. 26 diseases) and Class C (incl. 11 diseases).

The Pharmaceutical Administration Law of the PRC adopted at the seventh meeting of the Standing Committee of the Sixth National People’s Congress on September 20, 1984, and the China Vaccine Circulation and Vaccination Regulations adopted at the 83th Executive Meeting of the State Council on March 16, 2005, have played an important role in promoting orderly vaccination activities and regulating vaccine circulation in China. As health care services are spread throughout the country, the reform of the medical and health system has deepened. Consequently, the national health care system is improving, immunizations are being incorporated into the basic public health care service program, and

the coverage of immunization services is being extended with rising targets. Domestic vaccine production Results capacity is improving, the types of available vaccines are increasing, the vaccination security patterns are diversifying, and people’s awareness of vaccination is rising. All of these new trends and progresses bring both opportunities and challenges to vaccination activities in China. The China Vaccine Circulation and Vaccination Regulations Report revised on April 23, 2016 provides specifications for procurement of Type Ⅱ Vaccines and simplification of circulation. Along with economic development, various employment opportunities have emerged in China, such as rural workers in cities. Due to this development, numerous children have had to leave their (registered) permanent residences before completing their vaccinations, making them a prominent bottleneck in vaccination management nationally. Therefore, it is urgent to develop and implement a proper vaccination management model for migrant children. 1.5.1.1.3 Relevant policies for injury prevention The Program for Children’s Development in China (2011–2020) includes, for the first time, the reduction of child injuries as an independent indicator. It proposes “to mitigate the child deaths and disabilities caused by injuries and reduce the injury mortality rate among children under 18 by 1/6 from the level in 2010”. Thus, this program provides a policy support for the prevention and control of child injuries.

On September 4th, 1991, the 21st Meeting of the Standing Committee of the Seventh National People’s Congress adopted the Law of the PRC on the Protection of Minors to protect the physical and psychological health of adults and the legal rights and interests of minors. On October 28, 2003, the Fifth Meeting of the Standing Committee of the Tenth National People’s Congress adopted the Law of the PRC on Road Traffic Safety, which provided policy support for preserving the road traffic order, preventing

43 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

and reducing traffic accidents, protecting personal safety, and protecting property safety and other legal rights and interests of citizens, legal persons and other organizations. In 2003, the State Council approved the establishment of the United Symposium of Road Traffic Safety in China consisting of 17 ministries and commissions, at which the issues of road traffic safety are discussed. On April 28, 2004, the 49th Executive Meeting of the State Council adopted the PRC Regulations on the Implementation of Law on Road Traffic Safety, which functions as solid legal ground for the prevention and control of traffic injuries. On March 28, 2012, the 197th Executive Meeting of the State Council approved the implementation of the Regulations on School Bus Safety Management, which puts forward special requirements for school buses with regard to license, drivers, travel safety, and safety on board.

On February 22nd, 1993, the 30th Meeting of the Standing Committee of the Seventh National People’s Congress adopted the Law of the PRC on Product Quality, which states the legal norms for product quality supervision and administration and the social relations that may occur when the producers/operators assume liability of compensation for any personal injury or property loss to others arising from or by defective products produced or operated by producers/operators. In 2012, the State Council released the Quality Development Outline (2011–2020), addressing that such departments like the Departments of Quality Inspection and Health jointly set up the National Injury Surveillance System.

In 2011, the Department of Disease Control and Prevention of the former Ministry of Health issued the Interventions for Drowning among Children Guidelines, the Interventions for Road Injuries among Children Guidelines, and the Interventions for Falls among Children Guidelines. In 2016, China’s Centre for Disease Control and Prevention led the compiling and publishing of the series of Interventions for Preventing Injuries among Children Guidelines, including the Guidelines for Interventions to Prevent Injuries among Children – Drowning, the Guideline for Interventions to Prevent Injuries among Children – Road Traffic Injuries, the Guideline for Interventions to Prevent Injuries among Children – Falls, the Guideline for Interventions to Prevent Injuries among Children – Unintentional Poisoning, and the Guideline for Interventions to Prevent Injuries among Children – Dog Bites or Scratches. All of these guidelines provide professional references to the specific personnel engaged in prevention and control of injuries at all levels; the workers in schools, communities and other sectors; and the households. 1.5.1.2 Implementation of new medical reform program to fully improve the level of maternal and child health care services In China, along with the deepening reform of the medical and health care system, maternal and child health activities are further strengthened, women and children’s health rights and interests are more effectively secured, and the health status of women and children is improving. Since 2009, China has implemented the basic public health care service program and maternal and child major public health program. For the purposes of prevention-oriented and rural-focused securement of basic needs, reinforcement of primary care services and establishment of new mechanisms, efforts have been made to upgrade the equalization of basic public health care services. The public expenditures of basic public health care services have gradually been increased – to RMB45 per capita in 2016. Moreover, a series of national basic public health care services are provided to urban and rural residents for free, such as residents’ health records, health education, vaccination, child health management, maternal health management, elderly health management, health management of people with chronic diseases, health management of people with severe mental disorders, health management of people with tuberculosis, health management using traditional Chinese medicine, reporting and disposal of

44 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

infectious diseases and emergent public health events, and supervision and coordination by health and family planning departments.

The Chinese government has launched a series of major public health care service programs against serious issues that may affect women and children’s health, such as the program to “reduce the maternal mortality ratio and eliminate neonatal tetanus” and the program of hospital delivery subsidies for rural pregnant women. • Hospital delivery subsidies for rural pregnant women: In 2015, this program benefited 8.80 million rural pregnant women. The rural hospital delivery rate reached 99.5%, and maternal and child safety was efficiently maintained. • Rural women inspection service for “two cancers”: The government calls for the inspection for cervical cancer and breast cancer (“two cancers”) among rural women of childbearing age in pilot areas. The program was initiated in 2009. As of 2015, China’s Central Government had allocated RMB1.68 billion financial funds to the cervical cancer inspection for 51.95 million rural women and breast cancer inspection for 7.47 million rural women in 1,299 counties, both higher than the expected targets. Various rural women benefited from this. • HIV, syphilis and hepatitis B PMTCT: This program includes free testing of HIV, syphilis and hepatitis B for pregnant women and free interventions for PMTCT for infected pregnant women and their infants, such as drug treatment, safe midwifery, instruction and support on evidence-based feeding practices, and follow-up surveillance, in order to lower the prevalence of HIV, syphilis or hepatitis B infection among children via mother-to-child transmission. In 2001, the HIV-PMTCT pilot program was initiated in one county. Since 2004, the program has received funds from the central government,

enabling coverage to extend year after year. In 2010, the integrated HIV, syphilis and hepatitis B Results PMTCT program was launched. This program covered many more areas and items, comprehensively covering all counties of the country in 2015. Over the past decade, the central government has allocated RMB6.18 billion cumulatively to ensure the smooth implementation of the program. As a result, the coverage of HIV, syphilis and hepatitis B PMTCT in China has declined consistently and the number of additional children infected with these diseases has decreased year after year. • Folic acid supplementation to prevent neural tube defects: The medical community has demonstrated that folic acid deficiency leads to higher incidence of neural tube defects, such as anencephalus and rachischisis. In order to reduce the incidence of neural tube defects, the Chinese government provides a free folic acid supplementation service for rural women at reproductive ages three months before and after they become pregnant. In 2015, the program was carried out and covered 10.837 million rural reproductive women. • Child nutrition improvement in poverty-stricken areas: Since 2012, the program of child nutrition improvement in poverty-stricken areas was firstly mobilized in 100 pilot counties in 8 connected and severely poverty-stricken areas, using the support of RMB100 million allocated by the central government. The program consists of daily nutritional packages rich in protein, vitamins and minerals for children 6 months to 2 years of age, health publicity materials and health education resources on child nutrition for the purpose of improving the nutrition and health status of children in poverty-stricken areas. By 2015, the program had spread into 341 counties in 21 provinces/municipalities/autonomous regions helping up to 1.67 million infants and young children, with the central government’s funds

45 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

increasing up to RMB500 million. Children’s nutrition and health status improved greatly. • Neonatal disease screening in poverty-stricken areas: The neonatal disease screening network has improved, contributing to the increase in the neonatal disease screening and treatment rates. In 2015, the screening rates for inherited metabolic diseases and hearing throughout the country reached 93.5% and 83.9%, respectively. The program of neonatal disease screening in poverty-stricken areas has covered 364 counties/townships in 21 provinces/municipalities. In 2012–2015, the free screening service was provided to 3.39 million newborns, so that the babies with diseases could be diagnosed and treated as early as possible. • Pilot program of thalassemia prevention and control: Thalassemia is a common inherited blood disease that causes birth defects. In China, thalassemia is highly prevalent in the areas to the south of the Yangtze River, including 10 provinces/municipalities/autonomous regions, namely, Guangxi, Guangdong, Hainan, Yunnan, Guizhou, Jiangxi, Fujian, Hunan, Sichuan and Chongqing. In order to increase the screening rate for thalassemia, the pilot program of thalassemia prevention and control was initiated in 2012 with the central government’s financial support in Guangxi, Hainan and Yunnan. In this program, local people were provided with primary thalassemia screening, genetic testing and prenatal diagnosis for free. In 2013, the program was extended to 7 provinces/autonomous regions: Fujian, Jiangxi, Guangdong, Guangxi, Hainan, Guizhou and Yunnan. In 2015, the program covered 126 counties/townships in the 10 provinces/municipalities/autonomous regions with the highest prevalence of thalassemia. During 2012 to 2015, 577,000 couples in pilot areas were provided with a free thalassemia screening, so that the birth rate of babies with severe thalassemia was effectively reduced. 1.5.2 Systems Over years of construction and development, a maternal and child health care service system with Chinese characteristics has been established. This system is technically supported by medium and large medical facilities and relevant research and teaching institutions, and it is based upon maternal and child health care facilities as well as practically executed by primary-level medical and health facilities. By virtue of this system, comprehensive, consistent and customized medical care services are offered to women and children. The maternal and child health care facilities at all levels, as the organizers, managers and suppliers of maternal and child health care services in their respective jurisdictions, play a leading role in the maternal and child health activities. The primary-level medical and health facilities, residing at the base of the maternal and child health care service system, are responsible for providing maternal and child health care services and collecting basic information. The obstetrics and gynaecology hospitals, children’s hospitals and general hospitals carry out the medical care services, like diagnosis and treatment of women and children with diseases. As of 2014 in China, there had been 3,098 maternal and child health care facilities at all levels (involving 308,000 employees and 308,000 beds), 622 obstetrics and gynaecology hospitals, 99 children’s hospitals, 34,000 community health care service centres/stations, 37,000 township hospitals, and 640,000 village clinics [32].

Throughout the country, the total number of health care personnel amounted to 10.234 million in 2014, 0.443 million or 4.5% more than that in 2013, including 7.589 million medical officers and 1.058 million village doctors and assistant nurses. Among the medical officers, there were 2.893 million practicing (assistant) physicians and 3.004 million registered nurses. The number of medical officers increased by 0.379 million or 5.3% from the level in 2013; among them, there were 122,000 practicing (assistant) paediatricians, as 4.0% of the total number, which means that a thousand of children were corresponding with 0.54 practicing (assistant) paediatricians, on average. According to the relevant survey, in 2010, there

46 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

were 5.5 medical personnel (in disciplines of obstetrics and gynaecology, paediatrics, and maternal and child health care) available for 10,000 people.

The disease prevention and control system is responsible for the child disease prevention activities, such as the prevention, immunization and interventions for infectious diseases among children and the safe and sanitary drilling of water for children. In 2015, there were 3,585 disease prevention and control centres at the country, province, city and county levels, employing 192,000 medical personnel, representing 22% of the total number of doctors in professional public health facilities. 1.5.3 Health expenditure China’s total recurrent health expenditure was RMB3,212.80 billion in 2014, of which the recurrent health expenditure for children was RMB196.56 billion, accounting for 6.1%, and equivalent to RMB2,525.5 (or US$380.8) per child, which was higher than the per capita recurrent health expenditure (RMB2,348.9) in the country. This implies the high attention with which China focuses on child health.

Among China’s recurrent health expenditures for children in 2014, public financing channels contributed RMB96.09 billion, comprising 48.9%, which was recorded as the largest financial source. As the second financial source, the family health cost amounted to RMB80.53 billion, comprising 41.0%. The remaining part was sourced from voluntary health care financing channels such as commercial medical insurance. The medical insurance coverage among children, especially newborns, is not high in China. According to the 5th National Health Services Survey in China (2013), the medical insurance coverage among newborns was only 22.0% and the coverage among infants aged 1–11 months was 60.7%, much lower than the coverage among adults. As a result, 40% or more of the health expenditure for children was shared by the family health care cost. Results In view of money flow, the health expenditure for children is divided into five parts: treatment services (including rehabilitation); auxiliary services; medical products, preventive services, and governance; health administration; and financing management. In 2014, the expenses for treatment services comprised the highest proportion of China’s recurrent health expenditure for children, up to 56.0%, or equivalent to RMB110.09 billion, of which the outpatient treatment services shared RMB43.41 billion and the inpatient treatment services shared RMB66.68 billion, as 22.1% and 33.9%, respectively. The expenses for preventive services, in second place, amounted to RMB62.64 billion, comprising 31.9% of recurrent health expenditure for children. The expenses for retail drugs and other medical products, in third place, accounted for 6.9% of the recurrent health expenditure for children (Table 1-20).

Table 1-20 Proportion of service functions in the recurrent health expenditure for children, 2014

Service function Amount (RMB,×108) Proportion (%)

Treatment services (including rehabilitation) 1100.9 56.0 Outpatient 434.1 22.1 Inpatient 666.8 33.9 Auxiliary services (unclear functionality) 3.6 0.2 Medical products (unclear functionality) 135.2 6.9 Preventive services 626.4 31.9 Governance, health administration and financing management 99.6 5.1 Total 1965.6 100.0

47 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

In 2014, the majority of China’s recurrent health expenditures for children were accrued in hospitals, which amounted to RMB95.85 billion, or about 48.8%. The second largest part accrued in relation to preventive service suppliers amounted to RMB48.31 billion, or about 24.6%. The recurrent health expenditure for children accrued in primary-level medical and health facilities was RMB23.96 billion, or about 12.2%. Other parts mainly included drugs and other medical product retail, health administration and financing management organizations (Table 1-21).

Table 1-21 Proportion of service organizations in the recurrent health expenditure for children, 2014

Service organization Amount (RMB,×108) Proportion (%)

Hospitals 958.5 48.8 Grass-root medical and health facilities 239.6 12.2 Outpatient service agencies 46.0 2.3 Auxiliary service suppliers 3.6 0.2 Medical product retailers and other facilities 135.2 6.9 Preventive service suppliers 483.1 24.6 Health administration and financing management organizations 99.6 5.1 Total 1965.6 100.0

Among the expenses for treatment services for children, in view of the global burden of disease (GBD), the infectious, maternal, perinatal and nutrition diseases comprised the highest proportion – up to 58.6% in 2014, equivalent to RMB64.54 billion. Non-infectious diseases ranked second – about 30.6%, equivalent to RMB33.65 billion. Injuries accounted for 3.4%, and other symptoms or diseases accounted for 7.4%, which refers to the cases that were not diagnosed or not confirmed as diseases through diagnosis as recorded in the treatment history, such as the symptoms like pain and some TCM diagnoses (Figure 1-21). According to the ICD–10 classification, China’s expenses for treatment services for children in 2014

Other symptoms or diseases Injuries 7.4% 3.4%

Non-infectious Infectious, diseases maternal, perinatal 30.6% and nutrition diseases 58.6%

Figure 1-21 Distribution of expenses for treatment services for children by GBD, 2014 Јቨ෵ႥᠠၹႽჁ౞ੇ὆(#% Ѭዝ὇ڎ˗ࣲ ڏ

48 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

were mainly for respiratory system diseases, amounting to RMB49.63 billion, or about 45.1%, which is much higher than other diseases. Diseases caused by some perinatal cases comprised RMB14.57 billion, or about 13.2%. The infectious diseases and parasitosis ranked in the third place, with an amount of RMB7.86 billion, or about 7.1%. The diseases of the digestive system ranked in the fourth place, with an amount of RMB7.71 billion, or about 7.0%. These four types of diseases shared 72.5% of the total expenses for treatment services for children.

In descending order of expenses by age group, the proportions for total expenses of treatment services for children aged 0–1, 1–2, 2–3, 3–4 and 4–5 were 29.3%, 22.1%, 18.5%, 16.7% and 13.4%, respectively. 1.5.4 IT application 1.5.4.1 Maternal and child health informatization The annual reporting informational system for maternal and child health was established in China in the early 1980s. The national birth defect surveillance network was formed in 1986; the national maternal mortality and under-five mortality surveillance networks were formed in 1989 and 1991, respectively. For purposes of integrating resources and improving efficiency, the birth defect, maternal mortality and under- five mortality surveillance networks merged into one system in 1996. Since that time, it has become the largest maternal and child health surveillance network around the world, covering 140 million people in 334 counties, and involving 765 birth defect surveillance hospitals. Under this integrated network, population surveillance is performed for birth defects in 64 counties. In 2005, the National Maternal and Child Health Care Facilities Surveillance System was established. Along with the electronic and informational changes, the surveillance and reporting means have been upgraded substantially. For example, information on maternal and child health can be reported directly online, with much higher

quality and efficiency than before. Over the past years, relevant data in the national maternal and child Results health surveillance network were frequently cited by the National Bureau of Statistics of the PRC, the National Working Committee on Children and Women under State Council (NWCCW) and other international organizations. The information about maternal and child health was adopted by governments at all levels as rational evidence to create health policies, especially maternal and child health policies. 1.5.4.2 Child nutrition surveillance The nutrition surveillance in China includes investigation into the nutrition and health status of Chinese residents and specific surveys and monitoring on child nutrition and health. The latter is yielded from the Survey on Physique Growth of Under-seven Children in Nine Cities of China, the Chinese Food and Nutrition Surveillance System, and the National Child Nutrition and Health Surveillance.

The investigation on nutrition and health status of Chinese residents was conducted in 1959, 1982, 1992 and 2002, respectively. Since 2010, the investigation interval has been adjusted from 10 years to 5 years, and children under 5 have been selected as a target population.

The Survey on Physique Growth of Under-seven Children in Nine Cities of China was started in 1975. Since then, the decennial activity has been carried out in five rounds in nine cities including Beijing and Harbin. Since 1990, the Chinese Food and Nutrition Surveillance System has been used to monitor the nutrition and health indicators of children under five. During 1990 to 2010, 8 rounds of surveillance were completed. In 2010, the system was integrated into the Chinese Resident Nutrition and Health Surveillance System. The National Child Nutrition and Health Surveillance commenced in 2011 to detect the growth,

49 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

development and nutrition of children across China every year.

For years, the child nutrition surveillance systems have been improving. They provide convenient and efficient platforms for related parties to understand the updated nutritional status and its changes for children and also offer evidence for the state to create applicable policies and interventions for child health. 1.5.4.3 Injury surveillance system The former Ministry of Health of the PRC established the National Injury Surveillance System in 2005, in order to consistently and systematically analyse information about injuries collected from the emergency treatment departments (including injury-specific outpatient departments) of 127 hospitals in 43 counties of China. In 2012, Chinese Center for Disease Control and Prevention released the National Injury Surveillance Program and formally set up the integrated injury surveillance system. This system fully reflects the prevalence of injuries in target areas after comprehensively analysing injury cases, including deaths, hospitalization, outpatient and emergency treatment.

Moreover, as a part of the investigation on utilization of health care services in China, injuries were incorporated into the coverage of the extensive epidemiological survey. Due to this survey, the information in relation to injuries, such as origination, dangerous factors, and disease burden, was collected. The National Center for Chronic and Noncommunicable Disease Control and Prevention, China CDC and the Defective Product Administrative Center of General Administration of Quality Supervision, Inspection and Quarantine of the PRC made a joint study on the modes of product-induced injury surveillance. 1.5.4.4 Infectious disease reporting system In China, a real-time network surveillance system covering 37 notifiable infectious diseases is available currently. It is integral to China’s nationwide disease prevention/control and public health information systems. The real-time network surveillance system comprises a five-level (from county to state) infectious disease network surveillance and reporting system and a three-level (from city to state) network platform. As required, any case of infectious disease tested in a hospital shall be reported via Internet/NPN, in a real-time manner, to the central database of Chinese Center for Disease Control and Prevention. All medical and health facilities within the country are allowed to freely access the central database to search the information they want. Accordingly, the real-time reporting of individual infectious disease and the surveillance on dangerous factors and symptoms make it possible to keep a timely early warning against any potential disease. 1.5.4.5 Immunization information surveillance system China’s immunization information surveillance system includes vaccination case management, vaccine management, injector management, suspected adverse reactions after vaccination, and other aspects. It is designed to systematically collect, analyse and assess the information to be monitored under the extended program on immunization, including routine immunization and cold-chain equipment and vaccination organizations, so as to provide references for the scientific analysis, evaluation and improvement of immunization activities. 1.5.5 Supplies To ensure the implementation of basic and major maternal and child health care services, relevant authorities develop and enforce strict management systems. For example, clear management rules are kept in place with regards to key sectors such as the procurement, storage, transportation and distribution of certain drugs, vaccines, and nutritional packages, as well as capital management. Moreover, the supervision is thus enhanced. So far, China has made great achievements in supplying essential medicines to women and children. Nevertheless, the preventive iron agents/various micronutrients for pregnant

50 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

women, vitamin-A and zinc for children, and zinc agents for child diarrhoea have not been included in the National Essential Medicines List. Some medicines in the National Essential Medicines List, such as oral rehydration salts, have not been widely circulated. 1.5.5.1 National program of folic acid supplementation for preventing neural tube defects All provinces/municipalities/autonomous regions strengthen the management of bidding, procurement and distribution of folic acid, with clear responsibilities. The health and family planning administrative department of each province/municipality/autonomous region determines the annual quantity of folic acid demanded in the province/municipality/autonomous region, procures the folic acid by way of centralized bidding as required under the applicable national regulations, and distributes the folic acid procured to all counties by level according to the plan. The health and family planning administrative department of each county should organize, manage and supervise the distribution of folic acid in the county according to relevant procedures via services such as premarital health care, preconception health care, gestation health care, and family planning technical services, and they should report the quantity of folic acid demanded as required. The township/community hospitals are responsible for allocating the folic acid to village clinics, and also for instructing and supervising the village clinics in the appropriate distribution and management of folic acid. Moreover, the township/community hospitals are responsible for distributing folic acid to high-risk women planning to become pregnant within their prospective jurisdictions. The village doctors or health-care assistants are responsible for understanding the pregnancy plan of women at reproductive ages in the village, distributing folic acid to the women planning to become pregnant in the village (as well as follow-up thereafter), and collecting, collating and reporting the information about the distribution and taking of folic acid. The village doctors or health-care assistants also must report the information about the high-risk women planning to become pregnant in the village in a timely manner, and follow up, Results supervise and record the folic acid taken by these women. 1.5.5.2 Program of child nutrition improvement in poverty-stricken areas To ensure the smooth implementation of the program, NHC and All-China Women’s Federation jointly issued the implementation scheme and technical scheme. Under these schemes, 21 target provinces/ municipalities/autonomous regions are required to have strict management of the bidding, procurement, distribution and storage of nutritional packages, publicity, health education, training, information reporting, and supervision & evaluation; and they must clarify the roles and responsibilities of relevant departments at all levels. A program management office should be set up at each level of the maternal and child health care facilities. The health administration department of each province/municipality/autonomous region should determine the annual quantity of nutritional packages demanded depending on the average allocation per month, procure the nutritional packages by way of centralized bidding and as per applicable national regulations, and deliver the nutritional packages according to uniform procedures to all target counties as planned. The personnel of primary-level medical and health facilities are responsible for distributing the nutritional packages, with the support of women associations’ propaganda and mobilization and in conjunction with the activities of vaccination, child health care services, and guidance services for early family education for children. The health administration department and program management office of each county should arrange the distribution of nutritional packages according to relevant procedures, and carry out corresponding management activities. The township hospitals should distribute the nutritional packages to village clinics, and guide, follow up and supervise the village clinics in distribution and storage of the nutritional packages. The village doctor(s) should be responsible for distributing the nutritional packages and

51 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

conducting follow-up in the village, documenting periodic statistics and reporting, and working with the head of women’s representatives in the village to carry out publicity to educate villagers with regards to evidence- based feeding of children. 1.5.5.3 PMTCT materials supply management Chinese government provides full funding for the PMTCT materials. Through overall planning and uniform coordination, efficient materials are procured and supplies are provided under which the central government and local governments share the relevant work in a coordinative manner in order to ensure the sustained and timely supply of PMTCT materials.

The PMTCT materials mainly serve for screening among pregnant women and multiple aspects in relation to infected pregnant women and their infants, including test, treatment and feeding, and they are fully funded by the central government. The central bidding & local procurement mode and the local bidding & procurement mode are combined, and the materials procured are managed in a localized manner. The special or urgently-needed PMTCT materials are often supplied with the coordination of the central government. Over the past decade, the supply of PMTCT materials in China underwent a process evolving from the donation from international organizations to self-sufficiency, from the dominance of imported medicines to the dominance of domestic medicines, and from small-scale procurement to public procurement bidding arranged by the government. Thus, a set of complete, orderly and efficient PMTCT-material-procurement- supply-management system with Chinese characteristics has emerged gradually. This system facilitates the cost reduction and also the sustained and timely supply of necessary materials. 1.5.5.4 Cold-chain management of immunization vaccines In 31 provinces/municipalities/autonomous regions and the Xinjiang Production & Construction Corps of China, all disease prevention and control centres maintain cold-chain equipment and facilities for low-temperature storage and handling of immunization vaccines. This enables the vaccines to always be kept in the required cold state and ensure the vaccines’ reasonable potency throughout the process, from production to storage to transportation to distribution and finally to use. The former Ministry of Health of the PRC formulated and issued the Specification for Vaccination (MoH W-J [2005] No.373) to clarify stipulations on the management of cold-chain equipment for disease prevention and control of organizations at all levels. The Specification for Vaccination also put forward explicit requirements for the configuration, supplementation and updating of cold-chain equipment; the utilization and maintenance of common cold-chain equipment; the surveillance and evaluation of cold-chain systems; and other aspects. 1.5.6 Supervision and evaluation 1.5.6.1 Programs for women and children’s development in China NWCCW gathered relevant experts to create the supervision and evaluation work plan and set up an advisory group to supervise and evaluate the implementation of the Program for Women’s Development in China and the Program for Children’s Development in China in each province/municipality/autonomous region. To be specific, the interim and final realizations of targets in the programs were systematically evaluated, and the reproducible and generalizable practices in the implementation of these programs were summarized. The bottlenecks with regard to mechanisms/systems in the implementation of the programs were identified, and improvement measures were proposed. Moreover, the sense of responsibility of local governments at all levels and relevant departments was enhanced. Through all these efforts, a favourable social environment was created for women and children’s development in a well-rounded way.

52 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

1.5.6.2 Basic and major public health care services In addition to deepening the reform of the medical and health system, China offers basic and major public health care services. Multiple efforts were taken with regards to the supervision and evaluation of services to ensure these services were carried out as expected. The NHC created the supervision and evaluation work plan and arranged regular reviews to supervise and evaluate the management, capital operation, implementation, quality control and effectiveness of the services. The health and family planning administration departments at all levels were required to enhance the organizational leadership and management, and they were responsible for supervising and evaluating the implementation of the services. Each local government was required to schedule the implementation in a reasonable manner, depending on the actual situations within its jurisdiction, and intensify the supervision and inspection related to the preparation and execution of the implementation scheme as needed. Each health and family planning administrative department at the provincial level was required to submit an annual summary report to the NHC. The NHC specially examined the capital utilization and services implementation in each province/municipality/autonomous region when necessary. The supervision and evaluation systems were established, daily information was carefully collected, and relevant experts were regularly mobilized to supervise and evaluate the implementation at the grassroots level in order to measure the application of each intervention and put forward pertinent opinions and suggestions on future activities. 1.5.6.3 Assessment of demonstration counties with excellent maternal and child health care services In order to enable governments at all levels to pay more attention to maternal and child health care, comprehensively promote the quality and management of maternal and child health care services, improve the fairness and accessibility of maternal and child health care services, continuously enhance the maternal and child health care levels, creat new brand of excellent services, and facilitate the development of Results maternal and child health care causes, the NHC has launched a demonstration project to ensure excellent maternal and child health care services throughout the country. Starting in 2014, the NHC has been using this project to assess and select the demonstration counties with excellent maternal and child health care services every year. This project is designed to fully improve the level of maternal and child health care services through guidance, demonstration and popularization. The candidates are mainly assessed for performance of governmental duties, adherence to rational direction, establishment of a service system, improvement of rules and regulations, demonstration of routine supervision and management, improvement of service level, assurance of service quality, accomplishment of tasks/targets, acceptance of social supervision, and development of a good reputation in the industry. 1.5.6.4 Immunization activities Routine supervision and special supervision are carried out regularly on immunization activities throughout the country. Routine supervision involves the following: vaccination arrangement and personnel configuration for all disease prevention and control organizations, vaccine use management, management and operation of cold-chain equipment, safe injection and vaccination services, disease surveillance, activities for improving the immunization coverage, and other aspects. Special supervision involves the acute flaccid paralysis (AFP) case surveillance, safe injection, measles control and other aspects. Through such supervision, the vaccination activities in local areas/regions are evaluated to figure out any potential problem and cause; then, related solutions are proposed, and the specific work plan is prepared. Moreover, when a problem is found, solutions and work plan are reported in a timely manner to relevant authorities and directors. In this way, the level of immunization services in China is expected to improve.

53 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

2 Interventions and Cost-effectiveness 2.1 Maternal and child health care intervention package 2.1.1 Maternal and child health care intervention package Child health status and the supply, utilization, influencing factors, equity and health system support of child health care services in China were comprehensively analysed. Then, through a literature review, an expert workshop and continuous dialogue, the study team aligned the globally-advocated, traceable, and cost-effective interventions for reducing maternal and child mortality and promoting child development with China’s realities to determine the maternal and child health care intervention package, which includes a total of 106 interventions.

The service package involves six periods, i.e. adolescence period, preconception/pre-marriage period, foetus/gestational period, birth/delivery period, neonatal/postnatal period, and infancy and childhood period. In addition, it is specified that the interventions are implemented via channels at eight levels, namely: households; village clinics/community health care service stations; township hospitals and community health care service centres; medical facilities at the county level or above; communities; schools/nurseries and kindergartens; media; and other sectors, such as enterprises, water, agriculture, environmental protection, and transport, as indicated in Annexes 1–3. 2.1.1.1 Common interventions in all periods Various interventions are implemented at different levels. (1) Individuals and households: determination of personal hygiene behaviours. (2) All medical facilities (village, county, township level and above, and community health care service organizations): health education, configuration of handwashing facilities, and establishment of handwashing soap/liquid, handwashing posters and hot water, etc. (3) Media: health education. (4) Sectors such as enterprises, water, agriculture, environmental protection, and transport: environmental improvement to avoid lead poisoning, supply safe drinking water, improve lavatories and safe disposal of faeces, configure handwashing facilities, and make handwashing soap/liquid available. 2.1.1.2 Interventions in each period Except for the common interventions mentioned above, each of the six periods corresponds to unique interventions to be implemented via channels at different levels.

• Adolescence period (1) Township hospitals and community health care service centres: prevention of unwanted pregnancy, prevention and control of sexually transmitted diseases like HIV and syphilis, and nutritional counselling. (2) Medical facilities at county level or above (in addition to those at the level of township hospitals and community health care service centres): safe termination of pregnancy. (3) Schools/nurseries and kindergartens: nutrimeals and fortified foods for students.

• Preconception/pre-marriage period (1) Individuals and households: weight management, oral administration of nutritional supplements like folic acid. (2) Township hospitals and community health care service centres: pre-pregnancy counselling; dental care, screening for anaemia and diabetes; and tests for HIV, syphilis and hepatitis B. (3) Medical facilities at the county level or above (in addition to those at the level of township hospitals

54 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

and community health care service centres): prevention and control of sexually transmitted diseases, and screening for thyroid function.

• Foetus/gestational period (1) Individuals and households: weight management and intake of nutritional packages for pregnant women (supplementation of various nutrients like iron, folic acid, calcium and iodine). (2) Township hospitals and community health care service centres: gestational health management; nutritional counselling; prevention and treatment of pregnancy complications; early screening, intervention, treatment, follow-up and management for HIV, syphilis and hepatitis B; antenatal care; screening and referral of high-risk pregnant women; safe abortion in case of unintended pregnancy and post-abortion health care. (3) Medical facilities at the county level or above (in addition to those at the level of township hospitals and community health care service centres): antibiotic therapy for preterm premature rupture of the membrane, induction of labour due to pre-labour rupture of the membrane at-term, corticosteroids for babies <35 weeks gestation, screening for birth defects, preterm birth management, treatment and management of severe pregnancy complications, and technical guidance for subsidiaries.

• Birth/delivery period (1) Township hospitals and community health care service centres: hospital delivery; safe delivery; encouragement of vaginal delivery; timely identification and treatment of dystocia; prevention of preterm birth; prevention of postpartum haemorrhage; timely testing for HIV, syphilis and hepatitis B; safe midwifery and supporting treatments for infected pregnant women; screening for other high-risk factors; intrapartum monitoring and management for pregnancy complications; early detection and interventions for emergency and severe cases; neonatal resuscitation; prevention of birth injuries; special care and Results antiretroviral therapy for HIV-exposed children for PMTCT; special care for syphilis-exposed children; quantitative detection by non-syphilis treponemal antigen serological test; necessary prophylactic treatments; hepatitis B immunoglobulin immunization; delivery of health education; and safe referral. (2) Medical facilities at the county level or above (in addition to those at the level of township hospitals and community health care service centres): induction at 41 weeks, indications of caesarean section, haemostasis with uterus reserved, treatment of postpartum haemorrhage, and use of prophylactic antibiotics for high-risk pregnant women.

• Neonatal/postnatal period (1) Households: postnatal nutrition, breastfeeding, umbilical cord and skin care, thermal care, vitamin D supplementation, prevention of puerperal infection, and attention to puerperium mental health. (2) Village clinics/community health care service stations: postnatal care for babies within 28 days, postnatal care for mothers, and prevention of postpartum haemorrhage. (3) Township hospitals and community health care service centres: early initiation of breastfeeding, support feeding of underweight and preterm babies, timely thermal care, use of kangaroo mother care, neonatal disease screening, monitoring of newborns with risk of hypoglycaemia, newborn vitamin-K supplementation, guidance of breastfeeding, BCG and hepatitis B immunizations, antiretroviral therapy, preferential artificial feeding and prohibition of mixed feeding for HIV-exposed children, antiretroviral therapy for mothers or babies exclusively breastfeeding, testing and necessary treatment for syphilis- exposed children, and identification and referral of neonatal jaundice and other severe cases. (4) Medical facilities at county level or above (additional to those at the level of township hospitals and

55 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

community health care service centres): use of prophylactic antibiotics for newborns with the risk of bacterial infection; use of surfactants (for the respiratory system) to prevent preterm respiratory distress syndrome; use of continuous positive airway pressure (CPAP) to treat infant respiratory distress syndrome; treatment of neonatal septicaemia, meningitis and pneumonia; treatment of neonatal jaundice; and treatment of maternal anaemia.

• Infancy and childhood period (1) Households: exclusive breastfeeding under 6 months; breastfeeding and introduction of solid, semisolid or soft foods at 6-24 months; breastfeeding in special cases; administration of the child nutritional package; child injury prevention; and child abuse prevention. (2) Township hospitals and community health care service centres: child growth surveillance and intervention management, routine immunization, Type II vaccine immunizations, severe acute malnutrition management, nutrition interventions, child pneumonia management, diarrhoea management, HFMD management, comprehensive management of tuberculosis-exposed children, comprehensive management of HIV/syphilis- exposed children, antiretroviral therapy for HIV-exposed infants, and child injury surveillance. (3) Medical facilities at county level or above (in addition to those at the level of township hospitals and community health care service centres): diagnosis and treatment of severe child diseases. (4) Communities: child injury intervention and child abuse prevention. (5) Schools/nurseries and kindergartens: child health management, canteen safety and health management and catering instruction, and environmental lead poisoning. 2.1.2 High-impact intervention package Through expert consultations and workshops, traceable interventions that have been proven to reduce child mortality but not yet implemented effectively and widely in China were selected from the 106 interventions in the maternal and child health care intervention package as preferential interventions (thus named the high-impact intervention package), and these were well-aligned with current major and basic public health care services. These interventions also were analysed and estimated for cost-effectiveness by using the OneHealth Tool (OHT) recommended by WHO, together with the data from practical maternal and child health care interventions in China. 2.1.2.1 High-impact intervention package selection principles (1) The interventions included in both the Global Review of the Key Interventions Related to Reproductive, Maternal, Newborn and Child Health recommended by WHO and the Maternal and Child Health Care Intervention Package. (2) The traceable interventions, namely, those interventions also are included in the LIST module of the OHT. (3) Some interventions are to be deleted, added or split by the expert team depending on China’s reality. For example, the interventions that are incompatible with the situation in China (e.g. distribution of insecticide- treated nets for preventing maternal and child malaria) and cause no effect on the under-five mortality (e.g. hepatitis B vaccines for children) are excluded; the interventions with repeated content or action items are combined; and the interventions with generalized contents are subdivided to be more specific. 2.1.2.2 Process of high-impact intervention package selection Through 5 rounds of expert consultation and a 3-step selection (Figure 2-1), a high-impact intervention package consisting of 24 interventions was determined (Box 2-1).

56 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

CSS 24 inter- (106 interventions) 44 interventions 33 interventions ventions

Deleted: 62 interventions not Deleted: 16 interventions not traceable; Merged: 4 interventions merged recommended by WHO 3 interventions incompatible with the into 2 interventions. situation in China. Deleted: 7 interventions that Merged: 4 interventions merged into 2 already have covered all the interventions. population or cannot be estimated Subdivided: 4 interventions subdivided for effectiveness. into 12 interventions.

Figure 2-1 Process of high-impact intervention package selection

Box 2-1 High-impact intervention package consisting of 24 interventions

1 Syphilis surveillance and treatment 13 Neonatal septicaemia (antibiotic injection) 2 Safe termination of pregnancy 14 Exclusive breastfeeding under 6 months 3 Supplementation of nutrients like folic acid, iron and calcium for 15 Breastfeeding and introduction of solid, semisolid or soft foods at pregnant women 6-24 months 4 Oral administration of nutritional supplements like folic acid for 16 DPT vaccine perinatal pregnant women

5 Prevention and treatment of pregnancy-induced hypertension 17 Measles vaccine Results 6 Prevention and treatment of abortion complications 18 Haemophilus influenzae vaccine 7 Prevention and management of postpartum haemorrhage 19 Pneumococcal vaccine 8 Indicative caesarean section 20 Rotavirus vaccine 9 Use of antibiotic therapy for preterm premature rupture of the 21 Child pneumonia management (antibiotic therapy) membrane 10 Neonatal resuscitation 22 Diarrhoea management (ORS) 11 Kangaroo mother care 23 Diarrhoea management (zinc) 12 Neonatal septicaemia (fully supporting therapy) 24 Appropriate antibiotics for dysentery

2.2 Intervention bottleneck analysis Bottleneck analysis was conducted for the maternal and child health care intervention package in order to identify the barriers, bottlenecks and favourable factors that may restrict or facilitate the expected implementation of the interventions. The analysis covered 10 decisive factors related to the supportive environment, supply-side, demand-side and service quality (Table 2-1).

57 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

Table 2-1 Bottleneck analysis involving 10 decisive factors

Aspect Decisive factors

Supportive environment Social norms Policies and regulations Budget, financing and expenditure Management and coordination Supply-side Accessibility to basic medical supplies Accessibility to medical services and information that are provided by sufficient medical personnel Demand-side Impacts of economic factors on accessibility to services Society, culture, customs and behaviours Sustainable utilization of services Service quality Coverage of effective interventions

The bottleneck analysis for the maternal and child health care intervention package is detailed in Annex 4. For example, during the adolescence period, the bottlenecks are as follows: (1) Supportive environment: — Adolescents’ open sexual consciousness and earlier first sex; — Unavailability of national laws and regulations on adolescent health care and adolescent (non- school) medical insurance policies; — Lack of regular budget, but only the specific project fund is limited in amount; — Insufficient budget for free contraceptive distribution to cover the entire population at reproductive ages; — No long-acting mechanism of cooperation among sectors (e.g. Ministry of Education, Committee for the Wellbeing of the Youth, Health and Family Planning Commission, and communities). (2) Supply-side: — No service places, contraceptives, models, or propaganda materials in medical facilities; — No full-time medical staff or low consulting capabilities of medical staff; — Unavailability of adolescent health care outpatient services. (3) Demand-side: — No economic independence and no economic sources for adolescents because they are subject to their household economy; — Not speaking publicly about sex-related matters due to social customs and discrimination against premarital pregnancy due to social customs; — Inconvenience of receiving continuous services for out-of-school adolescents because they are mobile; — Inconvenience of receiving continuous services for in-school adolescents because they are subject to restrictions on their time due to their courses. (4) Service quality: — Coverage of only a few services and insufficient adolescent health care services.

58 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

2.3 Cost-effectiveness analysis By using the OHT, which already has been successfully applied in several countries to analyse maternal and child health status [42-59], the selected 24 high-impact interventions were analysed for cost- effectiveness. Then, based on the current maternal and child health activities in China, the modes and priorities recommended for implementing certain interventions were proposed. These recommendations provided helpful evidence to health decision makers in order for them to define the targets and focus with regards to maternal and child health during the time period of the 13th Five-Year Plan. 2.3.1 Effect analysis for the high-impact intervention package 2.3.1.1 Effect in reducing the child/maternal mortality During 2015–2020, the neonatal, infant and under-five mortality rates declined year after year as the coverage of the 24 interventions expanded (Figure 2-2). At the end of 2020, the neonatal, infant and under- five mortality rates will be 5.4‰, 6.2‰ and 8.3‰, respectively, having decreased by 29.9%, 30.3% and 29.1% from the levels reported in 2015. The deaths of 79,000 newborns and 126,000 children under-five can be avoided. In the same period, the maternal mortality ratio also will drop year after year, as the coverage of the 24 interventions expands. At the end of 2020, it will decline by 36.9% to 13.7/100,000 live births, and avoid the deaths of a total of 2,815 pregnant women (Figure 2-3). 2.3.1.2 Effects of interventions Among 24 interventions, the top 10 interventions with the optimal effects are (in descending order of number of preventable deaths in 6 years from 2015 to 2020): indicative caesarean section, child pneumonia management (antibiotic therapy), kangaroo mother care, exclusive breastfeeding under 6 months, pneumococcal vaccine, haemophilus influenzae vaccine, neonatal resuscitation, diarrhoea Results management (ORS), nutritional package for pregnant women (supplementation of nutrients like folic acid, iron and calcium for pregnant women), and neonatal septicaemia (fully supportive therapy) (Figure 2-4). Typically, the indicative caesarean section prevents the largest number of deaths: 34,000 in 6 years. All of

14.0 14.014.0 14.0 12.0 11.7 12.012.0 12.011.711.7 11.7 ↫ ↫ ↫ 10.↫0 8.9 ӑ10.010.0 10.08.9 8.9 8.9 ӑ ӑ 8.0ӑ 8.3 ⦷8.0 8.0 8.0 8.3 8.3 8.3 ⦷ ⦷ ⦷ 7.7 6.0 7.7 7.7 7.7 6.2 ‰6.0 6.0 6.0 6.2 5.46.2 6.2 ‰ ‰Mortality rate (‰) 4.0‰ 5.4 5.4 5.4 4.0 4.0 4.0 2.0 2.0 2.0 2.0 0.0 0.0 0.0 0.0 2015 20162017 20182019 2020 Year 201520152012015622016220101627 017 201017822018220101829 019 202019020202020

⦷ᯠ⭏ݯ↫ӑ⦷ Ⴄݯ↫ӑ⦷ ӄ኱ԕлݯㄕ↫ӑ ⦷ ᯠ⭏ݯ↫ӑ⦷Neonatalᯠ⭏ݯ↫ӑ⦷ mortalityᯠ⭏ݯ↫ӑ⦷ rate Ⴄݯ↫ӑ⦷Ⴄݯ↫ӑ⦷Infant Ⴄݯ↫ӑ⦷mortality rateӄ኱ԕлݯㄕ ӄ኱ԕлݯㄕӄ኱ԕлݯㄕUnder-five↫ӑ ↫ӑmortality⦷ ⦷↫ӑ rate

Јቨ൫̒ဋᄊԫӑᡖҹ ڏ Child mortalityЈቨ൫̒ဋᄊԫӑᡖҹЈቨ൫̒ဋᄊԫӑᡖҹ rateЈቨ൫̒ဋᄊԫӑᡖҹ in 2015–2020 ڏ2-2 ڏFigureڏ 59

25.0 ↫25.025.0 25.0 21.7 ↫ ↫ ↫ 21.721.7 21.7 ӑ 20.0 ӑ 20.ӑ020.ӑ0 20.0 ⦷ ⦷ ⦷ 15.⦷0 15.015.0 15.0 13.7 ⇿ 13.713.7 13.7 ⇿ ⇿ ⇿ 10.0 10. 010.0 10.0 5.0 з5.0 5.0 5.0 з з з 0.0 0.0 0.0 0.0 201520162017 2018 2019 2020 201522015220101526201620101627 017 201017820182012018920192012029020202020

ඈ ʺำ̗̗ݤ˗ߙ̗ݤ൫̒ဋԫӑᡖҹ ڏ ඈʺำ̗̗ݤ˗ߙ̗ݤ൫̒ဋԫӑᡖҹ ʺำ̗̗ݤ˗ߙ̗ݤ൫̒ဋԫӑᡖҹ ʺำ̗̗ݤ˗ߙ̗ݤ൫̒ဋԫӑᡖҹڏඈ ڏඈ ڏ 14.0 12.0 11.7

↫ 10.0 8.9 ӑ 8.3 ⦷ 8.0 7.7 6.0 6.2 ‰ 5.4 4.0 2.0 0.0 2015 20162017 20182019 2020

⦷ᯠ⭏ݯ↫ӑ⦷ Ⴄݯ↫ӑ⦷ ӄ኱ԕлݯㄕ↫ӑ

Јቨ൫̒ဋᄊԫӑᡖҹ ڏ Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

25.0 ↫ 21.7 ӑ 20.0 ⦷ 15.0 13.7 ⇿ 10.0 5.0

зMortality ratio (/100,000) 0.0 201520162017 2018 2019 2020 Year

Figure 2-3 Maternal mortality ratio (per 100 000 live births) in 2015–2020 ඈ ʺำ̗̗ݤ˗ߙ̗ݤ൫̒ဋԫӑᡖҹ ڏ

Indicative caesarean section

Child pneumonia management (antibiotic therapy)

Kangaroo mother care

Exclusive breastfeeding under 6 months

Pneumococcal vaccine

Haemophilus influenzae vaccine

Neonatal resuscitation

Diarrhoea management (ORS)

Supplementation of nutrients like folic acid, iron and calcium for pregnant women (nutritional package for pregnant women) Neonatal septicemia (fully supporting therapy)

Breastfeeding and introduction of solid, semisolid or soft foods at 6-24 months

Rotavirus vaccine

Oral administration of nutritional supplements like folic acid for perinatal pregnant women Use of antibiotic therapy for preterm premature rupture of membrane

Diarrhoea management (zinc)

Neonatal septicemia (antibiotic injection)

DPT vaccine

Prevention and management of postpartum haemorrhage

Prevention and treatment of pregnancy-induced hypertension

Measles vaccine

Dysentery (antibiotic therapy)

Syphilis surveillance and treatment

Safe termination of pregnancy

Prevention and treatment of abortion complications

Figure 2-4 Ranking of interventions by the cumulative number of preventable child and maternal ՊᮊࣰᮕᥘВЈቨdeaths in 2015–2020 ߙ̗ݤ൫̒஝ଆՐ ڏ

350.0 305.0 ᙫ 300.0 270.0 ᡀ 250.0 232.5 191.2 ᵜ 200.0 145.9 150.0 ӯ 94.5 100.0 ݳ 50.0 0.0 ᒤ 2015 2016 2017 2018 2019 2020

ᒰ ࣲᕲֶ Ᏺెೝᰎࣲ঴ੇవ὆̣Ћ὇ ڏ Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

ՊᮊࣰᮕᥘВЈቨ ߙ̗ݤ൫̒஝ଆՐ ڏ the top 10 interventions can prevent 105,000 deaths, meaning 91.0% of the total number of preventable deaths can be avoided by using the high-impact intervention package. 2.3.2 Cost estimation From 2015 to 2020, the direct costs (medicines/consumables/inspection costs) in implementing the 24 high-impact interventions will be RMB123.92 billion. As the coverage of the interventions expands, the medicines/consumables/inspection costs will grow year after year (Figure 2-5).

350.0 305.0

ᙫ) 8 300.0 270.0 ᡀ 250.0 232.5 191.2 ᵜ 200.0 145.9 150.0 ӯ 94.5 100.0 ݳ

Total costs (RMB, ×10 Total 50.0 0.0 ᒤ 2015 2016 2017 2018 2019 2020 Year

(Total medicines/consumables/inspectionᒰ ࣲᕲֶ Ᏺెೝᰎࣲ঴ੇవ὆̣Ћ὇ costs in 2015–2020 (RMB, ×108 ڏFigure 2-5

2.3.3 Cost-effectiveness analysis The top 10 interventions with regards to cost-effectiveness are: child pneumonia management (antibiotic therapy), kangaroo mother care, indicative caesarean section, exclusive breastfeeding under 6 months, neonatal resuscitation, neonatal septicaemia (antibiotic injection), prevention and treatment of abortion Results complications, neonatal septicaemia (fully supporting therapy), prevention and management of postpartum haemorrhage, and diarrhoea management (ORS) (Figure 2-6). Among these interventions, three interventions are for under-five children, four interventions are for newborns, and three interventions are for pregnant women. It is important to note that seven interventions are therapeutic interventions and three interventions are preventive interventions. 2.3.4 Scenario analysis 2.3.4.1 Stratified analysis of high-impact interventions Table 2-2 shows the top 10 interventions by cost-effectiveness and effect, respectively. In the table, the interventions marked in bold italics are coincidental: namely, interventions with both optimal effects and optimal cost-effectiveness. Such interventions are: child pneumonia management (antibiotic therapy), indicative caesarean section, kangaroo mother care, exclusive breastfeeding under 6 months, neonatal resuscitation, and neonatal septicemia (fully supporting therapy). The high-impact interventions are stratified into layers by cost-effectiveness and effects (Figure 2-7), and the analysis is carried out step-by- step for different layers.

Step 1: Analyse the impact on the costs and preventable deaths for the top six interventions of both optimal effects and optimal cost-effectiveness. The six interventions identified account for 69.6% of the 24 high-impact interventions with respect to preventable deaths, and only for 0.6% with respect to costs. Step 2: Analyse the cost and effect of the top 10 interventions with optimal cost-effectiveness, including the aforementioned six core high-impact interventions and additional four interventions with optimal

61 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

˅ݯㄕ㛪⚾㇑⨶Child pneumonia management˄ᣇ⭏㍐ (antibioticⲴ֯ therapy)⭘ 574.1 4903.9 㺻啐ྸྸᣔ⨶Kangaroo mother care 6805.2 ᤷᖱᙗࢆᇛӗIndicative caesarean section᡻ᵟ 11064.0 6Exclusiveњᴸ޵㓟⇽ңலޫ breastfeeding under 6 months ᯠ⭏ݯ༽㣿Neonatal resuscitation 18913.5 37664.3 ᯠ⭏ݯ䍕㹰⯷Neonatal septicemia (antibiotic-ᣇ⭏㍐⌘ injection)ሴࡲ 50689.1 ⍱ӗᒦਁ⯷䱢⋫Prevention and treatment of abortion complications 80365.7 (supporting᭟ᤱ⋫⯇ therapy ޘᯠ⭏ݯ䍕㹰⯷Neonatal septicemia (fullyᆼ 83742.6 - ӗਾࠪ㹰Ⲵ亴Prevention and management䱢઼ of㇑⨶ postpartum haemorrhage 85717.8 87640.5 ਓᴽ㺕⏢ⴀDiarrhoea management (ORS) 87746.6 ẵ∂Ⲵⴁ⍻оSyphilis surveillance ⋫⯇and treatment 293319.6 6Breastfeedingњᴸ-2኱㔗㔝⇽ң and introductionலޫ of solid,ᒦ␫ semisolid࣐䖵 or伏 soft foods at 6-24 months ሩ㛾㟌ᰙ⹤ᰙUse of antibiotic therapyӗݯ for ֯⭘pretermᣇ⭏ premature㍐ 377352.2 rupture of membrane 674961.6 ⍱ᝏఌ㹰㧼⯛㤇Haemophilus influenzae vaccine 934372.9 ᣇ⭏㍐⋫⯇Ⱂ⯮Dysentery (antibiotic therapy) തᆅྷྣਓᴽOral administration ofਦ䞨 nutritionalㅹ㩕 supplementsޫ㺕ݵࡲ like 1071579.5 1555384.0 folic acid for perinatal pregnant women 䖞⣦⯵∂⯛㤇Rotavirus vaccine 2474948.2 哫⯩⯛Measles vaccine㤇 2685079.6 ྺ儈⯷Ⲵ䱢⋫Prevention and treatment of pregnancy-induced 2865886.6 hypertension 7501756.2 㞩⌫㇑⨶˄䬼Diarrhoea managementࡲ˅ (zinc) 8774210.0 Ⲯⲭ⹤⯛㤇DPT vaccine 10722533.4 ᆹޘ㓸→ྺၐSafe termination of pregnancy 㛪⚾⨳㧼⯛㤇Pneumococcal vaccine ᆅྷਦ䞨ǃ䫱Supplementation of nutrientsǃ䫉ㅹ㩕 like folicޫ㺕 acid,ݵ iron and 8000000.010000000.012000000.0 4000000.06000000.0 0.02000000.0 calcium for pregnant women (nutritional package for pregnant women)

Cost-effectivenessᮊࣰᮕଐஷᄊੇవ஍౧උ of 24 interventions 6-2ڏ Figure

interventions亩=ݯㄕ㛪⚾㇑⨶˄ᣇ⭏㍐Ⲵ֯ = child pneumonia management (antibiotic 66 350.0 305.0 therapy),⭘˅ǃࢆᇛӗ᡻ᵟǃᇎ㹼㺻啐ᔿᣔ indicative caesarean section, kangaroo mother care, ᙫ 300.0 270.0 exclusive⨶ǃ6њᴸ޵㓟⇽ңலޫǃᯠ⭏ݯ༽ breastfeeding under 6 months, neonatal resuscitation (᭟ᤱ⋫⯇˅ (fully supporting therapyޘand㣿ᯠ⭏ݯ䍕㹰⯷ neonatal septicemia-ᆼ ᡀ 250.0 232.5 191.2 ᵜ 200.0 10 interventions = above 6 interventions + additional 4 145.9 interventions with optimal cost-effectiveness (i.e. neonatal 10亩=6亩+ᡀᵜ᭸᷌TOP10ަ։4亩 150.0 septicemia (antibiotic injection), prevention and treatment ᯠ⭏ݯ䍕㹰⯷-ᣇ⭏㍐⌘ሴࡲǃ⍱ӗ˄ ӯ 94.5 of abortion complications, prevention and management of ᒦਁ⯷Ⲵ㇑⨶ǃӗਾࠪ㹰Ⲵ亴䱢ǃ6 100.0 postpartum haemorrhage, and breastfeeding and introduction ݳ њᴸ-2኱㔗㔝⇽ңலޫᒦ␫࣐䖵伏 50.0 of solid, semisolid or soft foods at 6-24 months)

0.0 ᒤ 14 interventions = above 10 interventions + additional 20152016 2017 2018 2019 2020 4 interventions with optimal effects (i.e. pneumococcal vaccine,14亩=10 亩haemophilus+᭸᷌TOP10 influenzaeަ։4亩(㛪⚾ vaccine, diarrhoea management⨳㧼⯛㤇ǃ⍱ᝏఌ㹰㧼⯛㤇ǃ㞩⌫㇑ (ORS), nutritional package for pregnant women (supplementation⨶ਓᴽ㺕⏢ⴀǃᆅྷ㩕ޫव of nutrients like) folic acid, iron and calcium for pregnant women)

2424 interventions亩

ᰴ஍ࣰᮕӊᄊѬࡏ analysis of high-impact intervention packages ڏFigure 2-7 Stratified

62 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

cost-effectiveness. The additional four interventions account for saving an additional 14,000 preventable deaths, but these interventions need an additional investment of RMB260 million. In other words, the average cost-effectiveness ratio is about RMB20,000.

Step 3: Analyse the costs and expected effects of the top ten interventions with optimal cost-effectiveness and the top four interventions with optimal effects. The top four interventions with optimal effects account for saving an additional 13,000 preventable deaths, but they require an additional investment of RMB113.18 billion. In other words, the average cost-effectiveness ratio is about RMB8.38 million. Typically, pneumococcal vaccine is the key contributor to the reduction of preventable deaths and the increase in cost (Table 2-3).

Analysis shows that the maternal mortality ratio is greatly sensitive to four interventions of optimal cost- effectiveness (Table 2-4). Meanwhile, the under-five mortality rate is greatly sensitive to the pneumococcal vaccine intervention.

Table 2-2 Top 10 interventions by cost-effectiveness and effect

Top 10 interventions by cost-effectiveness Top 10 interventions by effect

Child pneumonia management (antibiotic therapy) Indicative caesarean section Kangaroo mother care Child pneumonia management (antibiotic therapy) Indicative caesarean section Kangaroo mother care Exclusive breastfeeding under 6 months Exclusive breastfeeding under 6 months Neonatal resuscitation Pneumococcal vaccine Neonatal septicaemia (antibiotic injection) Haemophilus influenzae vaccine

Prevention and treatment of abortion complications Diarrhoea management (ORS) Results Prevention and management of postpartum haemorrhage Neonatal resuscitation Neonatal septicaemia (fully supporting therapy) Nutritional package for pregnant women (supplementation of nutrients like folic acid, iron and calcium for pregnant women) Breastfeeding and introduction of solid, semisolid or soft foods at 6-24 months Neonatal septicaemia (fully supporting therapy)

Table 2-3 Costs and preventable deaths by layers

Costs Additional governmental Proportion of Preventable Proportion of Layer (RMB108) investment (RMB108) costs (%) deaths (104) effects (%)

6 interventions 7.1 1.6 0.6 8.9 69.6 10 interventions 9.8 3.3 0.8 10.3 80.0 14 interventions 1141.6 1128.9 92.1 11.6 90.5 24 interventions 1239.2 1148.4 100.0 12.8 100.0

Table 2-4 Mortality by layers

Effects 6 interventions 10 interventions 14 interventions 24 interventions

Maternal mortality ratio (per 100,000 live births) 16.5 14.9 14.8 13.7 Neonatal mortality rate (‰) 5.9 5.9 5.8 5.4 Infant mortality rate (‰) 6.8 6.8 6.4 6.2 Under-five mortality rate (‰) 9.2 9.2 8.9 8.3

63 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

2.3.4.2 Influence of pneumococcal vaccine price adjustment to the intervention package Pneumococcal vaccine is a WHO-recommended high-impact intervention, and it is an outstanding contributor to the reduction of under-five mortality in China. In this study, a scenario analysis was conducted for the pneumococcal vaccine at different prices.

The analysis was based on the sale price of pneumococcal vaccine within China, which is RMB777.0 per dose, much higher than the purchase price (RMB22.5 per dose) of WHO and the Global Alliance for Vaccines and Immunization (GAVI). Using the price of RMB22.5 per dose available to WHO and GAVI, the 6-year costs of the high-impact intervention package decrease by RMB74.6 billion or 60.0% (Figure 2-8). At the same time, the lower-price pneumococcal vaccine moves from the 23rd most cost-effective intervention to the 13th most cost-effective intervention. With this vaccine at the international minimum price, the proportion of costs for the 14 high-impact interventions will drop by 60.2 percentage points (Table 2-5).

1400.0 1239.2 ܎

) 1200.0 ҵ8 1000.0 ۈ 800.0 ۨ ߎ 600.0 493.2 剫䎏䡏呙࣫߄Current pneumococcalџࠀ vaccine price Total costs (RMB10 Total ь 400.0 剫䎏䡏呙߂ѺLowest pneumococcalџࠀ vaccine price 200.0

0.0

of different pneumococcal vaccine prices to total costs of the high-impact ־ˀՏႯᔠ͉ಫࠫᰴ஍ࣰᮕӊ঴ੇవᄊॖ ڏFigure 2-8 Influences intervention package

Table 2-5 Influences of pneumococcal vaccine price adjustment to cost-effectiveness

Costs Additional Proportion of Preventable Proportion of Layer (RMB, ×108) governmental costs (%) deaths (104) effects (%) investment (RMB, ×108)

6 interventions 7.1 1.6 0.6 8.9 69.6 10 interventions 9.8 3.3 0.8 10.3 80.0 14 interventions (international price) 395.5 382.9 31.9 11.6 90.5 14 interventions (domestic price) 1141.6 1128.9 92.1 11.6 90.5 24 interventions (international price) 493.3 402.3 39.8 12.8 100.0 24 interventions (domestic price) 1239.2 1148.4 100.0 12.8 100.0

64 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

3 Monitoring and Evaluation Indicators Monitoring and evaluation are integral to studying child survival and development. They are the main means to check and promote the execution of programs, and they are a tool to objectively appraise the implementation of interventions and diagnose the realization, influence and sustainability of objectives. Governments at all levels can use indicators to evaluate and measure the implementation of interventions. The monitoring and evaluation indicators are defined for the implementation of 106 interventions. Totally, there are 86 indicators in 10 categories (i.e. behavioral factors, illness, death, growth and development, maternal health care, child health care, premarital health care, family planning, health education, and facilities), involving four aspects (i.e. decisive factors of health, health status, coverage of health care services, and health input), as shown in Table 2-6. The formulas and data sources of the indicators are provided in Annex 5.

Table 2-6 Surveillance and evaluation indicators for interventions

Aspect Category Qty. of indicators S/N of indicators

Decisive factors of health (8) Behavioural factors 8 1–8 Illness 12 9–20 Health status (30) Death 10 21–30 Growth and development 8 31–38 Maternal health care 22 39–60 Child health care 16 61–76 Coverage of health care services (46) Premarital health care 4 77–80

Family planning 1 81 Results Health education 3 82–84 Health input (2) Facilities 2 85–86 Total 86

65 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

Strategies and Measures

In October 2016, the State Council issued the Healthy China 2030 Plan. The Plan was prepared and implemented according to the instructions proposed at the Fifth Plenary Session of the 18th CPC Central Committee with the purpose to push forward the construction of Healthy China and ensure the health of the Chinese people. It is significant since it encourages the building of a moderately well-off society in an all- round way. Moreover, it is a practical action for China to take as it participates in global health governance and works to fulfil its commitments to the UN’s 2030 Agenda for Sustainable Development. The construction of Healthy China highlights the people’s health. Health has been incorporated into all policies, aiming to ensure China’s people’s health in an all-around and full-cycle manner, and aiming to significantly improve the health level and health equity throughout the country. Through prevention first and then securing basic needs, reinforcing primary services and establishing new mechanisms, governments lead all population to take the initiative and address all matters in relation to the health of the people, especially women and children, migrants and low-income people. The National Child Development Plan (2014-2020) for Poverty- Stricken Areas also proposes to effectively safeguard the survival and developmental rights and interests of children in poverty-stricken areas and ensure health throughout the life-cycle for children in poverty- stricken areas from the aspect of the government, households and society. The Opinions on Strengthening the Reform and Development of Medical and Health Care Services for Children, issued by six ministries and commissions including NHC in 2016, raised awareness to promote medical and health care for children and realize child health targets by intensifying the training and development of paediatricians, improving the medical and health care service system for children, and performing reforms and innovations related to medical and health care services for children.

Women and children make up two-thirds of China’s population; therefore, their health is of significant importance for the health of entire Chinese population. Maternal and child health has always been a key subject in China’s health reform and development. The Fifth Plenary Session of the 18th CPC Central Committee launched the policy that a couple is allowed to have two children, known as the two-child policy. As the two-child policy becomes realized, the cumulative birth demand will increase sharply, leading to the drastic increase of a newly-born population. Moreover, the proportion of pregnancies occurring during advanced maternal age will rise, and these pregnancies will be accompanied with higher risks for maternal comorbidities and complications. These situations have brought new challenges to further reduce the maternal and child mortality and ensure maternal and child safety.

To fulfil the commitments to international communities and respond effectively to realize the vision of Healthy China, the following strategies and measures have been developed to be adapted to new situations and challenges for maternal and child health, especially in order to promote the protection and development of children in China.

• Strategy 1: Strengthen the Capacity Building of Child Medical and Health Care Service Personnel The training of professional personnel engaged in midwifery, neonatal care and treatment, and child health care services is strengthened, and a long-acting training mechanism is established. The information about

66 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

maternal health care, midwifery skills and child survival, protection and development are integrated into the examinations of practicing physicians, and the key knowledge and skills are incorporated into the standardized training and continued medical education for resident physicians.

Cascade training with wider coverage is performed. Trainees may include the medical personnel engaged in obstetrics and gynaecology, paediatrics, neonatology, maternal health care, child health care and other services in medical facilities at all levels, as well as village doctors. Training content may focus on midwifery skills, basic neonatal care, neonatal resuscitation, identification and treatment of maternal and child emergency and severe cases, and health management of children aged 0–6. Through the training, the service capacities of professional personnel, especially first-line personnel, can be improved.

The construction of newborn-related technical training institutions is enhanced. At least one newborn- related technical training base is constructed at the provincial or municipal level, and the training content, timing and methods are designed and edited regularly. Professional training is regularly and effectively provided for equivalent or primary-level medical personnel engaged in paediatrics and neonatology.

Measure 1: Strengthen the training of personnel specialized in midwifery, neonatal care and treatment, and child health care services, and establish a long-term training mechanism. Measure 2: Perform thorough cascade training and expand the training coverage, in order to improve the professional capability of service personnel, especially the first-line personnel. Measure 3: Stress the construction of neonate-related professional skill training institutions.

• Strategy 2: Reinforce the Construction and Management of the Obstetrics Department and Neonatology Department, and Build a Sound Maternal and Neonatal Service Network The construction of the obstetrics department and neonatology department is reinforced to improve the Strategies and Measures capacities of maternal health care, midwifery services and basic neonatal care. According to the regional health plan and the plan for medical facilities, obstetrics departments, neonatology departments or wards are set up in maternal and child health care service organizations, hospitals and township hospitals. The configuration of facilities is accelerated, necessary equipment and personnel are assigned, and management and quality control are intensified in order to satisfy the demand of maternal health care, midwifery and neonatal health care services in the region. In principle, any medical organization offering midwifery services should have neonatal wards and at least one medical organization within a county should have special neonatal wards.

Prenatal screening, prenatal diagnosis and neonatal disease screening capacities are strengthened. According to regional planning, service organizations are arranged properly to meet the demand for services. The prenatal screening, prenatal diagnosis, neonatal inherited metabolic disorders and hearing screening service networks are established, the inter-organization business communication is reinforced, and the referral and group consultation systems are built to keep the intractable or confirmed cases so that they will be timely referred, followed and understood.

The construction of treatment capacities for maternal and neonatal emergencies and severe cases is

67 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

enhanced. At least one standardized treatment centre for maternal emergencies and severe cases and one standardized treatment centre for neonatal emergencies and severe cases are set at the level of province, municipality or county. The treatment centre for neonatal emergencies and severe cases at the county level should have special neonatal wards; the treatment centre for neonatal emergencies and severe cases at the municipal level should be capable of offering respiratory support services; and the treatment centre for neonatal emergencies and severe cases at the provincial level should be able to provide full life support and surgical treatment services.

The regional maternal and neonatal emergency transport systems are established to ensure that pregnant women and children in emergencies and severe cases can be transferred quickly, smoothly and efficiently. Focusing on the treatment centres for maternal and neonatal emergencies and severe cases within the specific jurisdiction, a first-aid, consultation and referral network for maternal and neonatal emergencies and severe cases will be established. This network will entail graded responsibility, up-down linkage, orderly responsiveness and efficient performance. The “integrated, active, whole-process and three- dimensional” transfer service mode is followed. Moreover, necessary vehicles, instruments, medicines and communication equipment are prepared, and well-trained transfer personnel are maintained in order to reduce neonatal mortality.

Measure 1: Reinforce the construction of the obstetrics department and neonatology department, and improve the capacities of maternal health care, midwifery services and basic neonatal care. Measure 2: Make more efforts to improve the capacities of prenatal screening, prenatal diagnosis of birth defects and neonatal disease screening. Measure 3: Enhance capacity building for maternal and neonatal emergencies and severe cases treatment. Measure 4: Establish and improve the regional maternal and neonatal emergency transfer systems and create sound green channels for transferring pregnant women and newborns with emergency and severe cases.

• Strategy 3: Increase the Input in Child Disease Prevention and Improve the Child Health Input-Benefit Ratio Child disease prevention, as a key function of a government, should be supported by governmental funds rather than family finance. Governments at all levels should invest more into child disease prevention services, especially in poverty-stricken areas. Meanwhile, governments should launch relevant preferential policies to increase governmental subsidies for low-income people. The governments should extend the coverage of free child disease prevention services, include haemophilus influenza and pneumococcal vaccine into Type I vaccines that the governments provides for free, and the government should make the national exemption policies incorporate more and more basic child health care services.

Measure 1: Intensify the input in child disease prevention services, especially those provided to poverty-stricken areas and low-income people. Measure 2: Extend the coverage of free child disease prevention services, and incorporate more basic child health care services under national free policies.

68 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

• Strategy 4: Further Improve the Basic Medical Care System Available resources are integrated, the basic reproductive service guarantee mechanism for urban and rural residents is established, basic reproductive services are gradually extended throughout the country, and whole-process services with regard to birth and rearing of children are upgraded. The nationwide uniform maternal and child health handbook is distributed, and the basic medical care services throughout the premarital, preconception, gestation, puerperal and neonatal periods are provided, in order to reduce the birth defects and newborn deaths. The health management of children aged 0–6 is strengthened. The supportive policies for infant and young child feeding in poverty-stricken areas are practically implemented, and the coverage of national child nutrition supports is expanded gradually. Care is taken to addressing migrant children, left-behind children and children in remote or poverty-stricken areas.

Child medical insurance and rescue policies are improved. Phased and relatively independent child medical insurance is purchased and reimbursement policies are designed specifically for children under five. An automatic postnatal medical insurance policy for newborns is developed, and all existing automatic and free postnatal medical care services for newborns are implemented gradually. The child serious disease insurance indemnity policies are upgraded to mitigate the burden of medical expenses on individuals. On the basis of comprehensive implementation of urban and rural resident's serious disease insurances, the child serious disease insurance indemnity policies are developed properly and connected with urban medical insurance and new rural cooperative medical insurance effectively. The proportion that can be reimbursed by the government and the social medical insurances in expenses from treating serious diseases affecting child survival and health, which are unaffordable for residents, is increased gradually. The reimbursable proportion under the urban medical insurance and new rural cooperative medical insurance for child diseases treated at different levels of medical facilities is increased and adjusted properly, and the parents of children with diseases are instructed to consult a doctor in a timely manner and properly select medical facilities in order to reduce child deaths. The adolescence (non-school) Strategies and Measures medical insurance policies are improved.

The list of essential drugs for children is adjusted to incorporate basic medicines for child health care and disease prevention/treatment, such as zinc (for diarrhoea management).

Measure 1: Establish the basic reproductive service guarantee mechanism for urban and rural residents, and introduce gradually free basic reproductive services across the country. Measure 2: Further improve the child health insurance and rescue policies; ensure newborns enjoy basic medical security from their birth, improve the child serious disease insurance indemnity policies, and increase and properly adjust the proportion of reimbursement for child diseases; improve the adolescent (out of school) medical insurance policies. Measure 3: Improve the list of essential drugs for children by incorporating essential medicines for child health care and disease prevention and treatment, such as zinc (for diarrhoea treatment).

69 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

• Strategy 5: Take Step-by-Step Actions to Gradually Extend the Categories and Coverage of Key Services/Measures The maternal and child health care intervention package developed in this study is comprised of 106 interventions, including the current major and basic maternal and child health care interventions that are closely related to the survival and development of children. The package involves six periods, i.e. adolescence period, preconception/pre-marriage period, foetus/gestation period, birth/delivery period, neonatal/postnatal period, and infancy and childhood period, and mainly performed via eight hierarchies from households to relevant sectors. Many interventions in the package are unevenly carried out in the country, with the worst performance observed in the poverty-stricken areas in West China. Each province should gradually promote the maternal and child health care intervention package to realize a wider coverage, step by step, through practical applications after the cost-effectiveness analysis of interventions. Special attention will be paid to the provinces/municipalities/autonomous regions with high mortality and huge deaths, and to the migrant pregnant women and newborns and other representative populations.

First, six interventions with both optimal effects and optimal cost-effectiveness defined in this study, i.e. antibiotic therapy for child pneumonia, kangaroo mother care, indicative caesarean section, exclusive breastfeeding under six months, neonatal resuscitation, and neonatal septicaemia (fully supporting therapy), are determined as core interventions, with uniform contents and implementation criteria configured. All provinces/municipalities/autonomous regions are required to promote and implement these interventions thoroughly during the period of 13th Five-Year Plan.

Second, eight interventions with good effects or cost-effectiveness are selected in this study, i.e. prevention and treatment of abortion complications, prevention and management of postpartum haemorrhage, neonatal septicaemia (antibiotic injection), breastfeeding and introduction of solid, semisolid or soft foods at 6-24 months, pneumococcal vaccination, haemophilus influenza vaccination, diarrhoea management (ORS), and intake of nutritional packages for pregnant women. Each province/municipality/autonomous region is required to implement these interventions step by step depending on its actual child health status and demands, and they will endeavour to realize the effective implementation of two-thirds or a higher proportion of the interventions during the period of the 13th Five-Year Plan.

Moreover, supervision management is enhanced and periodical supervision and evaluation are made concerning the implementation of the interventions. Each province should define its monitoring and evaluation indicators for interventions and make periodical supervision and evaluation on the implementation of its interventions. The central government supervises the operations in each province. A wide range of health education is performed in order to improve people’s perception of gestation, puerperal and child health care and intensify the service recipients’ continuous access to maternal and child health care services. Well-organized and scheduled policy advocacy and health promotion activities, with regard to birth and rearing of children, maternal and child health care, and disease prevention/ treatment, are systematically provided to key target populations (e.g. couples planning for pregnancy, pregnant women, lactating women and caretakers for children aged 0–6) via television, radio, journals, the Internet and other channels. Additionally, more efforts are made in publicity of health care knowledge for poor and migrant pregnant women and in sex and reproductive health education for adolescents in order to ensure they have sustainable access to maternal and child health care services.

70 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

Measure 1: Define core interventions for maternal and child health care, specify the contents and implementation standards for the interventions, and promote and implement the interventions in all provinces/municipalities/ autonomous regions across the country during the period of 13th Five-Year Plan. Measure 2: Gradually popularize the maternal and child health care intervention package, and extend the coverage of interventions; place emphasis on the areas with high mortality and large number of deaths as well as migrant pregnant women and newborns. Measure 3: Enhance the supervision management and make periodical supervision and evaluation on the implementation of the interventions. Measure 4: Perform a wide range of health education, and intensify the service recipients’ continuous access to maternal and child health care services.

• Strategy 6: Accelerate and Improve the Formulation and Implementation of Relevant Policies Efforts are made to accelerate and improve the formulation and implementation of relevant policies. Applicable laws and regulations for early childhood development and adolescent health care are developed. Adolescent and adult vaccinations are incorporated into national policies. Relevant regulations for maternal health care are improved by including the pregnancy nutritional package and reinforcing the management of migrant pregnant women. Technical specifications for puerperal mental health care are optimized. Relevant national strategies and goals for drinking water and lavatory improvement are upgraded to cover all organizations and populations, especially the impoverished population. Relevant laws and regulations for child injury are formulated and implemented. The mechanisms of coordination among the sectors such as government, media, police, transport, community, and health are enhanced, and a sound injury reporting and surveillance system is established. Strategies and Measures

Measure 1: Accelerate and improve the formulation of policies for early childhood development promoting, adolescent health care, adolescent and adult vaccination, maternal health care, puerperal mental health care, drinking water and lavatory improvement, and other aspects. Measure 2: Implement relevant policies for child injury prevention.

• Strategy 7: Enhance Multi-sector Cooperation to Ensure the Policies are Effectively Implemented The Program for Children’s Development in China and Program for Women’s Development in China (2011–2020) are implemented in a coordinative manner, through enhanced hierarchical and multi-sector cooperation under a long-acting mechanism. The principle of “child first” is highlighted, and the key indicators with regard to child development are integrated into the overall and special plans for economic and social development. The implementation of the maternal and child health care intervention package involves diverse levels and sectors. This study defines the maternal and child health care interventions, which are the responsibilities of households, village clinics, medical facilities at the county level or above, communities, schools/nurseries and kindergartens, media, and various sectors, such as enterprises,

71 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

agriculture, water, environmental protection, and transport. Accordingly, the hierarchical and multi-sector cooperation should be followed in the implementation of the maternal and child health care intervention package.

The multi-sector cooperative prevention and control mechanism for child injuries is established. The working mechanism of “government leadership, multi-sector cooperation, expert support, public participation, and child benefit” is effectively adopted. Locally, under the leadership of the government and the guidance of medical facilities, such sectors work together, like the women’s association, police, education, transport and media. The mechanism and network of child injury prevention and control involving the whole community are established, and relevant policies for child injury prevention and control are developed and implemented. Four modes, i.e. safe school, safe kindergarten, safe community and safe household, are considered to ensure the effective connection and integration of interventions at the levels of school, kindergarten, community and household. Special attention should be paid to the prevention and control of injuries among children in rural areas.

Measure 1: Enhance hierarchical and multi-sector cooperation, and establish the mechanisms of coordination among medical and health facilities at all levels within the health and family planning system and between the health and family planning sector and the government, education, media, enterprise, environmental protection, water, community, and other sectors. Measure 2: Establish the multi-sector cooperative prevention and control mechanism for child injuries, and figure out the feasibility of the "four-in-one” intervention mode by integrating the household, school, road and community.

72 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action Infancy and childhood period Exclusive breastfeeding under 6 months Breastfeeding and introduction of solid, semisolid or soft foods at 6-24 months Breastfeeding in special cases (preferential artificial feeding and prohibition of children; mixed feeding for HIV-exposed antiretroviral therapy for mothers or babies exclusive breastfeeding) Administration of child nutritional package Child injury prevention: household safety checklist, improvement of household environment and parent behaviours, etc. Determination of personal hygiene behaviours (including safe drinking water, use of sanitary latrine, washing hands with soap, etc.) Child abuse prevention Health education Configuration of handwashing facilities Setting up and using handwashing soap/ posting handwashing liquid and hot water, posters, etc.

■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Postnatal nutrition: supplementation of nutrients like iron, folic acid, vitamin-D, calcium and iodine Newborns: breastfeeding, umbilical cord and skin care, thermal care, supplementation of vitamin-D Prevention of puerperal infection Postnatal care for mothers (prevention of postpartum depression) Determination of personal hygiene behaviours (including use of safe drinking water, sanitary latrine, washing hands with soap, etc.) Health education Postnatal care for newborns Postnatal care for mothers Prevention of postpartum haemorrhage Configuration of handwashing facilities Setting up and using handwashing soap/liquid and posting handwashing hot water, posters, etc. Neonatal/postnatal period

■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Birth/delivery period Annexes period Foetus/gestation Weight management Weight Intake of nutritional packages for pregnant women (supplementation of various nutrients like iron, folic acid, calcium and iodine) Determination of personal hygiene behaviours (including safe drinking water, use of sanitary latrine, washing hands with soap, etc.) Health education Configuration of handwashing facilities Setting up and using handwashing soap/ liquid and hot water, posting handwashing posters, etc.

■ ■ ■ ■ ■ ■ Annexes marriage period Preconception/pre- Weight management Weight Oral administration of nutritional supplements like folic acid Determination of personal hygiene behaviours (including safe drinking use of sanitary water, latrine, washing hands with soap, etc.) Health education (smoking/wine cessation, syphilis and and HIV, hepatitis B PMTCT) Configuration of handwashing facilities Setting up and using handwashing soap/liquid posting and hot water, handwashing posters, etc.

■ ■ ■ ■ ■ ■ Determination of personal hygiene behaviours (including safe use drinking water, of sanitary latrine, washing hands with soap, etc.) Health education Configuration of handwashing facilities Setting of handwashing soap/ liquid, handwashing posters and hot etc. water,

Adolescence period ■ ■ ■ ■ Channel Households Village clinics/ Village community health care service stations Annex 1: Maternal and Child Health Care Intervention Package Annex 1: Maternal and Child Health Care

73 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action Infancy and childhood period Child growth surveillance and intervention management Routine immunization haemophilus influenza, Vaccines: II Type pneumococcus and rotavirus vaccine (optional) Severe acute malnutrition management Nutrition intervention Child pneumonia management Diarrhoea management HFMD management Comprehensive management of tuberculosis-exposed children Activation of highly-active anti-retroviral children therapy for HIV-exposed Periodic visiting, testing, and timely treatment of HIV/syphilis-exposed children Child injury surveillance (drowning, road asphyxia, mechanical poison, falling, injury, burn, scald)

■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Early initiation of breastfeeding (within one hour after birth) Support feeding of underweight and preterm babies thermal care (keep the Timely baby warm), use of kangaroo mother care Neonatal disease screening (PKU, CH, and hearing screening) Monitoring of newborns with risk of hypoglycaemia Newborn vitamin-K supplementation Guidance of breastfeeding BCG and hepatitis B immunization Antiretroviral therapy, preferential artificial feeding and prohibition of mixed feeding children; for HIV-exposed mothers for therapy antiretroviral or babies who are exclusive breastfeeding and necessary treatment Testing for syphilis-exposed children (quantitative detection by non- syphilis treponemal antigen serological test) and necessary treatment Identification and referral of neonatal jaundice (pathologic and breast-feeding) other severe cases Neonatal/postnatal period

■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

uterine ② ③ medicines, such ① surgical haemostasis surgical ④ Birth/delivery period Hospital delivery encouragement of Safe delivery, vaginal delivery (clearly defining indications of caesarean delivery) identification and treatment Timely of dystocia Prevention of preterm birth Prevention of postpartum haemorrhage Screen for women with high risk of postpartum haemorrhage preventive actions properly: Take referral, reservation of blood, establishment of intravenous access preventive measures for Take laceration of birth canal Accurately measure the amount of postpartum bleeding measures for effective Take haemostasis: as oxytocin, prostaglandin (e.g. misoprostol, carboprost); massaging of the uterus; packing; Determination and timely testing syphilis and hepatitis for HIV, B infection, safe midwifery and supporting treatments for infected pregnant women Screening for other high-risk factors Intrapartum monitoring and management for pregnancy complications Early detection and interventions and severe cases for emergency Neonatal resuscitation Prevention of birth injuries Special care and antiretroviral children therapy for HIV-exposed for PMTCT Special care for syphilis-exposed children, quantitative detection by non-syphilis treponemal antigen serological test, necessary prophylactic treatments Hepatitis B immunoglobulin immunization for hepatitis B-exposed children Delivery of health education Preparation for referral and safe referral (once for all)

1. 2. 3. 4. 5. ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ period Foetus/gestation Gestation health management (inquiry about medical history, fasting blood glucose, weight management) Nutritional counselling (rational diet and feeding knowledge, etc.) Prevention and treatment of pregnancy complications (pregnancy-induced hypertension syndrome, gestational diabetes, anaemia in thyroid pregnancy, diseases) Early screening for syphilis and HIV, hepatitis B Proper intervention, treatment, visit and management for HIV, syphilis or hepatitis B infected persons Regular antenatal care, screening and referral of high-risk pregnant women of abortion in case Safe unintended pregnancy Post-abortion health care

■ ■ ■ ■ ■ ■ ■ ■ marriage period Preconception/pre- Pre-pregnancy counselling (nutritional, genetic, and birth health counselling) Dental care Screening for anaemia and diabetes syphilis and for HIV, Test hepatitis B, prevention and control of sexually transmitted diseases

■ ■ ■ ■ Prevention of unwanted pregnancy (consultation, informed consent and pharmaceutical supplies) Prevention and control of sexually transmitted diseases and syphilis like HIV Nutritional counselling

Adolescence period ■ ■ ■ Channel and community of village clinics) health care service centres (in addition Township hospitals Township to those at the level

74 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action Infancy and childhood period Diagnosis and treatment of severe childhood diseases Child injury intervention: environmental improvement including road surface, light, pond and recreational facilities Child abuse prevention Child health management of nurseries and kindergartens Canteen safety and health management catering instructions Child injury intervention and surveillance falling, poisoning, (drowning, road injury, mechanical asphyxia, burn, scald) Health education

■ ■ ■ ■ ■ ■ ■ Use of prophylactic antibiotics for newborns with the risk of bacterial infection Use of surfactants (for respiratory system) for preventing preterm respiratory distress syndrome Use of continuous positive to airway pressure (CPAP) treat infant respiratory distress syndrome of neonatal Treatment septicaemia, meningitis and pneumonia of neonatal jaundice Treatment (pathologic) of maternal anaemia Treatment Neonatal/postnatal period

■ ■ ■ ■ ■ ■ Birth/delivery period Induction at 41 weeks Indications of caesarean section (for saving the mothers and babies) Haemostasis with uterus reserved of postpartum Treatment haemorrhage (surgical haemostasis), such as suture haemostasis (thrombosis), ascending uterine artery ligation, local or B-lynch (bundled) suture, and vascular thrombosis; uterine packing (water pocket or gauze); hysterectomy Use of prophylactic antibiotics for high-risk pregnant women (premature rupture of membrane, septicaemia caesarean delivery, etc.) Configuration of handwashing facilities handwashing soap/ Available handwashing liquid, hot water, posters etc.

■ ■ ■ ■ ■ ■ ■ period Foetus/gestation Antibiotic therapy for preterm premature rupture of membrane Induction of labour for at-term premature rupture of membrane Corticosteroids for babies <35 weeks gestation Screening for birth defects Preterm birth management and Treatment management of severe complications of pregnancy (pregnancy- induced hypertension syndrome, gestational diabetes, thyroid diseases, etc.) guidance for Technical subsidiaries

■ ■ ■ ■ ■ ■ ■ Annexes marriage period Preconception/pre- Screening for thyroid function

■ Safe termination of pregnancy Nutrimeals and fortified foods for students Health education (sexual and reproductive health) hot water, Available handwashing posters etc.

Adolescence period ■ ■ ■ ■ centres) Channel Communities additional for and community above (possibly those at the level of village clinics, Medical facilities Schools/nurseries and kindergartens at county levels or health care service township hospitals

75 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action Infancy and childhood period Health education via media Lavatory improvement and safe disposal of faeces safe drinking water Available Prevention of road injury

■ ■ ■ ■ Health education via media Lavatory improvement and safe disposal of faeces safe drinking water Available Neonatal/postnatal period

■ ■ ■ Birth/delivery period Health education via media Lavatory improvement and safe disposal of faeces safe drinking water Available

■ ■ ■ , configuration of handwashing facilities, and available soap/liquid, in all periods are assigned as one intervention. period Foetus/gestation Health education via media Lavatory improvement and safe disposal of faeces safe drinking Available water

■ ■ ■ marriage period Preconception/pre- Health education via media Lavatory improvement and safe disposal of faeces safe drinking Available water

■ ■ ■ Health education via media Lavatory improvement and safe disposal of faeces safe Available drinking water to reduce There is no operable measure to prevent environmental lead poisoning from the source for children. It recommended Environmental lead poisoning (gestation, infancy and childhood periods). contact with lead and uptake through health education, supplementation of nutrients, lead-free foods others.

Adolescence period ■ ■ ■ ■ Media Channel agriculture, Enterprises, including water, including water, transport sectors environment and Notes: use of sanitary latrines, washing hands with soap, etc.) in all periods are assigned as one intervention. 1. Six interventions that determine personal hygiene behaviours (including safe drinking water, interventions for weight management during preconception and foetal periods are assigned as one intervention. Two 2. 3. Six interventions for health education in all periods are assigned as one intervention. 4. Six interventions for health education via media in all periods are assigned as one intervention. 5. Four interventions, i.e. lavatory improvement and safe disposal of faeces, available drinking water interventions for child abuse prevention are assigned as one intervention. Two 6.

76 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action agriculture, transport sectors environment and Enterprises, water, Enterprises, water, √ √ Media √ ★ ★ ★ ★ Schools/ nurseries and kindergartens √ √ √ ★ ★ ★ ★ Communities √ √ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ Medical or above facilities at county level √ √ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ Township hospitals Township care service centres and community health √ √ ★ ★ ★ ★ ★ Village clinics/ Village community health care service stations ★ ★ ★ ★ Households Annexes Prevention and control of sexually transmitted and syphilis diseases like HIV Safe termination of pregnancy Nutrimeals and fortified foods for students Configuration of handwashing facilities Determination of personal hygiene behaviours use of sanitary (including safe drinking water, latrines, washing hands with soap, etc.) handwashing soap/liquid, hot water, Available handwashing posters, etc. Prevention of unwanted pregnancy (consultation, informed consent and pharmaceutical supplies) Nutritional counselling Health education (sexual and reproductive health) Preconception weight management Interventions Oral administration of nutritional supplements like folic acid Screening for anaemia and diabetes Dental care Determination of personal hygiene behaviours use of sanitary (including safe drinking water, latrine, washing hands with soap, etc.) handwashing soap/liquid, hot water, Available handwashing posters, etc. Pre-pregnancy counselling (nutritional, genetic and birth health counselling) Health education (smoking/alcohol cessation, syphilis and hepatitis B PMTCT) and HIV, Configuration of handwashing facilities Stage of intervention marriage period Preconception/pre- Adolescence period Annex 2: Implementation Channels for Maternal and Child Health Care Interventions Maternal and Child Health Care Annex 2: Implementation Channels for

77 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action agriculture, transport sectors environment and Enterprises, water, Enterprises, water, √ Media Schools/ nurseries and kindergartens ★ ★ Communities √ √ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ Medical or above facilities at county level √ √ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ Township hospitals Township care service centres and community health √ √ ★ ★ ★ Village clinics/ Village community health care service stations ★ ★ ★ Households Interventions Screening for thyroid function Test for HIV, syphilis and hepatitis B, for HIV, Test prevention and control of sexually transmitted diseases Pregnancy weight management Intake of nutritional packages for pregnant women (compound micronutrients) to supplement various nutrients like iron, folic acid, calcium and iodine Post-abortion health care Safe abortion in case of unintended pregnancy Regular antenatal care, screening and referral for high-risk pregnant women Proper intervention, treatment, visit and syphilis or hepatitis B management for HIV, infected persons Early screening for HIV, syphilis and hepatitis Early screening for HIV, B Prevention and treatment of pregnancy complications (pregnancy-induced hypertension syndrome, gestational diabetes, anaemia in thyroid diseases) pregnancy, Nutritional counselling (rational diet and feeding knowledge, etc.) Determination of personal hygiene behaviours use of sanitary (including safe drinking water, latrines, washing hands with soap, etc.) handwashing soap/liquid, hot water, Available handwashing posters etc. Gestation health management (inquiry about fasting blood glucose, weight medical history, management) Pregnancy health education Configuration of handwashing facilities period Stage of intervention Foetus/gestation

78 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action agriculture, transport sectors environment and Enterprises, water, Enterprises, water, Media Schools/ nurseries and kindergartens Communities ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ Medical or above facilities at county level ★ ★ ★ ★ ★ ★ ★ Township hospitals Township care service centres and community health Village clinics/ Village community health care service stations Households

Annexes c . Take Take ③ Take preventive Take medicines, such Take effective effective Take ② a . ⑤ surgical haemostasis. surgical d . massaging of the uterus, b . Accurately measure the amount ④ Screen for women with high risk of Interventions Screening for other high-risk factors Determination and timely testing of HIV, Determination and timely testing of HIV, syphilis and hepatitis B infection, safe midwifery and supporting treatments for infected pregnant women Prevention of postpartum haemorrhage: ① postpartum haemorrhage; actions properly: referral, blood reserving, establishment of intravenous access; preventive measures for laceration of the birth canal; of postpartum bleeding; measures of haemostasis: as oxytocin, prostaglandin (e.g. misoprostol, carboprost), uterine packing, and Prevention of preterm birth Timely identification and treatment of dystocia Timely Antibiotic therapy for preterm premature rupture of membrane Induction of labour for at-term premature rupture of membrane gestation Corticosteroids for babies <35 weeks’ Screening for birth defects Preterm birth management pregnancy severe of management and Treatment complications (pregnancy-induced hypertension diseases, thyroid diabetes, gestational syndrome, etc.) guidance to subsidiaries Technical encouragement of vaginal Safe delivery, delivery (clearly defining indications of caesarean delivery) Hospital delivery Stage of intervention Birth/delivery period

79 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action agriculture, transport sectors environment and Enterprises, water, Enterprises, water, √ Media Schools/ nurseries and kindergartens Communities √ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ Medical or above facilities at county level √ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ Township hospitals Township care service centres and community health √ ★ Village clinics/ Village community health care service stations ★ ★ Households Interventions Delivery health education Induction at 41 weeks Indications of caesarean section (for saving the mothers and babies) Haemostasis with uterus reserved of postpartum haemorrhage (surgical Treatment haemostasis), such as suture haemostasis (thrombosis), ascending uterine artery ligation, local or B-lynch (bundled) suture, and vascular thrombosis; uterine packing (water pocket or gauze); hysterectomy Use of prophylactic antibiotics for high- risk pregnant women (premature rupture of septicaemia etc.) membrane, caesarean delivery, Hepatitis B immunoglobulin immunization for hepatitis B-exposed children Preparation for referral and safe (once for all) Special care for syphilis-exposed children, quantitative detection by non-syphilis treponemal antigen serological test, necessary prophylactic treatments Special care and antiretroviral therapy for HIV- exposed children for PMTCT Prevention of birth injuries Neonatal resuscitation Early detection and interventions for emergency Early detection and interventions for emergency and severe cases Intrapartum monitoring and management for pregnancy complications Postnatal nutrition: supplementation of nutrients of nutrients supplementation nutrition: Postnatal like iron, folic acid, vitamin-D, calcium and iodine Newborns: breastfeeding, umbilical cord and skin care, thermal supplementation of vitamin-D period Stage of intervention Neonatal/postnatal

80 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action agriculture, transport sectors environment and Enterprises, water, Enterprises, water, √ Media Schools/ nurseries and kindergartens Communities √ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ Medical or above facilities at county level √ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ Township hospitals Township care service centres and community health √ ★ ★ ★ ★ ★ ★ ★ ★ Village clinics/ Village community health care service stations √ √ √ ★ ★ ★ Households Annexes Interventions Prevention of puerperal infection Postnatal care for mothers (prevention of postpartum haemorrhage) Guidance of breastfeeding Newborn vitamin-K supplementation Monitoring of newborns with risk hypoglycaemia Early initiation of breastfeeding (within one hour after birth) Support for feeding underweight and preterm babies thermal care (keep the baby warm), use Timely of kangaroo mother care Neonatal disease screening (PKU, CH, and hearing screening) Available handwashing soap/liquid, hot water, handwashing soap/liquid, hot water, Available handwashing posters etc. Configuration of handwashing facilities Prevention of postpartum haemorrhage Postnatal care for mothers Neonatal health education Determination of personal hygiene behaviours use of sanitary (including safe drinking water, latrine, washing hands with soap, etc.) Postnatal care for babies within 28 days Testing and necessary treatment for syphilis- Testing exposed children (quantitative detection by non- and test) serological antigen treponemal syphilis necessary treatment Antiretroviral therapy, preferential artificial Antiretroviral therapy, feeding and prohibition of mixed for children; antiretroviral therapy for HIV-exposed mothers or babies exclusively breastfeeding BCG and hepatitis B immunization Stage of intervention

81 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action agriculture, transport sectors environment and Enterprises, water, Enterprises, water, √ Media ★ ★ Schools/ nurseries and kindergartens V ★ Communities ★ ★ ★ ★ ★ ★ ★ ★ ★ Medical or above facilities at county level √ √ ★ ★ ★ Township hospitals Township care service centres and community health √ √ √ √ ★ ★ Village clinics/ Village community health care service stations ★ ★ ★ ★ ★ ★ Households Interventions Use of prophylactic antibiotics for newborns with the risk of bacterial infection Use of surfactants (for respiratory system) for preventing preterm respiratory distress syndrome Use of continuous positive airway pressure for treating infant respiratory distress (CPAP) syndrome of neonatal septicaemia, meningitis Treatment and pneumonia of neonatal jaundice (pathologic) Treatment of maternal anaemia Treatment Breastfeeding and introduction of solid, semisolid or soft foods at 6-24 months Breastfeeding in special cases (preferential artificial feeding and prohibition of mixed children; antiretroviral feeding for HIV-exposed therapy for mothers or babies exclusively breastfeeding) Administration of child nutritional package Child injury prevention: household safety checklist, improvement of household environment and parent behaviours, etc. Determination of personal hygiene behaviours use of sanitary (including safe drinking water, latrine, washing hands with soap, etc.) Health education in childhood period Exclusive breastfeeding under 6 months Configuration of handwashing facilities Identification and referral of neonatal jaundice (pathologic and breast-feeding other severe cases) Stage of Infancy and intervention childhood period

82 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action agriculture, transport sectors environment and Enterprises, water, Enterprises, water, √ √ Media √ √ √ √ √ √ √ ★ ★ ★ Schools/ nurseries and kindergartens √ √ ★ ★ Communities ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ Medical or above facilities at county level ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ Township hospitals Township care service centres and community health √ ★ Village clinics/ Village community health care service stations Households Annexes Interventions Available handwashing soap/liquid, hot water, handwashing soap/liquid, hot water, Available handwashing posters etc. Child growth surveillance and intervention management Diagnosis and treatment of severe child diseases Child health management of nurseries and kindergartens Canteen safety and health management catering instruction Child injury surveillance (drowning, road falling, poisoning, mechanical asphyxia, injury, burn, scald) Child injury intervention: environmental pond light, surface, road including improvement and recreational facilities Periodic visit and testing timely treatment of HIV/syphilis-exposed children Child pneumonia management Diarrhoea management HFMD management Comprehensive management of tuberculosis- exposed children Activation of highly-active anti-retroviral children therapy for HIV-exposed Nutrition intervention Routine immunization haemophilus influenza, Vaccines: Ⅱ Type pneumococcal vaccine and rotavirus (optional) Severe acute malnutrition management Stage of intervention

83 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action ★ ★ ★ ★ agriculture, transport sectors environment and Enterprises, water, Enterprises, water, √ ★ Media √ ★ Schools/ nurseries and kindergartens √ ★ ★ Communities √ Medical or above facilities at county level √ Township hospitals Township care service centres and community health √ Village clinics/ Village community health care service stations √ ★ Households Interventions Lavatory improvement and safe disposal of faeces Child abuse prevention safe drinking water Available Health education via media Environmental lead poisoning (gestation, infancy and childhood periods) Child injury intervention and surveillance falling, poisoning, (drowning, road injury, mechanical asphyxia, burn, scald) represents the primary implementer, and √ represents the coordinative or cooperative implementer. and √ represents the coordinative or cooperative implementer. represents the primary implementer, Stage of ★ All periods intervention Note:

84 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action √ √ √ √ Infancy and childhood period √ √ √ √ √ Neonatal/ postnatal period √ √ √ period Birth/delivery √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ period Foetus/gestation √ √ √ √ √ √ √ √ √ √ √ Preconception/ pre-marriage period √ √ √ √ √ √ √ √ period Adolescence Annexes Interventions Prevention and control of sexually transmitted diseases like HIV and syphilis Prevention and control of sexually transmitted diseases like HIV Nutritional counselling (all periods) Safe termination of pregnancy Nutrimeals and fortified foods for students Health education (all periods) handwashing posters etc. hot water, Available Preconception weight management Oral administration of nutritional supplements like folic acid Pre-pregnancy counselling (nutritional, genetic and birth health counselling) Dental care Screening for anaemia and diabetes syphilis and hepatitis B, prevention control of sexually transmitted diseases for HIV, Tests Screening for thyroid function Pregnancy weight management Nutritional package for pregnant women (compound micronutrients), supplementation of various nutrients like iron, folic acid, calcium and iodine fasting blood glucose, weight management) Gestation health management (inquiry about medical history, Pregnancy nutritional counselling (rational diet, weight management and feeding knowledge, etc.) Prevention and treatment of pregnancy complications (pregnancy-induced hypertension syndrome, thyroid diseases) gestational diabetes, anaemia in pregnancy, syphilis and hepatitis B Early screening for HIV, syphilis or hepatitis B infected persons Proper intervention, treatment, visit and management for HIV, Regular antenatal care, screening and referral of high-risk pregnant women Safe abortion in case of unintended pregnancy Post-abortion health care Antibiotic therapy for preterm premature rupture of membrane Induction of labour for at-term premature rupture membrane Prevention of unwanted pregnancy (consultation, informed consent and pharmaceutical supplies) Determination of personal hygiene behaviours (including safe drinking water, use of sanitary latrine, Determination of personal hygiene behaviours (including safe drinking water, washing hands with soap, etc.) Annex 3: Maternal and Child Health Care Interventions by Periods Annex 3: Maternal and Child Health Care

85 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action Infancy and childhood period Neonatal/ postnatal period √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ period Birth/delivery √ √ √ √ √ period Foetus/gestation Preconception/ pre-marriage period period Adolescence

③ surgical haemostasis. surgical d . Accurately measure the amount of postpartum medicines, such as oxytocin, prostaglandin (e.g. ④ uterine packing, and a . c . Interventions Screen for women with high risk of postpartum haemorrhage; ① massaging of the uterus, b . Take effective measures of haemostasis: effective Take ⑤ Take preventive actions properly: referral, blood reserving, establishment of intravenous access; Take Corticosteroids for babies <35 weeks gestation Screening for birth defects Preterm birth management and management of severe pregnancy complications (pregnancy-induced hypertension Treatment syndrome, gestational diabetes, thyroid diseases, etc.) guidance to subsidiaries Technical Hospital delivery encouragement of vaginal delivery (clearly defining indications caesarean delivery) Safe delivery, identification and treatment of dystocia Timely Prevention of preterm birth Prevention of postpartum haemorrhage: ② preventive measures for laceration of birth canal; Take bleeding; misoprostol, carboprost), syphilis and hepatitis B infection, safe midwifery Determination and timely testing of HIV, supporting treatments for infected pregnant women Screening for other high-risk factors Intrapartum monitoring and management for pregnancy complications and severe cases Early detection and interventions for emergency Neonatal resuscitation Prevention of birth injuries children for PMTCT Special care and antiretroviral therapy for HIV-exposed Special care for syphilis-exposed children, quantitative detection by non-syphilis treponemal antigen serological test, necessary prophylactic treatments Hepatitis B immunoglobulin immunization Preparation for referral and safe (once all) Induction at 41 weeks Indications of caesarean section (for saving the mothers and newborns) Haemostasis with uterus reserved haemostasis), such as suture haemostasis (thrombosis), of postpartum haemorrhage (surgical Treatment ascending uterine artery ligation, local or B-lynch (bundled) suture, and vascular thrombosis; packing (water pocket or gauze); hysterectomy

86 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action √ √ √ Infancy and childhood period √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ Neonatal/ postnatal period √ period Birth/delivery period Foetus/gestation Preconception/ pre-marriage period period Adolescence - Annexes Interventions Use of prophylactic antibiotics for high-risk pregnant women (premature rupture membrane, caesarean septicaemia, etc.) delivery, Postnatal nutrition: supplementation of nutrients like iron, folic acid, vitamin-D, calcium and iodine Newborns: breastfeeding, umbilical cord and skin care, thermal supplementation of vitamin-D Prevention of puerperal infection Postnatal care for mothers (prevention of postpartum haemorrhage) Postnatal care for babies within 28 days Postnatal care for mothers Prevention of postpartum haemorrhage Early initiation of breastfeeding (within one hour after birth) Support to feed underweight and preterm babies thermal care (keep the baby warm), use of kangaroo mother Timely Neonatal disease screening (PKU, CH, and hearing screening) Monitoring of newborns with risk hypoglycaemia Newborn vitamin-K supplementation Guidance of breastfeeding BCG and hepatitis B immunization preferential artificial feeding and prohibition of mixed for HIV-exposed Antiretroviral therapy, children; antiretroviral therapy for mothers or babies exclusively breastfeeding and necessary treatment for syphilis-exposed children (quantitative detection by non-syphilis Testing treponemal antigen serological test) and necessary treatment Identification and referral of neonatal jaundice (pathologic breast-feeding other severe cases Use of prophylactic antibiotics for newborns with risk bacterial infection Use of surfactants (for respiratory system) for preventing preterm distress syndrome for treating infant respiratory distress syndrome Use of continuous positive airway pressure (CPAP) of neonatal septicaemia, meningitis and pneumonia Treatment of neonatal jaundice (pathologic) Treatment of maternal anaemia Treatment Exclusive breastfeeding under 6 months Breastfeeding and introduction of solid, semisolid or soft foods at 6-24 months Breastfeeding in special cases (preferential artificial feeding and prohibition of mixed for HIV exposed children; antiretroviral therapy for mothers or babies exclusively breastfeeding)

87 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ Infancy and childhood period √ √ √ √ Neonatal/ postnatal period √ √ √ √ period Birth/delivery √ √ √ √ √ period Foetus/gestation √ √ √ √ Preconception/ pre-marriage period √ √ √ √ period Adolescence Interventions Vaccines: haemophilus influenzae, pneumococcal vaccine and rotavirus vaccine(optional) Vaccines: Ⅱ Severe acute malnutrition management Nutrition intervention Child pneumonia management Diarrhoea management HFMD management Comprehensive management of tuberculosis-exposed children children Activation of highly-active anti-retroviral therapy for HIV-exposed Periodic visit and testing timely treatment of HIV/syphilis-exposed children falling, poisoning, mechanical asphyxia, burn, scald) Child injury surveillance (drowning, road injury, Diagnosis and treatment of severe child diseases recreational and pond light, surface, road including improvement environmental intervention: injury Child facilities Child health management of nurseries and kindergartens Canteen safety and health management catering instruction falling, poisoning, mechanical Child injury intervention and surveillance (drowning, road injury, asphyxia, burn, scald) Child abuse prevention Configuration of handwashing facilities handwashing posters, etc. handwashing soap/liquid, hot water, Available Lavatory improvement and safe disposal of faeces safe drinking water Available Environmental lead poisoning (gestation, infancy and childhood periods) Child injury prevention: household safety checklist, improvement of environment and parent behaviours, etc. Child growth surveillance and intervention management Routine immunization Type Administration of child nutritional package

88 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action Coverage of effective of effective interventions Service quality Less coverage of preconception health care services Small coverage of services, and insufficient adolescent health care services services Sustainable utilization of Low compliance with folic acid supplementation Inconvenience to receive continuous services for out-of- school adolescents who are mobile Inconvenience to receive continuous services for school adolescents who are subject to courses Demand-side behaviours Economy, society, society, Economy, culture, customs and Lack of preconception health care awareness and recognition on its importance Economic independence and no economic sources for adolescents who are subject to household economy Not speaking publicly about sex-related matters and customs, social to due discrimination against premarital pregnancy due to social customs Service delivery Less preconception health care outpatient services Unavailability of adolescent health care outpatient services Personnel Supply-side Insufficient low number, technical high and capacity mobility of first- line personnel No full-time or medical staff low consulting capabilities of medical staff materials Equipment and Short HIV, Short HIV, syphilis and hepatitis B testing devices and agents at primary-level medical facilities No places of service, contraceptives, models, or propaganda materials in medical facilities and coordination Management No long-acting multi-sector (civil administration department, community, health and family planning, women’s association, etc.) cooperation mechanism No long-acting mechanism of among cooperation sectors (e.g. Child Working Care Committee under the Ministry of Education, National. Health Commission, and Communities Annexes Budget and expenditure No budget for pre- pregnancy health care for urban couples of childbearing age and the supply-side; No budget for folic acid supplementation for urban women at reproductive ages No regular budget, but only specific project fund which is limited in amount Insufficient budget for free contraceptive distribution to cover the entire population at reproductive ages Supportive environment regulations Policies and Compulsory ante marital examination No policy advocacy No relevant laws and regulations adolescent health care No adolescent (non-school) medical insurance policies Social norms Adolescents’ Adolescents’ open sexual consciousness and earlier first sex period Intervention Preconception/ pre-marriage period Adolescence period Annex 4: Bottleneck Analysis for the Maternal and Child Health Care Intervention package the Maternal and Child Health Care Analysis for Annex 4: Bottleneck

89 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action Coverage of effective of effective interventions Service quality Unsatisfactory level of screening and diagnosis for birth defects, especially for complicated diseases like CHD Fast determination but lagging implementation of syphilis and HIV, hepatitis B treatment measures Unsatisfactory awareness and capability of pregnancy weight and management, nutrition and insufficient coverage of services services Sustainable utilization of Lack of knowledge about preconception health care Low accessibility for poor and migrant pregnant women to receive relevant services directly due economic low their to level Social discrimination, infection of sexually transmitted diseases/ fertility and mental disorders that affect the utilization of services Demand-side behaviours Economy, society, society, Economy, culture, customs and Low awareness of actively receiving gestational health care services Late in early antenatal check-up, especially the poor and migrant pregnant women Periodic antenatal care by manners affected and customs in ethnic minority areas Service delivery Less accessibility of migrant pregnant women health gestation to care services Difficult to conduct tracings and visits for HIV/syphilis- infected pregnant women Difficult to acquire the about information birth defects via tracing and visits; Inconvenient to take folic acid in some areas Personnel Supply-side Insufficient low number, technical high and capacity mobility of first- line personnel Insufficient knowledge and capability of first-line personnel in consultation and diagnosis clinical syphilis of HIV, and hepatitis B Medical staff’s discrimination against HIV/ syphilis-infected persons materials Equipment and Lack of essential antenatal care equipment and screening and diagnosis instruments, equipment and materials in primary-level medical facilities birth assess to used defects, especially at maternal and child health care facilities at the county level Lack of HIV, syphilis and hepatitis B testing agents and devices in primary-level medical facilities Lack of pregnancy nutritional package production and supply and coordination Management Insufficient cooperation in referral of high- risk pregnant women and screening, diagnosis and treatment for syphilis and HIV, hepatitis B Inadequate participation of outside personnel in PMTCT Less coordination among the functional sectors (e.g. media, enterprises, police, and community, health facilities) in management of and services for migrant pregnant women Budget and expenditure No budget for the pregnancy nutritional package for women in poverty-stricken areas Insufficient funds for screening and diagnosis for birth defects, including visits Lack of funds for regard with training to maternal health care services Supportive environment regulations Policies and Nutritional package for pregnant women not included in the regulations for maternal health care Inadequate supervision on policy execution No regulations and long-acting mechanism for management of migrant pregnant No guidance for weight pregnancy management Conflicts existing in industry service standards (e.g. the standards for syphilis treatment) Social norms period Intervention Foetus/ gestation period

90 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action Coverage of effective of effective interventions Service quality Insufficient knowledge and skills of medical staff Insufficient measures for prevention of postnatal depression No implementation of referral preparation and safe referral No safe midwifery measures in place for coverage low PMTCT; of basic obstetrics and comprehensive obstetrics Inadequate attention to natural delivery Unsatisfactory implementation of measures for preventing and treating postpartum haemorrhage, such as correct measurement of haemorrhage services Sustainable utilization of Poor compliance PMTCT to HIV and sustained medication for mothers and infants Insufficient medical security for poor and migrant pregnant women, thus affecting the sustainable utilization of services traffic No effective referral mechanism in communities, and utilization of hospital delivery by increase affected of opportunity cost Demand-side behaviours Economy, society, society, Economy, culture, customs and The convention of “confinement in childbirth” leading to puerperal infection and failure to access medical treatment on time No idea of expected date of confinement, less awareness of advance hospitalization for especially for delivery, impoverished pregnant women in remote areas Hospital delivery may by customs be affected and religions in ethnic minority areas Service delivery Difficult implementation of household postnatal health care services Insufficient proper propaganda and consultation of medical staff Insufficient coverage of publicity Personnel Supply-side Insufficient attention of medical staff No well-trained obstetricians who are capable of early discovery and identification of mental diseases like postnatal depression, as a result, the possibility of puerperal infection is not discovered and treated in a timely manner Less attention of medical staff to prevention and treatment of postpartum haemorrhage, preparation for referral Insufficient low number, technical high and capacity attrition of first- line personnel Medical staff’s discrimination against HIV/ syphilis-infected persons materials No places for services Insufficient medicines No screening scales and intervention processes for mental health Equipment and Few disinfection packages and instruments, equipment and medicines for safe midwifery in primary-level medical facilities Insufficient measurement devices, oxytocin and medicines (e.g. haemostatic) for postpartum haemorrhage, as well as training aids Insufficient first- aid medicines and devices, vehicles and process maps with regard to referral and coordination Management No efficient processes of referral and group consultation among medical facilities at levels different No long-acting cooperation mechanism for obstetrics and psychology No mechanism of communication between delivery hospital and postnatal care hospital No efficient processes of referral and group consultation among medical facilities at levels different Annexes Budget and expenditure Insufficient funds for puerperium health care Few funds for propaganda Few funds for appropriate training Supportive environment regulations Policies and Barriers existing in implementation of some provisions in maternal health care regulations Unavailability of puerperal mental health care regulations Inadequate implementation of maternal health care regulations Social norms Certain misconception on vaginal delivery Excruciating pain during vaginal delivery High rate of caesarean delivery due to the worry about bodily form and other reasons period Intervention Puerperium Birth/delivery period

91 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action Coverage of effective of effective interventions Service quality Low coverage of basic and comprehensive neonatal health care services Incapability of primary-level medical facilities to neonatal health offer care services Less capability of medical staff in primary-level medical facilities No paediatric outpatient services in primary-level organizations Insufficient consultation and guidance for infancy and childhood health care services Sustainable utilization of Not timely medical treatment due to lack of parents’ awareness care health and knowledge less Parents’ knowledge, skills and techniques of infant and young child feeding, such as exclusive breastfeeding and rational food conversion to solid, semisolid, or soft foods Demand-side behaviours Economy, society, society, Economy, culture, customs and Affected by household Affected economy Refusal to see a doctor in some areas due to customs Abandonment of colostrum, late initiation of breastfeeding or feeding newborns with water or other foods subject to customs and religions No timely medical treatment due to household economy Poor knowledge, behaviours and capability of hazardous factors identification of parents Poor awareness of parents in child health care Premature introduction of solid, semisolid or soft foods subject to traditional culture and customs in local areas, or insufficient variety, frequency or quality of solid, semisolid or soft foods introduced Service delivery No neonatal wards in primary-level hospitals No special personnel and equipment for newborn rescue and treatment in primary- level midwifery organizations No paediatric outpatient services in primary-levels of organizations No paediatric professionals Personnel Supply-side Insufficient number and capability of first-line personnel Less awareness of medical staff on neonatal care Insufficient number and capability of first-line personnel materials Insufficient first- aid devices for newborns in primary-level organizations Equipment and No standard on- the-job and pre- job training packages No basic child health care packages for remote areas and coordination Management Less coordination between departments of medical facilities, such as the obstetrics department and neonatology department No coordination mechanism established for media government, and other sectors Unsmooth coordination between departments of medical facilities Budget and expenditure No budget for neonatal health care Low coverage of medical insurance for newborns Insufficient budget education health for with regard to household child feeding and disease prevention Insufficient budget for child nutritional package (only for children in poverty- stricken areas currently) Supportive environment regulations Policies and Insufficient policy advocacy Insufficient coverage of neonatal medical insurance in some areas Insufficient types of medicines for children Zinc (for diarrhoea treatment) not included as a basic medicine Inadequate implementation of policies for infant and young child feeding Social norms --- period Intervention Neonatal care Infancy and childhood period

92 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action Coverage of effective of effective interventions Service quality Low immunization coverage in remote areas services Sustainable utilization of Compliance to sustainable immunization due of to side effects vaccines in some areas Demand-side behaviours Economy, society, society, Economy, culture, customs and Service delivery Incomplete outpatient services in western areas No sound injury reporting and surveillance system Personnel Supply-side Insufficient number and capability of first-line personnel Insufficient training for relevant personnel in education and medical treatment sectors materials Equipment and Process monitoring for transfer cold-chain to be improved, including the varieties and quantity of vaccines transported, environmental temperature, and temperature of vaccines, etc and coordination Management No mechanism of coordination among government, media, enterprises, police, community, health and other functional sectors No coordination mechanism for health and family planning administrative departments, medical and health facilities, and disease control centres Annexes Budget and expenditure No budget for child injury prevention No funds for first- line personnel Supportive environment regulations Policies and Incomplete policies and difficult implementation of policies No immunization regulations, policies and specifications in place Immunization for adults and adolescence not included in national policies Social norms period Intervention Child injury Immunization

93 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action Coverage of effective of effective interventions Service quality Insufficient quality central of quantity and water supply Low coverage of public lavatories with soap for handwashing services Sustainable utilization of Inadequate hygiene management and operation maintenance for central water supply facilities Inadequate guidance, publicity and education on use and maintenance of sanitary latrines Demand-side behaviours Economy, society, society, Economy, culture, customs and In ethnic minority areas, health the people’s awareness and behaviours are greatly affected by local cultures and customs(e. g. the toilet cannot be built indoors or in the court otherwise it the geomancy will affect filthy ate have no disease) Service delivery Sanitation is not market-oriented; no awareness of sanitation improvement, no idea about the selection of appropriate sanitation and technology, not convenient to acquire sanitation products Personnel Supply-side Insufficient professionals for water supply management and sanitation technology promotion materials Equipment and Low coverage of central water imperfect supply, water disposal process, and low rate of satisfactory water quality Low proportion of harmless sanitary latrine, and insufficient public lavatories Few handwashing facilities, less configuration of soap or handwashing liquid and coordination Management Mechanisms to coordinate sectors (e.g. coordination and organization, forum) WASH are required, and the overall health status should be incorporated into the national report Budget and expenditure Excessive reliance on external funds such as governmental funds Supportive environment regulations Policies and National policies are incomplete to cover all organizations and population, especially the people in poverty-stricken areas; instead, the national strategies and goals with regard to drinking water and lavatory improvement should be revised Social norms General devoid of of devoid General correct sanitation and hygiene concepts and behaviours. It is necessary to develop a series of new rules (for instance, lavatory should be a clean and comfortable place; public lavatory is not a matter for only the individual), change the traditional concepts (for instance, a faeces are baby’s deemed clean or less-harmful), break the taboos with regard to the lavatory (for instance, lavatory-related matters are not mentioned at the table, except the concept that it is necessary to pay for drinking water), and form the consciousness that it is unhealthy to take foods with dirty hands or impolite to shake others’ hands with your dirty hands period Intervention Water, Water, sanitation and hygiene

94 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action Sampling survey Sampling survey Sampling survey Sampling survey Sampling survey Complete survey Complete survey Complete survey Sampling survey Survey method Complete survey Complete survey Special survey Special survey Special survey Special survey Special survey Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health China Statistical Yearbook; Health Health Yearbook; Statistical China and family planning statements Data source Annual Report on Maternal and Child Health Health and family planning statements Number of babies at 6–23 months meeting the minimum dietary diversity and the minimum meal frequency in last 24 hours / Number of babies at 6–23 months investigated Number of babies at 6–23 months breastfeeding and non-breastfeeding meeting the minimum frequency of introduction solid, semisolid or soft foods in the past 24 hours / Number of babies at 6–23 months investigated Number of babies at 6–23 months with intake 4 or more types of foods in the past 24 hours / Number babies at 6–23 months investigated × 100% Number of infants at 6–8 months with introduction solid, semisolid or soft foods in the past 24 hours / Number of infants at 6–8 months investigated × 100% Number of babies under 24 months with initiation breastfeeding within 1 hour after birth / Number of babies under 24 months × 100% Number of infants at 0–5 months with breastfeeding / infants at 0–5 months investigated × 100% Number of infants at 0–5 months with exclusive breastfeeding / Number of infants at 0–5 months with breastfeeding investigated × 100% Number of live births women at 15–19 age / 15–19 age × 1000‰ Formula Number of postnatal women with maternal anaemia (with Hb under 100 g/L) / Number of postnatal women who have received maternal haemoglobin testing × 100% Number of married persons (male or female) at reproductive ages with contraceptives / Number of married women aged 15–49 × 100% Annexes Proportion of babies at 6–23 months meeting the minimum dietary diversity and the minimum meal frequency in last 24 hours in a region statistical year Proportion of babies at 6–23 months breastfeeding and non- breastfeeding meeting the minimum frequency of introduction of solid, semisolid or soft foods (including the intake milk for babies with non-breastfeeding) in a region statistical year Proportion of babies at 6–23 months with intake 4 or more types of foods in a region statistical year Proportion of infants at 6–8 months with introduction solid, semisolid or soft foods in a region statistical year Proportion of initiation breastfeeding within 1 hour after birth among babies under 24 months in a region statistical year Proportion of breastfeeding among infants at 0–5 months in a region in a statistical year Proportion of exclusive breastfeeding among infants at 0–5 months in a region statistical year Number of live births per 1000 women at 15–19 age in a region in a statistical year Definition Proportion of postnatal women with maternal anaemia (with Hb under 100 g/L) out of the postnatal women who have received maternal haemoglobin testing in a region This is a key indicator to reflect woman’s statistical year. nutrition and health status. Proportion of married women aged 15–49 with contraceptives (for themselves or their mates) in a region at time point Minimum acceptable diet (%) Minimum meal frequency (%) Minimum dietary diversity (%) Introduction of solid, semisolid or soft foods at 6–8 months(%) Early initiation of breastfeeding(%) Breastfeeding under 6 months (%) Exclusive breastfeeding under 6 months (%) Fertility rate for women at 15–19 age(%) Indicator Prevalence of maternal anaemia with Hb under 100 g/L(%) Contraceptive prevalence among women aged 15–49 who are married(%) 8 7 6 5 4 3 2 No. 1 10 9 Annex 5: Evaluation Indicators of the Maternal and Child Health Care Intervention Package Annex 5: Evaluation Indicators of the Maternal and Child Health Care

95 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action Survey method Complete survey, Complete survey, Sampling survey Complete survey, Complete survey, Sampling survey Sampling survey Complete survey, Complete survey, Sampling survey Complete survey Complete survey Complete survey Complete survey Complete survey Complete survey Complete survey Data source Maternal and Child Health Annual Surveillance System, Report on Maternal and Child Health Maternal and Child Health Surveillance System, Major Public Health Statement Maternal and Child Health Surveillance System Disease Prevention & Control System, Maternal Mortality and Direct Reporting Tetanus Neonatal System Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Information system of HIV, syphilis and hepatitis B PMTCT Annual Report on Maternal and Child Health Information system of HIV, syphilis and hepatitis B PMTCT Annual Report on Maternal and Child Health Information system of HIV, syphilis and hepatitis B PMTCT Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Formula Number of maternal deaths / live births × 100,000/100,000 Number of neural tube defect cases / perinatal babies × 10,000/10,000 Number of birth defect cases / perinatal babies × 10,000/10,000 Number of neonatal tetanus cases / live births in a region × 1000‰ Number of women with cervical cancer / who have received the screening for cervical cancer × 100% Number of hepatitis B-infected pregnant women / women who have received hepatitis B testing × 100% Number of syphilis-infected pregnant women / women who have received syphilis testing × 100% Number of HIV-infected pregnant women / Number of Number of HIV-infected testing × 100% who have received HIV Number of children at 6–59 months with moderate to severe anaemia / Number of children under 5 years who have received maternal haemoglobin testing × 100% Number of children at 6–59 months with anaemia / under 5 years who have received maternal haemoglobin testing × 100% Number of postnatal women with maternal anaemia (with Hb under 80 g/L) / Number of postnatal women who have received maternal haemoglobin testing × 100% Definition Maternal mortality per 100 000 live births in a region statistical year Proportion of neural tube defect cases out the number perinatal babies in a region statistical year Proportion of birth defect cases out the number perinatal babies in a region statistical year Proportion of neonatal tetanus cases out the live births in a region in a statistical year Proportion of women with cervical cancer out the who have received screening for cervical cancer in a region a statistical year Proportion of hepatitis B-infected pregnant women out the pregnant women who have received hepatitis B testing in a region in a statistical year Proportion of syphilis-infected pregnant women out the pregnant women who have received syphilis testing in a region in a statistical year Proportion of HIV-infected pregnant women out of the Proportion of HIV-infected testing in a region pregnant women who have received HIV a statistical year Proportion of children under 5 years (or at 6–59 months) with moderate to severe anaemia out of the children under 5 years who have received maternal haemoglobin testing in a region a statistical year. Proportion of children under 5 years (or at 6–59 months) with anaemia out of the children under 5 years who have received maternal haemoglobin testing in a region statistical year. Proportion of postnatal women with maternal anaemia (with Hb under 80 g/L) out of the postnatal women who have received maternal haemoglobin testing in a region This is a key indicator that reflects women’s statistical year. nutrition and health status. Indicator Maternal mortality ratio (per 100,000 live births) Incidence of neural tube defects Incidence of birth defects Incidence of neonatal tetanus(%) Prevalence of cervical cancer(%) Hepatitis B prevalence among pregnant women(%) Prevalence of syphilis among pregnant women(%) HIV prevalence among HIV pregnant women(%) Prevalence of moderate to severe anaemia among children under 5 years (%) Prevalence of anaemia among children under 5 years (%) Prevalence of maternal anaemia with Hb under 80 g/L(%) No. 21 20 19 18 17 16 15 14 13 12 11

96 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action Survey method Complete survey Complete survey Complete survey Complete survey Complete survey Sampling survey Complete survey Complete survey Complete survey Sampling survey Sampling survey Complete survey, Complete survey, Sampling survey Complete survey, Complete survey, Sampling survey Complete survey, Complete survey, Sampling survey Sampling survey Data source Special survey Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Disease Prevention and Control System Maternal Mortality and Neonatal Direct Reporting System Tetanus Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Maternal and Child Health Surveillance System Maternal and Child Health Surveillance System Annual Report on Maternal and Child Health, Maternal and Health Surveillance System Annual Report on Maternal and Child Health, Maternal and Health Surveillance System Annual Report on Maternal and Child Health, Maternal and Health Surveillance System Maternal and Child Health Annual Surveillance System, Report on Maternal and Child Health Formula Number of children under 5 with height for weight

97 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action Survey method Complete survey Complete survey Complete survey Complete survey Complete survey Complete survey Complete survey Complete survey Complete survey Complete survey Complete survey Sampling survey Complete survey Sampling survey Sampling survey Data source Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Special survey Annual Report on Maternal and Child Health Special survey Special survey 3 ≤ 3 / Number of 2 and > > Formula Number of high-risk pregnant women who deliver in hospitals / Number Number / in hospitals who deliver women pregnant of high-risk Number of high-risk pregnant women × 100% Number of high-risk pregnant women under management / high-risk pregnant women × 100% Number of high-risk pregnant women / × 100% Number of live births delivered by caesarean / × 100% Number of live births delivered in hospitals / × 100% Number of pregnant women under systematic management / women who have delivered live births × 100% Number of mothers who have received postnatal care for at least one visit within 28 days / Number of mothers who have delivered live births × 100% Number of pregnant women who have received antenatal care for at least five visits / Number of women who have delivered live births × 100% Number of pregnant women who have received antenatal care for at least one visit / Number of women who have delivered live births × 100% Number of pregnant women who have received antenatal care in the early 12 weeks / Number of women who have delivered live births × 100% Number of pregnant women recorded / × 100% Number of preterm live births / × 100% Number of macrosomia / live births × 100% children under 5 who have received height/weight examination × 100% Number of children under 5 with height for weight Z / Number of children under 5 who have received height/weight examination × 100% Number of children under 5 with height for weight Z Definition Proportion of high-risk pregnant women who deliver in hospitals out of total high-risk pregnant women in a region statistical year Proportion of high-risk pregnant women under management statistical a in region a in women pregnant high-risk total of out year Proportion of high-risk pregnant women out total women in a region statistical year Proportion of live births delivered by caesarean out total births in a region statistical year Proportion of live births delivered in hospitals out the total live births in a region statistical year Proportion of pregnant women under systematic management out of the women who have delivered live births in a region a statistical year Proportion of mothers who have received postnatal care for at least one visit within 28 days out of the mothers who have delivered live births in a region statistical year Proportion of pregnant women who have received antenatal care for at least five visits out of the women who have delivered live births in a region statistical year Proportion of pregnant women who have received antenatal care for at least one visit compared to the number of women who have delivered live births in a region statistical year Proportion of pregnant women who have received antenatal care in the early 12 weeks compared to women who have delivered live births in a region statistical year Proportion of pregnant women recorded compared to the total number of pregnant women in a region statistical year Proportion of preterm live births out total in a region in a statistical year Proportion of macrosomia out the live births in a region statistical year Proportion of children under 5 with obesity in the under 5 who have received a height/weight examination in region in a statistical year Proportion of overweight children under age 5 out the children under age 5 who have received height/weight examination in a region statistical year Indicator Proportion of hospital delivery within high-risk pregnant women(%) Management rate of high- risk pregnant women(%) Proportion of high-risk pregnant women(%) Births by caesarean section section caesarean by Births (%) Hospital delivery rate (%) Systematic management rate for pregnant women (%) Postnatal care coverage for mothers - at least one visit within 28 days (%) Antenatal care coverage - at least five visits (%) Antenatal care coverage - at least one visit (%) Antenatal care coverage - in the early 12 weeks (%) Recording rate for pregnant women(%) Incidence of preterm births(%) Macrosomia newborns (%) Children under age 5 with obesity (%) Children under age 5 with overweight (%) No. 49 48 47 46 45 44 43 42 41 40 39 38 37 36 35

98 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action Survey method Complete survey Complete survey Complete survey Complete survey Sampling survey Sampling survey Complete survey Complete survey Complete survey Complete survey Data source Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Information System of HIV, Information System of HIV, Syphilis and Hepatitis B PMTCT Information System of HIV, Information System of HIV, Syphilis and Hepatitis B PMTCT Annual Report on Maternal and Child Health Information System of HIV, Syphilis and Hepatitis B PMTCT Annual Report on Maternal and Child Health Information System of HIV, Syphilis and Hepatitis B PMTCT Annual Report on Maternal and Child Health Information System of HIV, Syphilis and Hepatitis B PMTCT Annual Report on Maternal and Child Health Formula Number of pregnant women who are definitive in diagnosis prenatal birth defects / Number of pregnant women who have received diagnosis of prenatal birth defects × 100% Number of pregnant women who have received diagnosis prenatal birth defects / Number of pregnant women × 100% Number of high-risk pregnant women received prenatal screening / Number of pregnant women who have received prenatal screening × 100% Number of pregnant women who have received prenatal screening / Number of pregnant women × 100% Number of syphilis-infected pregnant women who have been treated by interventions / Number of syphilis-infected pregnant women × 100% Number of HIV-infected pregnant women who have been treated by Number of HIV-infected pregnant women × antiretroviral therapy / Number of HIV-infected 100% Number of pregnant women who have received hepatitis B testing / Number of pregnant women × 100% Number of pregnant women who have received syphilis testing / Number of pregnant women × 100% Number of pregnant women who have received HIV testing / Number Number of pregnant women who have received HIV of pregnant women × 100% Number of pregnant women who have received haemoglobin testing / Number of pregnant women × 100% Annexes Definition Proportion of pregnant women who are definitive in diagnosis of prenatal birth defects out total pregnant women who have received diagnosis of prenatal birth defects in a region statistical year Proportion of pregnant women who have received diagnosis prenatal birth defects out of total pregnant women in a region in a statistical year Proportion of high-risk pregnant women out total women who have received prenatal screening (only serological screening, but excluding ultrasonic screening) in a region statistical year Proportion of pregnant women who have received prenatal screening (only serological screening, but excluding ultrasonic screening) out of total pregnant women in a region statistical year Proportion of syphilis-infected pregnant women who have been been have who women pregnant syphilis-infected of Proportion treated by interventions out of total syphilis-infected pregnant women in a region statistical year Proportion of HIV-infected pregnant women who have been Proportion of HIV-infected treated by antiretroviral therapy out of total HIV-infected pregnant women in a region statistical year Proportion of pregnant women who have received hepatitis B testing out of total pregnant women in a region statistical year Proportion of pregnant women who have received syphilis testing out of total pregnant women in a region statistical year Proportion of pregnant women who have received HIV testing Proportion of pregnant women who have received HIV out of total pregnant women in a region statistical year Proportion of pregnant women who have received haemoglobin haemoglobin received have who women pregnant of Proportion testing out of total pregnant women in a region statistical year Indicator Definitive diagnosis rate of prenatal birth defects(%) Diagnosis rate of prenatal birth defects(%) Proportion of high-risk pregnant women received prenatal screening(%) Prenatal screening rate(%) Interventions coverage among syphilis-infected pregnant women for (%) PMTCT Antiretroviral therapy coverage among HIV- infected pregnant women (%) for PMTCT Hepatitis B testing rate among pregnant women(%) Syphilis-testing rate among among rate Syphilis-testing pregnant women(%) HIV-testing rate among HIV-testing pregnant women(%) Haemoglobin-testing rate for pregnant women (%) No. 59 58 57 56 55 54 53 52 51 50

99 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action Survey method Sampling survey Sampling survey Sampling survey Sampling survey Sampling survey Complete survey Complete survey Complete survey Complete survey Complete survey Complete survey Data source Special survey Special survey Information System of HIV, Information System of HIV, Syphilis and Hepatitis B PMTCT Information System of HIV, Information System of HIV, Syphilis and Hepatitis B PMTCT Information System of HIV, Information System of HIV, Syphilis and Hepatitis B PMTCT Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health National Neonatal Disease Screening Information System Annual Report on Maternal and Child Health National Neonatal Disease Screening Information System Annual Report on Maternal and Child Health National Neonatal Disease Screening Information System Annual Report on Maternal and Child Health Major Public Health Statement Formula Number of children at 0–59 months with diarrhoea in the past two weeks / Number of children at 0–59 months investigated × 100% Number of children at 0–59 months with pneumonia in the past two weeks / Number of children at 0–59 months investigated × 100% Number of hepatitis B-exposed children who have received B immunoglobulin immunization / Number of children delivered by hepatitis B-infected pregnant women × 100% Number of syphilis-exposed children who have received interventions / Number of children delivered by syphilis-infected pregnant women × 100% Number of HIV-exposed children who have received antiretroviral Number of HIV-exposed pregnant therapy / Number of children delivered by HIV-infected women × 100% Number of newborns who have received screening for hearing / of live births × 100% Number of newborns who have received screening for PKU / of live births × 100% Number of newborns who have received screening for CH / live births × 100% Number of children under 5 who have received haemoglobin testing / Number of children at 6–59 months who should receive haemoglobin testing × 100% Number of babies within 28 days who have received postnatal care / Number of live births × 100% Number of persons who have taken folic acid / should take folic acid × 100% Definition Proportion of children at 0–59 months with diarrhoea in the past two weeks out of total children at 0–59 months investigated in a region at time point Proportion of children at 0–59 months with pneumonia in the past two weeks out of total children at 0–59 months investigated in a region at time point Proportion of hepatitis B-exposed children who have received hepatitis B immunoglobulin immunization out of total children delivered by hepatitis B-infected pregnant women in a region in a statistical year Proportion of syphilis-exposed children who have received interventions out of total children delivered by syphilis- infected pregnant women in a region statistical year Proportion of HIV-exposed children who have received Proportion of HIV-exposed antiretroviral therapy out of total children delivered by HIV- infected pregnant women in a region statistical year Proportion of newborns who have received screening for hearing out of total live births in a region statistical year Proportion of newborns who have received screening for PKU out of total live births in a region statistical year Proportion of newborns who have received screening for CH out of total live births in a region statistical year Proportion of children under age 5 who have received haemoglobin testing out of the children at 6–59 months who should receive haemoglobin testing in a region statistical year Proportion of babies within 28 days who have received postnatal care compared to total live births in a region statistical year Proportion of persons who have taken folic acid out total persons who should take folic acid in a region statistical year in a region statistical Indicator Two-week prevalence of Two-week diarrhoea among children under age 5(%) Two-week prevalence of Two-week children among pneumonia under age 5(%) Hepatitis B immunoglobulin immunization coverage (%) Interventions coverage among syphilis-exposed (%) children for PMTCT Antiretroviral therapy coverage among HIV- exposed children for (%) PMTCT Neonatal hearing screening screening hearing Neonatal (%) Screening rate for phenylketonuria (PKU)(%) Screening rate for congenital hypothyroidism (CH)(%) Haemoglobin testing rate for children aged 5 years (%) Postnatal care coverage for babies within 28 days (%) Proportion of taking folic acid(%) No. 70 69 68 67 66 65 64 63 62 61 60

100 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action Survey method Complete survey Complete survey Complete survey Complete survey Complete survey Sampling survey Sampling survey Sampling survey Sampling survey Sampling survey Sampling survey Data source Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Annual Report on Maternal and Child Health Immunization Information System Immunization Information System Immunization Information System Immunization Information System Immunization Information System Special survey Formula Number of certain family plan surgical complication cases / Number of Number of certain family plan surgical certain family plan service cases × 10,000/10,000 Number of persons with serious heredity diseases / with diseases detected in premarital medical check-up × 100% Number of persons with sexually transmitted diseases / persons with infectious diseases detected in premarital medical check- up × 100% Number of persons with infectious diseases / diseases detected in premarital medical check-up × 100% Number of persons who have consulted for premarital health / of persons who have registered for marriage × 100% Number of children who have received DTP3 immunization within one year of age / Number children at 12–23 months investigated × 100% Number of children who have received poliomyelitis immunization within one year of age / Number children at 12–23 months investigated × 100% Number of children who have received at least one MCV immunization Number of children who have received at least one MCV within one year of age / Number children at 12–23 months investigated × 100% Number of newborns who have received BCG immunization / of live births × 100% Number of 1-year-old children who have received 3 doses of HepB Number of 1-year-old children × 100% immunization / Number of 1-year-old Number of children at 0-59 months with diarrhoea in the past two weeks two weeks past the in diarrhoea with 0-59 months at Number of children receiving oral rehydration therapy / Number of children at 0–59 months investigated × 100% Annexes Definition Proportion of certain family plan surgical complication cases Proportion of certain family plan surgical out of total certain family plan service cases in a region statistical year Proportion of persons with serious heredity diseases out of total total of out diseases heredity serious with persons of Proportion persons with diseases detected in premarital medical check-up in a region statistical year Proportion of persons with sexually transmitted diseases out of total persons with infectious diseases detected in premarital medical check-up in a region statistical year Proportion of persons with infectious diseases out total persons with diseases detected in premarital medical check-up in a region statistical year Proportion of persons who have consulted for premarital health out of total persons who have registered for marriage in a region in a statistical year Proportion of children who have received DTP3 immunization within one year of age out total children at 12–23 months investigated in a region statistical year Proportion of children who have received poliomyelitis immunization within one year of age out total children at 12–23 months investigated in a region statistical year Proportion of children who have received MCV immunization Proportion of children who have received MCV within one year of age out total children at 12–23 months investigated in a region statistical year Proportion of newborns who have received BCG immunization out of total live births in a region statistical year Proportion of 1-year-old children who have received 3 doses of Proportion of 1-year-old children in a region HepB immunization out of total 1-year-old in a statistical year Proportion of children aged <5 years with diarrhoea in the past two weeks receiving oral rehydration therapy out of total children aged <5 years investigated in a region at time point Indicator Incidence of certain family complication plan surgical Proportion of serious detected in disease heredity diseases(%) Proportion of sexually transmitted diseases in infectious disease(%) Proportion of infectious diseases in detected diseases(%) Counselling rate of premarital health(%) Diphtheria, tetanus, toxoid and pertussis (DTP3) immunization coverage (%) among 1-year-olds Poliomyelitis immunization coverage (%) among 1-year-olds Measles (MCV) immunization coverage (%) among 1-year-olds Bacillus calmette guerin (BCG) immunization coverage among newborns (%) Hepatitis B (HepB3) immunization coverage (%) among 1-year-olds Children aged <5 years with diarrhoea receiving oral rehydration therapy (%) No. 81 80 79 78 77 76 75 74 73 72 71

101 Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action Survey method Sampling survey Sampling survey Sampling survey Sampling survey Sampling survey Data source Special survey Special survey Special survey Special survey Special survey Formula Population covered by central water supply / Total population Total Population covered by central water supply / investigated in a region × 100% Number of sanitary latrines / investigated × 100% Number of informants who have correctly wash hands / informants investigated × 100% Number of health behaviours that the informants have formed / of health behaviours investigated × 100% Number of questions to which the respondents provide correct answers / Number of questions on the questionnaire × 100% Definition Proportion of the population covered by central water supply out of the total population investigated in a region during time period Proportion of sanitary latrines out total investigated Proportion of informants who wash hands for at least 20s with and soap/handwashing liquid every time before moving water, eating, after relieving themselves, work, touching paper currency or coins, after leaving a hospital, out of total informants investigated Proportion of health behaviours that the informants have formed out of total health behaviours investigated during the investigation period Proportion of questions to which the respondents provide correct answers out of total questions on the questionnaire during the investigation period Indicator Central water supply coverage(%) Proportion of sanitary latrine(%) Rate of using soap to wash hands(%) Formation rate of health behaviour(%) Awareness rate of the Awareness health knowledge(%) No. 86 85 84 83 82

102 References 103

. 2013(03):56-60. 1, 19(5):288-290. References Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action to from Evidence in China: Aged 0–6 of Children Development and for Survival Strategies United Nations Children’s Fund (UNICEF). Committing to Sept_2013.pdf Child2013[EB/OL]. https://www.unicef.org/lac/Committing_to_Child_Survival_APR_9_ Survival: A Promise Renewed Progress Report World Health Organization and UNICEF. Accountabilityfiles.pdf Update[EB/OL]. http://countdown2030.org/wp-content/uploads/2013/05/Countdown_2013-Update_nopro for Maternal, Newborn and Child Survival: World Health TheOrganization. 2013Born Too Soon: the Global Action Report on Preterm Birth.[EB/OL]. www.who.int/pmnch/media/news/2012/201204_borntoosoon-report.pdf [2012-04] http:// Statistical Information Center of NHC. Analysis Report of National Medical College Press, 2015. Beijing: Peking Union Health Services Survey in China (2013) [R]. Department of Disease Control and Prevention of the Ministry of Health and Chinese Center for Disease Control and Prevention. HBV Sero-epidemiological Survey Report for People in China [R]. Beijing: People’s Medical Publishing House, 2011. Cui Fuqiang, Wang Fuzhen, Wu Zhenhua, et al. Analysis on HBV Cases Reported in China 2005–2010 [J]. 17(6):483-486. and Immunization. 2011, Chinese Vaccines Journal of Vaccines of Journal 2000 [J]. Chinese China in in Epidemiology of Measles Analysis Kean. Wang Zhu Xu, Lixia, Wang and Immunization. 2001, 7(6):326-327. Ma Chao, Hao Lixin, Su Qiru, et al. Measles Epidemiology Characteristics and Progress Measles Toward Elimination Immunization. 2012, 18(3):193-197. and Vaccines in China [J]. Chinese Journal of Li Junhong, Li Yixing, Shao Zhuju, Surveillance. 2010, 25(10): 770-772. et al. Analysis on ECM SurveillanceDong M Zhao Y, Yang Z L ResultsetY, Y, al. Comparison inof MalnutritionChina Prevalence 2009of Children [J].under Environmental Sciences. 2016, 29(3):165-176. between 2002 and 2013[J]. Biomedical and 5 Years in DiseaseChina Chang Suying, He Wu, Chen Chunming. The Growth Characteristics of Children Journal of Hygiene Research. 2006, 35(6):768-771. under 5 in the Past 15 Years [J]. General Office of the State Council. Program for Food and Nutrition Development in China[2014-02-10]. http://www.nhfpc.gov.cn/jkj/s5877/201402/e0c27e00e4004aa39f3a24fbeb027fb3.shtml (2014–2020). [EB/OL] Cao Lei, Wang Huaqing, Zheng Jingshan, et al. National Immunization Immunization. 2012, 18(5): 419-424. and Vaccines Journal of into EPI since 2008 [J]. Chinese Coverage Vaccines More Survey in China after Integrated Zheng Jingshan, Cao Lei, Guo Shicheng, et al. and Immunization [J]. 2012, 18(3): 233-237. SurveyVaccines in China. Chinese Journal of on Years Aged 1 to 2 Children the Immunization Status of Category B Vaccine among Analysis Report of Chinese Iodine Jun. Deficiency Disorders in 2002 [J]. Chinese Journal Liu Yu Shoujun, Su Xiaohui, 2003, 22(1): 142-144. of Endemiology. General Office of the Ministry of Health. Surveillance Report of National Iodine Deficiency Disorders in 2010OL].[2011-06-10]http://www.nhfpc.gov.cn/zwgkzt/wsbysj/201105/51576.shtml [EB/ Zheng Qingsi, Xu Jing, Dong Huijie, et Signficance for Control andal. Prevention of IDD [J]. Chinese Journal of Control ofChina Endemic Diseases. 2010, 25(6): 428- Surveillance System for Iodine 430. Deficiency Disorders and its Teng Honghong, Wang Xiaohua, Li Hui. Study on Chinese Child Vitamin A Deficiency inJournal of Child Health Care. 2006, 14(3): 270-271. 2000-2004 [J]. Chinese in Analysis of Health Selective Survey Result of Aidong. Children Women and Pregnant Dongmei, Liu Yu Zhao Liyun, China in 2006 [J]. Journal of Hygiene Research. 2008, 37(1):65-67. Guo Haijun, Zhang Bing. Progress of Study on Interventions for Child A DeficiencyVitamin [J]. Journal of Hygiene Research. 2009, 4(38): 510- 510. Meng Yucui, Zhang Yuhan, Hou Yanli, et al. Survey on Maternal Anemia during Pregnancy China [J]. Publishing House of Chinese Journal of Family Planning. 201 in Three Provinces of Li Hu, Hu Jiayu, Tao Lina, et al. Epidemiological Features and Immunization Strategies of Congenital Rubella Zhao Ning, Shen Junlong, Zhao Kun, et al. The Status Quo of Maternal and Child Health Investment in Policy of Public Finance [J]. Chinese Journal of Health under the Prospective West China [2] [3] [4] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [1] Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action

Syndrome [J]. Shanghai Journal of Preventive Medicine. 2005, 17(2):72-74. [25] Hou Linpu, Jiang Yingtao, Gao Ying, et al. Serologic and Epidemiologic Survey on Rubella Virus-Infected Women Aged 15-49 in 7 Provinces/Municipalities [J]. Chinese Journal of Epidemiology. 2004, 25(5):455. [26] Si, LP, Guan RH. Survey on Rubella Antibody Level In Women of Child Bearing Age in Shanxi Province [J]. Prog Mic Immun. 2008, 36(2):28-30. [27] Feng Dongyan, Chen Meirong, Wang Pingping. Investigation of Infection Rate of Cytomegalo Virus, Rubella Virus and Toxoplasma Gondii in Married Women at Reproductive Ages [J]. Chinese Journal of Birth Health and Heredity. 2005, 13(8):113-114. [28] Bai Yana, Zhang Wenhui, Du Weiyun, et al. Investigation on IgM and IgG of Serum of Rubella Infection in No- pregnancy and Pregnancy Women [J]. Chinese Primary Health Care. 2004, 18(6):43-44. [29] Center for Health Statistics and Information, the Ministry of Health. Analysis Report of National Health Services Survey in China (2008) [R]. Beijing: Peking Union Medical College Press, 2009. [30] General Office of the Ministry of Health. Half Drinking Water in Chinese Rural Areas under “Bottom Line” of Hygienic Standard[EB/OL]. http://politics.people.com.cn/GB/1027/6891949.html. [31] United Nations Children’s Fund. Water, Sanitation and Hygiene, 2012[EB/OL]. http://www.unicef.cn/cn/uploadfile/201 3/0410/20130410033740994.pdf [32] National Health and Family Planning Commission of the PRC. 2015 China Health and Family Planning Statistical Yearbook[R]. Beijing: Peking Union Medical College Press, 2015. [33] UNICEF. Soap, Lavatory and Water Faucet, 2009[EB/OL]. http://www.unicef.cn/cn/index.php?m=content &c=index&a=show&catid=59&id=158 [34] Wang Shunqin, Zhang Jinliang. Blood Lead Levels of Children in China [J]. Journal of Environment and Health. 2004, 21(6):3-8. [35] Jin Yinlong, Liang Chaoke, He Gongli, et al. Study on Distribution of Endemic Arsenism in China [J]. Journal of Hygiene Research. 2003, 32(6):519-540. [36] Chen Zhi. Distribution of Endemic Fluorosis in China [J]. Chinese Journal of Public health. 1997, 13(3):133-134. [37] Guo Mei, Yu Jie. Study on Influence Factors for Breastfeeding [J]. Maternal and Child Health Care of China. 1996, 11(6): 30-32. [38] Jiang Jie, Wu Peiyan, Huang Haixing, et al. Factor Analysis on Breastfeeding and Care of Babies under 4 Months [J]. Maternal and Child Health Care of China. 2006, 21(11): 1565-1566. [39] Jiang Yan, Guo Lina, Zhang Li, et al. Infant and Young Child Feeding and Its Influence Factors in Rural Areas in 4 Provinces/Municipalities in Central-West China [J]. Chinese Journal of Health Education. 2013, 29(5): 394-397. [40] National Center for Chronic and Noncommunicable Disease Control and Prevention, China CDC, and Safe Kids. Survey on Unintentional Injuries among Children and Parents’ Perception in Three Cities of China [R]. Beijing: Peking Union Medical College Press, 2004. [41] Meng Qun, Xu Ling, Zhang Yaoguang, et al. Trends in Access to Health care services and Financial Protection in China between 2003 and 2011: a Cross-Sectional Study [J]. The Lancet. 2012, 379 (9818): 805-814. [42] Johns B, Sigurbjornsdottir K, Fogstad H, et al. Estimated Global Resources Needed to Attain Universal Coverage of Maternal and Newborn Health care services [J]. Bull World Health Organ. 2007, 85(4):256-263. [43] Stenberg K, Axelson H, Sheehan P, et al. Advancing Social and Economic Development by Investing in Women’s and Children’s Health: a New Global Investment Framework [J]. Lancet. 2014. 383(9925):1333-1354. [44] Van Ekdom L, Stenberg K, Scherpbier RW, et al. Global Cost of Child Survival: Estimates from Country-Level Validation [J]. Bull World Health Organ. 2011, 89(4):267-277. [45] Adesina A, Bollinger LA. Estimating the Cost-Savings Associated with Bundling Maternal and Child Health Interventions: a Proposed Methodology [J]. BMC Public health. 2013, 13 Suppl 3:S27. [46] Bartlett L, Weissman E, Gubin R, et al. The Impact and Cost of Scaling up Midwifery and Obstetrics in 58 Low-and Middle-Income Countries [J]. PLoS One. 2014, 9(6):e98550. [47] Byrne A, Hodge A, Jimenez-Soto E. Accelerating Maternal and Child Health Gains in Papua New Guinea: Modelled Predictions from Closing the Equity Gap Using LiST [J]. Matern Child Health J. 2015, 19(11):2429-2437. [48] Chola L, McGee S, Tugendhaft A, et al. Scaling Up Family Planning to Reduce Maternal and Child Mortality: The Potential Costs and Benefits of Modern Contraceptive Use in South Africa [J]. PLoS One. 2015, 10(6):e0130077. [49] Chola L, Michalow J, Tugendhaft A, et al. Reducing Diarrhoea Deaths in South Africa: Costs and Effects of Scaling up

104 References 105

World Health Organ. 2014, 92(10):706-715. Health Organ. World Strategies for Survival and Development of Children Aged 0–6 in China: from Evidence to Action to from Evidence in China: Aged 0–6 of Children Development and for Survival Strategies Marsh A, Munos M, Baya B, et al. Using LiST to Model Potential Reduction in under-Five Mortality in Burkina Faso [J]. [J]. Faso Burkina in Mortality under-Five in Reduction Potential Model to LiST Using al. et B, Baya M, Munos A, Marsh BMC Public health. 2013, 13 Suppl 3:S26. McPake B, Edoka I, Witter S, et al. Cost-Effectiveness of Community-Based 2015, 93(9):631-639A. Health Organ. PractitionerWorld Indonesia and Kenya[J]. Bull Programmes in Ethiopia, Michalow J, Chola L, McGee S, Return et on Triple al. Investment: the Cost and Impact of 13 Interventions that Could Prevent Stillbirths and Save the Lives of Mothers and Babies in South Africa [J]. BMC Pregnancy Childbirth. 15:39. 2015, Mubiru D, Byabasheija R, Bwanika JB, et al. Evaluation of Integrated Community Case Management in Eight Districts of Central Uganda [J]. PLoS One. 2015, 10(8):e0134767. 2013, 13 Suppl 3:S1. (LiST) [J]. BMC Public health. Tool Saved IK. Overview of the Lives Friberg Y, Tam N, Walker Essential Interventions to Prevent and Treat Diarrhoea in Under-Five Children [J]. BMC Public health. 2015, 15:394. [J]. BMC Public Children Diarrhoea in Under-Five Treat and to Prevent Essential Interventions George CM, Vignola E, Ricca J, et al. EvaluationCoverage ofof Keythe Child EffectivenessSurvival Interventionsof and Care Reducing Groupsunder-5 Mortality:in 15:835. Public health. 2015, (LiST) [J]. BMC Tool Expandinga Lives Saved Comparative AnalysisPopulation Using the Haroon S, Das JK, Salam RA, et al. Breastfeeding Promotion Interventions and Breastfeeding Practices: a Systematic health. 2013, 13 Suppl 3:S20. Review[J]. BMC Public AH, A, et Mullany The LC, al. of effect Baqui Imdad Umbilical Cord Cleansing with Chlorhexidine on Omphalitis and BMC Public health. 2013, 13 s: a Meta-Analysis [J]. Community Settings in Developing Countrie Neonatal Mortality in Suppl 3:S15. Impact and of Cost- the Effectiveness National Vietnam: in Vaccination of Years I, Thirty et Friberg al. Jit TT, M, Dang 1:A233-239. 2015, 33 Suppl Vaccine. on Immunization [J]. Expanded Programme Elimination: User-Fee after Year One Mortality Child and Maternal of Estimation al. et R, Heinmuller V, Ridde M, Johri and Modeling Study in Burkina Faso [J]. Bull an Impact Evaluation [55] [56] [57] [58] [59] [50] [51] [52] [53] [54]