Regional disparities in child mortality within China 1996-2004: epidemiological profile and health care coverage.

OBJECTIVE: China was one of the 68 "countdown" countries prioritized to attain Millennium Development Goals (MDG 4). The aim of this study was to analyze data on child survival and health care coverage of proven cost-effective interventions in China, with a focus on national disparities.
METHODS: National maternal and child mortality surveillance data were used to estimate child mortality. Coverage for proven interventions was analyzed based on data from the National Health Services Survey, National Nutrition and Health Survey, and National Immunization Survey. Consultations and qualitative field observations by experts were used to complement the Survey data.
RESULTS: Analysis of the data revealed a significant reduction in the overall under-5 (U5) child mortality rate in China from 1996 to 2007, but also great regional disparities, with the risk of child mortality in rural areas II-IV being two- to sixfold higher than that in urban areas. Rural areas II-IV also accounted for approximately 80% of the mortality burden. More than 60% of child mortality occurred during the neonatal period, with 70% of this occurring during the first week of life. The leading causes of neonatal mortality were asphyxia at birth and premature birth; during the post-neonatal period, these were diarrhea and pneumonia, especially in less developed rural areas. Utilization of health care services in terms of both quantity and quality was positively correlated with the region's development level. A large proportion of children were affected by inadequate feeding, and the lack of safe water and essential sanitary facilities are vital indirect factors contributing to the increase in child mortality. The simulation analysis revealed that increasing access to and the quality of the most effective interventions combined with relatively low costs in the context of a comprehensive approach has the potential to reduce U5 deaths by 34%.
CONCLUSIONS: China is on track to meet MDG 4; however, great disparities in health care do exist within the country. It is therefore necessary to specifically target rural areas II-IV. Many causes of child mortality can be prevented or averted through the provision of basic health care. However, the leading predisposing factor contributing to child mortality in China is the insufficient coverage and poor quality of maternal and child health care services. Based on these data, we recommend that the government put more effort to ensure the health of the Chinese people, particularly in terms of providing the most vulnerable populations, i.e., children from the poorest areas and households, with access to good quality essential health care services.