Review
An appraisal of China’s progress toward the Millennium Development Goals as they relate to children Mark A. Strand1, Philip R. Fischer2 1
Pharmacy Practice, Master of Public Health Program, North Dakota State University, Fargo, North Dakota, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
2
Since their inception in 2000, the Millennium Development Goals (MDGs) have improved understanding of the global development process. Although the goals will not be significantly achieved on a global scale, each country has had accomplishments deserving of attention and analysis. With regard to the MDGs as they relate to children, China has made significant achievements, the deeper understanding of which might help in the process of refreshing the MDGs beyond 2015. China’s accomplishments in economic development and human welfare, and the benefits this has brought to its children potentially teach lessons that can be modelled by other countries moving from low- to middle-income status. Keywords: Paediatrics, China, Development, Global health, Millennium Development Goals
Introduction
Methods
In 2003, China filed their first report on progress toward the Millennium Development Goals.1 In only 3 years they were confident of their ability to reach most of the targets. In the 2010 United Nations report on the Millennium Development Goals, China had become something of an outlier for her success.2 On many of the East Asia and the Pacific indicators, such as ‘eradicate extreme hunger and poverty,’ China was excluded from analyses.3 For one thing, much of the global progress, and certainly progress in Eastern Asia, was attributable to China’s success alone. Thus, China’s success skewed the data so that other countries’ successes were dwarfed, and failures less evident. Furthermore, it was difficult for MDG officials to know what to make of China’s apparent success. Should they be excluded from analyses, or should they be set up as an example, and their success and its methods looked to as a model for other countries? China’s progress toward the 2015 MDG deadline merits deeper analysis. Uncertainty about how to deal with China’s success stems from lack of a cultural-historical understanding of China and her development. This article is meant to fill that gap in understanding and report on some key indicators from the Millennium Development Goals (Table 1).
This narrative review set out to find reliable, official data on issues deemed by the authors to be crucial with regard to China and the Millenium Development Goals. The review relied on data available from the People’s Republic of China official government websites, including the Ministry of Health, Ministry of Education, Ministry of Water and the Ministry of Health and Family Planning Commission, UNICEF and the World Health Organization, as cited in the references section. Additionally, to enrich the explanatory power of the paper, peer-reviewed publications were selected to provide data on issues not addressed in the official websites.
Correspondence to: M A Strand, Pharmacy Practice, Master of Public Health Program, North Dakota State University, Fargo, ND, USA. Email: [email protected]
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ß W. S. Maney & Son Ltd 2014 DOI 10.1179/2046905513Y.0000000083
Report on China’s Progress toward MDGs Related to Children MDG1: Eradicate extreme poverty and hunger Poverty. Reduction of the poverty rate in China has been one of its more remarkable achievements since the start of the era of openness and reform in the early 1980s. More than 500 million people have been lifted out of poverty between 1990 and 2008 (using the $1.25 a day poverty line).4 This has meant reducing the proportion of people who are income-poor from 60.2% in 1990 to 13.1% in 2008.5 As a Confucian society, family income is directly invested back into the family, so this reduction in poverty has been an essential feature of improved welfare of children in China. Underweight. In 1990, the prevalence of underweight children (defined as ,-2 SD weight-for-age
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NCHS) was 7.1 and 21.2% in urban and rural areas, respectively,6 dropping to 2 and 9% by 2010,3 which suggests that underweight is a significant problem in rural China. Therefore, continued attention to underweight children in China should focus primarily on rural areas, and those provinces with particularly high rates of underweight. Using a cross-sectional study of rural areas in 10 provinces of China, with a total of 84,009 children under aged 5, Zhang et al. reported the prevalence of stunting, underweight and wasting to be 14.59%, 7.19% and 3.07%, respectively.7 Stunting and underweight occur mostly before 2 years of age. Intervention strategies and programmes should be developed to target preventable risk factors such as rural residence and non-Han Chinese ethnicity. Two provinces have significantly worse rates of undernutrition, Guizhou and Guangxi, with prevalences of stunting among children under 5 years of 38.3% and 20–30%, respectively. Both these provinces have nonHan Chinese populations of over 40%. Breastfeeding and micronutrients. Exclusive breastfeeding at 4 months ranged from 23% in Chongqing to 85% in Shenzhen.8 Following changes introduced in the 1990s, such as the Baby Friendly Hospital
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initiative, and the efforts of the Maternal and Child Health (MCH) stations, the breastfeeding rate in China increased. Since the mid-1990s, ‘any breastfeeding’ rates in the majority of cities and provinces, including minority areas, have been above 80% at 4 months,8 but most cities and provinces did not reach the national target of 80% ‘exclusive breastfeeding’. The mean duration of ‘any breastfeeding’ in the majority of cities or provinces was between 7 and 9 months. ‘Exclusive breastfeeding’ rates in minority areas were relatively lower than in comparable inland provinces. Common reasons for ceasing breastfeeding before 4 months were perceived breast-milk insufficiency, mother going to work, maternal and child illness and breast problems, such as inverted or sore nipples.8 China’s MCH stations have been very successful in carrying out public health interventions for mothers and children. At different times, and with great regional disparity, workers have been involved in micronutrient supplementation programmes. In northern China, which has a high prevalence of rickets, vitamin D and calcium supplementation has been commonly implemented for children in the 1st year of
Table 1 Progress in China toward Key Millennium Development Goals as they relate to children Goals and targets Goal 1: Eradicate extreme poverty and hunger Target 1A: Between 1990 and 2015, halve the proportion of people whose income is ,$1/day Target 1C: between 1990 and 2015, halve the proportion of people who suffer from hunger Goal 2: Achieve universal primary education Target 2A: Ensure that by 2015 children everywhere boys and girls alike will be able to complete a full course of primary schooling Goal 3: Promote gender equality and empower women Target 3A: Eliminate gender disparity in primary and secondary education, preferably by 2005, and in all levels of education no later than 2015 Goal 4: Reduce child mortality Target 4A: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate Goal 5: Improve maternal health Target 5A: Between 1990 and 2015, reduce maternal mortality by three-quarters Goal 6: Combat HIV/AIDS, malaria and other diseases Target 6C: By 2015, to halt and have begun to reverse the incidence of malaria and other major diseases
Goal 7: Ensure environmental sustainability Target 7C: By 2015, halve the number without sustainable access to safe drinking water and basic sanitation Goal 8: Develop a global partnership for development Target 8A: Further develop an open, rule-based, predictable, non-discriminatory trading and financial system. Includes a commitment to good governance, development and poverty reduction, nationally and internationally.
China’s progress
Proportion of people who are income-poor declined from 60.2% in 1990 to 13.1% in 2008 Prevalence of underweight children in 1990 was 7.1% and 21.2% in urban and rural areas, respectively, and in 2010 2% and 9% in urban and rural areas School-age children enrollment rates of 97.8% in 1990 and 99.8% in 2011.
In 1991, 98.7% and 96.9% of boys and girls were enrolled in school in China, rising to over 99% for both genders by 2011
Mortality rate of children under 5 years declined from 13.8 and 45.7 (per 1000 live births) in urban and rural areas in 2000 to 7.1 and 19.1% in 2011. Maternal mortality rate declined from 29.3 and 69.6 (per 100,000 live births) in urban and rural areas in 2000 to 25.2 and 26.5 in 2011. By 2005–2011, 96% of births attended by skilled health personnel. Malaria incidence decreased by .75% from 2000–2011. Incidence of HIV/AIDS among all persons rose from 1 to 1.53/100,000 from 2000 to 2010. Measles immunization coverage of children in China rose from 84 to 99% between 2000 and 2010. 89% of the population has access to drinking-water from improved sources, up from 67% in 1990. General government expenditure on health as % of total government expenditure increased from 10.9–12.1% during 2000–2010.44,45 Basic healthcare coverage increased from 15% in 2000 to 95% in 2010.
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life. In poorer regions, zinc and vitamin A supplementation programmes have been used occasionally, depending on the UNICEF funding cycle, but rarely sustained under local funding. Anaemia remains a particular problem in rural elementary schools in poor provinces such as Shaanxi, where 21.5% of schoolchildren were found to have anaemia using a cut-off of 11.5 g/dl.9 Therefore, an increased intake of animal protein needs to be ensured through school cafeterias. Distribution of micronutrient supplements should continue, but to targeted at-risk populations.
MDG2: Achieve universal primary education
Figure 1 Change in under-5 mortality rate in China Since the introduction of the MDGs
The enrollment rate of all school-age children in China in 1990 was 97.8%. A drive for universal primary education was launched in 1996. It has been successful in significantly developing rural education and reducing inequalities in rural education,10 so that from 2000 to 2011 the enrollment rate of all schoolage children rose even further, from 99.1% to 99.8%. In 2004, 9 years of education was made compulsory in China, and school fees were eliminated in 2007. But in recent years urban migration has reduced village populations by nearly half, so that many villages can no longer sustain an elementary school, much less a middle school. Therefore, many village children have to travel considerable distances to attend school, including boarding for most rural middle- and high-school students. However, there is concern that the cost and inconvenience, including the difficulty for these commuting or boarding rural children to fit in with their new classmates, is significant. Additionally, as young teachers aspire to better working conditions, some are unwilling to accept postings to more rural schools. This leaves many schools with a severe shortage of teachers, and sometimes they have to employ unqualified teachers to fill the gap. This compromises the quality of education and contributes to the growing urban/rural economic and social divide.
2011. In the early years of the MDGs, under-5 mortality rates declined rapidly in rural areas and gradually in urban ones (Fig. 1). Since the mid-2000s both have plateaued. This is because in some areas the challenges of extreme poverty and absence of medical services make it impossible to achieve further reduction of child mortality rates. This highlights the significant rural/urban disparity that remains in many areas of China. China has successfully reduced child mortality with a combination of system-wide implementation of broad maternal and child health initiatives, as well as targeted interventions in diseases which contribute significantly to child mortality, e.g. diarrhoeal disease, pneumonia and neonatal tetanus.13 China has had a well organized immunization programme with substantial government subsidization. Measles immunization coverage was 98% in 1990, 84% in 2000 and 99% in 2010.14 Coverage with DTP3 and HepB3 were both 99% in 2010. The Chinese government has used some progressive policies, such as strategic planning every 10 years when they revise their Maternal and Child Health guidelines document nn中国妇女发展纲要、中国儿童 发展纲要2011–2020mm. Each province also has a 10year plan with details specific to their region. The purpose is to ensure that at every level the government is implementing policies that are in the best interests of women and children. This long-range plan contributes to reducing under-5 mortality.
MDG3: Promote gender equality and empower women In 1991, 98.7% of boys and 96.9% of girls were enrolled in school in China, with a gender disparity of 0.98.11 Official government reports show that by 2011 female students stood at 46.23% of all primary school students, 47.13 of middle school students, 49.98% of high school students, 50.40% of university baccalaureate students, 50.8% of master’s degrees and 36.13% of doctor’s degrees.12 So, parity in education has clearly been achieved.
MDG5: Improve maternal health Maternal health among Chinese women has improved as the fertility rate has declined and medical services have improved. Total fertility rate was six children per woman in 1970. While China’s one-child policy has been restrictive, it has increased the rate of contraception use to 85%14 and has reduced the total fertility rate to 1.6 per woman in 2010.14 With the one-child policy, families invest more heavily in antenatal care for the pregnant mother and preventive care for her only child. The MCH stations
MDG4: Reduce child mortality The mortality rate of children under 5 years declined from 13.8 and 45.7 (per 1000 live births) in urban and rural areas, respectively, in 2000 to 7.1 and 19.1 in
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Figure 2 Change in maternal mortality rate in China since introduction of the MDGs
and some hospitals have developed antenatal care, with coverage of 93.7% in 2011. This has been particularly so in rural areas where government funding of MCH stations has improved community-level antenatal care, and rural hospitals have received training in safe delivery.15 This resulted in the World Health Organization pronouncing China free of maternal and neonatal tetanus as of 30 October 2012 after a monthlong validation exercise. Skilled health personnel attend 95% of births; usually, they are modestly trained, but highly experienced midwives.14 One area of concern is the high rate of Caesarean section (46%).16 While China is on track to achieve national Millennium Development Goal targets for maternal and child health, women and children in western provinces suffer from substantial health inequities in access to antenatal and skilled birth and post-partum care.17 This is a result of the ten-fold difference in average provincial GDP between the richest and poorest provinces in China.18 This is one of the problems of the MDGs being aggregated at national level. Furthermore, this inequality has contributed to migration from rural to urban areas, which frequently puts migrant workers in cities at even greater risk because they do not enjoy privileges because of their migrant status.19 The maternal mortality rate declined from 29.3 and 69.6 (per 100,000 live births), respectively, in urban and rural areas in 2000 to 25.2 and 26.5 in 2011 (Fig. 2). This is a sign of more equality in health care. However, if the data are further disaggregated, great disparities are seen by region and province in China. As a participant in the ‘Evidence for Policy and Implementation project (EPI4)’, China hopes to make development more localized, reduce inequalities of health care, and to report disaggregated data more thoroughly to ensure accountability of low-performing regions.20
MDG 6: Combat HIV/AIDS, malaria and other diseases With the exception of Yunnan Province and Hainan Island, China is considered a low-risk country for
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malaria, with good control, as assessed by the World Health Organization. Furthermore, malaria case incidence decreased by more than 75% between 2000 and 2011.21 The nationwide incidence of HIV/AIDS in China increased from one to 1.53 per 100,000 between 2000 and 2011, with an AIDS mortality rate of 0.688 per 00,000.22 Antiretroviral therapy coverage among people with advanced HIV infection was 32% in 2010,14 yet China’s HIV/AIDS epidemic is not as severe as was once predicted, partly because of China’s political resolve after 2003 to tackle HIV/ AIDS seriously.23 Since then, China has participated in 267 collaborative international projects to arrest the HIV/AIDS epidemic.24 HIV/AIDS health knowledge is greater than for TB which is a far more prevalent problem.25 Despite that success, as of 2007, approximately 700,000 people in China were living with HIV/AIDS.26 Each of these individuals represents a family and possibly children who are affected by the epidemic. Most children of HIV-infected parents are in households of low economic status with family anxiety and shame. Strangely, non-orphans and their families were less likely than orphans to receive social support from the community.27 A great deal of work is needed to prevent these children from growing up as double victims of their parents’ disease and social discrimination. Implications for intervention programmes include the need for psychological support and special counselling services, greater public education in accurate knowledge of HIV/AIDS to decrease stigma and discrimination, and financial programmes to decrease the economic and care-giving burden on these children.28 China implemented universal bacillus CalmetteGue´rin (BCG) vaccination against tuberculosis in the early 1930s. Despite the fact that the BCG vaccine is known to confer immunity inconsistently, it is essential in a country such as China with a high prevalence of TB. TB prevalence rates in children did not decrease between 1979 and 2000.29 For infants, the TB progression rate decreases exponentially from birth to the age of 2 years.30 Cases of TB in children this young result from community or family transmission. Therefore, prevention and health-care efforts in areas with a high prevalence of TB such as China should be aimed at patients younger than one as well as those with extrapulmonary disease and severe TB. Maternal and child health workers as well as clinicians within the local Centers for Disease Control, who are responsible for managing infectious diseases, need to pay particular attention to children living with adults with active TB.
MDG 7: Ensure environmental sustainability United Nations officials report that 89% of China’s population has access to drinking-water from
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improved sources, up from 67% in 1990.31 China’s geology falls along a north–south divide, with southern provinces experiencing perennial floods, and northern China in perpetual drought. It is expected that by 2030 the volume of water used overall in China will have increased by 16%, with a 21% increase in the north, where there is the greatest lack of water.32 There is also a rural–urban divide in inequality in the availability of clean water and access to sanitary latrines. Even amongst the most modest urban residents, a higher proportion enjoy clean water and sanitary toilets than do the wealthiest rural ones.33 As important as volume of water is its cleanliness. Many water sources have been polluted by industry and agriculture. Only 58.3% of the riverways, 49.7% of lakes, 79.5% of reservoirs and 38.7% of groundwater wells met the quality criteria for water source.34 A growing number of toxins harmful to humans are found in water sources, including heavy metals, organic pollutants and emerging micro-pollutants.35 Many water sources in China have high fluoride levels that are not controlled before delivery to the public.2 Better treatment technology is needed. Air pollution in China continues to be a major contributor to elevated rates of asthma in children. While the government has worked hard to reduce the burning of fossil fuels in cities, the increased use of automobiles threatens to reverse improvements in air quality. Poor air quality contributes to the significant burden of respiratory disease at all ages.
beyond dependence on foreign aid. In the early years, China received aid from global bilateral agencies. The model was that recipient countries would be subsidized to do the work laid out by the donor organization or nation, such as training in safe deliveries in rural clinics, or health education for safe sex to prevent the spread of HIV. As China has established its own development plan and source of funding, it has had greater empowerment and capacity to design and implement its own development agenda. Furthermore, with economic growth, it is able to expand the sources of revenue to include domestic tax. Therefore, as they have achieved upper middle economy status and ceased to be eligible for foreign aid, they have been able to maintain their development. This development pathway is one which many countries in the world could learn from, and should be shared more broadly through international conferences and partnerships.
Lessons Learned from China’s Experience of the MDG process The importance of health equity There is evidence that focusing on equality to improve the lives of the most disenfranchised is the best way to achieve the UN MDGs.37 This involves transferring capital to remote and needy areas to build the infrastructure and basic services required for primary health care. China ranks 101st out of 168 UN member nations on the Human Development Index, and they still have large pockets of poverty, so there remains a long way to go.5 As a whole, they have striven to build a stable infrastructure in geographic areas of greatest need to meet the most pressing issues. This is an approach that needs to be emulated in low-income countries. Of course this is very difficult to do because by definition nations in greatest need lack adequate national revenue to make such allocations. One of China’s greatest accomplishments has been making training an essential part of the development process. This training component has accomplished the dual purpose of adding rigour to the projects being carried out, and increasing the capacity of the grassroots healthcare workers for the longer term. This is key to achieving the MDGs and an essential underpinning of sustainable development. A testimony to this process is the panic in China during SARS, and then their relatively straightforward response to similar outbreaks since, such as the avian flu outbreak in 2008 and the H7N9 outbreak in 2013. At all levels in China, people now know the protocols to follow, and have the capacity to make sound decisions at their level of responsibility.
MDG 8: Develop a global partnership for development In the 1980s and ‘90s, as China was implementing a policy of openness and reform, they benefitted from large World Bank loans and grants from UNICEF and the World Health Organization for health and development. These grants were used primarily for training and the establishment of systems needed to address pressing population-wide needs such as maternal and child health and infectious disease. China received many UNICEF grants in the 1990s, during which time they grew their maternal and child health system in line with UNICEF programmes such as Baby Friendly Hospitals, the establishment of MCH stations, micronutrient supplementation and safe deliveries. China used the money well and was able to repay these loans, so that, as their economy grew, they were able to move forward without dependence on foreign aid. This is a lesson for other lower- and lower-middle-income countries. As has been argued by Moyo, reliance on foreign aid is not sustainable and can be an impediment to sustainable development.36 The support provided in the early years of China’s era of openness and reform was essential, but the country eventually demonstrated that it is possible to move
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The risk of an excessive market approach to health care In 1985, China abandoned their low-cost but extensive primary health-care system in pursuit of a highly
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medicalized market approach.23,28 The result was a medical system that increased the level of technical expertise in large tertiary hospitals, but left 80% of the population largely beyond reach of medical services, either geographically or financially. This short-sighted approach came to a head in 2003 with the SARS pandemic which revealed the absence of a basic public or primary health care system. This precipitated China’s health-care reform debate, resulting in the reinstatement in 2007 of a system of broad coverage and primary health care of modest cost. Cost-effective investments such as immunization and antenatal care bring greater population-wide returns than expensive, high-tech investments which benefit only the few who can afford them. From a nationwide perspective, the former bring a greater return on investment. The political will after 2003 to provide affordable care to more people changed the course of China’s health-care system. Beginning in 2007 in urban areas and in 2009 in rural ones, China implemented a Basic Public Health plan in order to establish community health centres in close proximity to the people. These centres are responsible for establishing medical records for all residents, screening for chronic diseases and delivering vaccination and basic well-child care. The government has funded these programmes. The skill of workers in these health centres is limited, so progress is slow, but the infrastructure on which to build a sustainable public and primary health-care system is being put in place.
Political will As China’s economy has grown, the government has provided minimal, but sufficient and steadily increasing funding for health care. The concept of government support for necessary social services was encapsulated in the ‘Harmonious Society’ doctrine established by then President Hu Jintao in 2006. The doctrine enshrined the belief that, for a society to develop in a harmonious way, equality in basic service provisions was essential. From 2000 to 2009, total expenditure on health as a percentage of gross domestic product increased from only 8.3 to 8.4%, but general government expenditure on health as a percentage of total government expenditure increased from 10.9 to 12.1%. This increasing commitment to health care was also demonstrated by expenditure on health as a percentage of total government expenditure increasing from 38.3 to 52.5%. The government has shouldered a steadily increasing portion of the healthcare expenditure. This is also reflected in the decline of out-of-pocket expenditure as a percentage of private expenditure on health from 95.6 to 78.9%.14 Private expenditure on health care and health insurance is not reimbursed by the government. Out-of-pocket costs
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are those that are not reimbursed by an insurance company or other health-care financing source, including non-reimbursable expenses, defined individual contributions to some charges such as services or pharmaceuticals (co-payments) and deductibles. The financial investment was mainly in building sustainable primary health-care systems. The Community Health Service programme described previously provides 95% of all Chinese with some kind of health care, up from just 15% in 2000. Although it is still somewhat rudimentary, a primary health-care system framework is being established, the quality and value of which can be increased over time.39 It is likely that China’s successes in achieving MDGs are owing to prioritization of health-care rather than simply disease treatment.
The role of economic development China is already the second largest economy in the world and will be the largest within this generation. The economy has grown at 9.3% annually even since the economic downtown which began in 2007.40 This has resulted in a steady flow of federal revenue which the government can then use to fund social services and other domestic programmes. This is a reminder that economic growth is essential to human development in general.41 If one imagines a cycle with three components – economics, health and education – one would quickly see that each is dependent on the other. Economic development depends on a healthy and well educated populace. For people to be able to receive education, funding is needed, and the people need to be healthy enough to learn from the education they receive. Finally, improved health depends on access to educational opportunities and the economic benefits it brings. The mutual interdependence of these components is clear. While open to debate, it is hard to deny that on a global scale economic development has been the critical and essential element in human development, from which flow education and improved health. Therefore, sustainable economic development as the engine for and not at the expense of education and health care is a model to be emulated globally.
The limitations of global goals Global goals in the aggregate must be analyzed carefully. Consider, for example, the global success in MDG 1 to eradicate extreme poverty and hunger. This so-called global success is mainly owing to a drop in China’s poverty rate from 60.2% in 1990 to 13.1% in 2008. Because China and India have such large populations, changes to the world’s poverty rate depend heavily on their performance. Therefore, this global goal does not give smaller countries much incentive to address poverty because by doing nothing they can still celebrate global success.
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Serious consideration needs to be given to the best and most sustainable model for global development. The Sachs model advocates transfer of money from donor to recipient nations so that they can provide essential services.42 This is the basis of the Millennium Development Goals. Goals are established by global expert committees and participating nations are then given various types of support to achieve them. By establishing clear targets, national leaders are better able to design simple development agendas, particularly important as public health in many countries falls far behind GDP growth in national priorities. But it is essential that national leaders are actively engaged in the process of establishing these goals so that they have a stake in their realization. In terms of funding, the Sachs model might lead to significant short-term gains, but such successes rarely outlive the funding cycle. Aid should be seen either as relief funding to address a current challenge without which lives would be lost, or as development funding which brings with it the need for sustainability at the end of the funding cycle. Achieving sustainable economic and human development in countries currently dependent on foreign aid remains a serious global conundrum. It is essential to consider how the global community can work together towards improving the lives of people in the developing world. An alternative model is what might be called the community-up approach, advocated by Easterly and others.43 This model assumes that every country has what Easterly calls ‘searchers’ who identify local problems and use local expertise and resources to address them. The Millennium Development Goals would do well to seek such searchers around the world who might then become the agents of change and development in their own countries.
The Millennium Development Goals were adopted by countries around the world as an add-on or a reprioritization of existing development goals. In fact, each country was in the process of development at that time, with both strengths and weaknesses. In the case of China, successful development leading to health improvements for children preceded the year 2000. China’s success in achieving the MDGs is because they had a ‘running start’. In fact, the majority of their success towards the goals happened before the advent of the millennium. In summary, China is prepared to achieve the majority of the Millennium Development Goals by 2015 (Table 1). Key accomplishments have been reducing the rate of poverty and providing equal universal education for all children. Poor rural areas and ethnic minority regions have experienced improvement, but continue to lag behind others in all categories. From China the world can learn that the key trigger of improvement in social services is economic development. Additionally, the Chinese government’s consistent and increasing investment in health and education, with a primary focus on infrastructure and workforce development, has driven this economic growth to improve public welfare. Lingering shortcomings include environmental challenges such as reducing air pollution and ensuring sufficient amounts of clean water for all. Additionally, China is still in the process of establishing global partnerships for development.
Lessons Learned About Global Development Since 2000 The Millennium Declaration was meant to be a promise by developing countries to re-focus on primary care and basic development issues in exchange for funding from global friends. This has been accomplished to some extent: global donors have now been able to combine their funding rather than duplicate efforts. But real partnership of equals remains elusive. Perhaps the last MDG, which deals with ‘global partnership’, should be the first and a prerequisite to all the others. Development of a nation is a function of strong central government, and is only moderately responsive to the pressures of other countries or global organizations. One of the key roles of any government is to transcend tribal or caste divisions. China has made tremendous progress in this regard, and ethnic minorities are given unique privilege in some areas such as educational opportunities, but overall and not inconsistent with the situation in many resource-rich nations, minority people still experience health disparities compared with the majority Han population. A collectivist social ethic, as is seen in East Asian countries, is also a contributor to public health because people are more inclined to sacrifice individual rights in exchange for the public good.
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The Millennium Development Goals after 2015 The Millennium Development Goals have been met to varying degrees around the world. As the 2015 deadline looms, it is time to consider how to build on lessons learned since the inception of the goals in 2000. Degree of development and areas of need vary from country to country. To foster more equal collaborative progress, country goals should be weighted so that each country has to work equally hard to reach their targets, and, where, countries are weighted to ensure that the contribution of each country is balanced. Countries could choose from a basket of MDG goals, focusing on areas in which progress is most crucial in their own country and which will make the largest contribution to global goals. Self-determinism and clear incentives to development at national level are essential in a country taking development seriously. Global partnership requires that every country be at the table as an equal partner, and each country is able to make unique contributions to the global good.
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If these are global goals, then every well meaning country should participate. Using the formula described above, the United States would then participate on a relatively equal footing with every other country. This might motivate all nations to work toward these goals in earnest. Furthermore, lines of accountability for the achievement of the goals need to be clarified. Sustainable primary health-care systems, not isolated funding agencies built around disease-related groups, are the greatest health-care need globally. Therefore the MDGs should be biased to reward countries for an overall integrated and balanced program that favorably impacts healthy behaviors, disease prevention, and disease management. This would meet the MDGs in a more sustainable way. The MDGs have followed a global development pattern that defines ‘global partnership’ in terms of transfer of funds from donor to recipient nations.42 While the MDGs have clarified the targets, one has to wonder how much the funding formula has contributed to the accomplishment of these goals. This issue needs robust dialogue in 2015 so that the MDGs can be extended meaningfully. China is on the way to significant achievement of many of the Millennium Development Goals related to children (Table 1). While each country’s developmental trajectory is different, inter-country comparison can reveal important lessons learned. China’s accomplishments in economic development and human welfare since the 1980s have been remarkable, and potentially have lessons for other countries moving from low income to middle income status. The Millennium Development Goals have helped the world to better understand and track the development process. In order for these noble goals to be meaningful after 2015, they need to be refreshed and updated. Analyzing the real experience of member countries is the best method of revitalizing the Millennium Development Goals so that they achieve yet greater accomplishments in the future.
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References 1 United Nations. Millennium Development Goals, China’s Progress, 2003. Beijing, China: Office of the United Nations, Resident Coordinator in China, 2004. 2 United Nations. The Millennium Development Goals Report 2010. New York: United Nations, 2010. 3 UNICEF. Progress for Children: Achieving the MDGs with equity. New York: UNICEF, 2010. 4 Chen S, Ravallion M. More relatively-poor people in a less absolutely-poor world. Washington, DC: World Bank, 2012. 5 Malik K. The Rise of the South: Human Progress in a Diverse World. New York: United Nations Development Programme, 2013; p 13. 6 Mason J, Garcia M. United Nations Administrative Committee on Coordination, Subcommittee on Nutrition. United Nations, 1994. Available from: http://www.unsystem.org/SCN/archives/ rwns94update/ch02.htm#TopOfPage 7 Zhang J, Shi J, Himes JH, Du Y, Yang S, Shi S. Undernutrition status of children under 5 years in Chinese rural areas – data
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from the National Rural Children Growth Standard Survey, 2006. Asia Pac J Clin Nutr. 2011;20:584–92. Xu F, Qiu L, Binns CW, Liu X. Breastfeeding in China: a review. Int Breastfeed J. 2009;4:6. Luo R, Kleiman-Weiner M, Rozelle S, Zhang L, Liu C, Sharbono B, et al. Anemia in rural China’s elementary schools: prevalence and correlates in Shaanxi province’s poor counties. Ecol Food Nutr. 2010;49:357–72. Xie T. Analysis on inter-provincial disparities. Int J Educ Manag. 2004;25:714–23. Zhang X. Education for All: The Year 2000 Asssessment Reports. UNESCO, New York: World Education Forum, 2000. China Ministry of Education. 2011 Statistical File Beijing, China: China Ministry of Education; 2012. Available from: http://www.moe.gov.cn/ Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE, et al. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet. 2012;379:2151–61. World Health Organization. World Health Statistics 2012. Geneva: WHO, 2012. You F, Huo K, Wang R, Xu D, Deng J, Wei Y, et al. Maternal mortality in Henan Province, China: changes between 1996 and 2009. PLoS ONE. 2012; 7:e47153 p. Lumbiganon P, Laopaiboon M, Gu¨lmezoglu AM, Souza JP, Taneepanichskul S, Ruyan P, et al. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007–08. Lancet. 2010;375:490–9. Wellhoner M, Lee AC, Deutsch K, Wiebenga M, Freytsis M, Drogha S, et al. Maternal and child health in Yushu, Qinghai Province, China. Int J Equity Health. 2011;10:42. Tang S, Meng Q, Chen L, Bekedam H, Evans T, Whitehead M. Tackling the challenges to health equity in China. Lancet. 2008;372:1493–501. Thomsen S, Hoa DTP, Ma˚lqvist M, Sanneving L, Saxena D, Tana S, et al. Promoting equity to achieve maternal and child health. Reprod Health Matters. 2011;19:176–82. Thomsen S, Ng N, Biao X, Bondjers G, Kusnanto H, Liem NT, et al. Bringing evidence to policy to achieve health-related MDGs for all: justification and design of the EPI-4 project in China, India, Indonesia, and Vietnam. Glob Health Action. 2013;6:10. World Health Organization. WHO Global Malaria Programme World Malaria Report 2012. Geneva: WHO, 2012; p 87. China Ministry of Health and Family Planning Commission Web page. Beijing, China: Ministry of Health; 2013. Available from: http://www.moh.gov.cn/wsb/index.shtml. UNAIDS. Report on the Global AIDS Epidemic 2006. Geneva: UNAIDS, 2006. Wu Z, Wang Y, Detels R, Rotheram-Borus MJ. China AIDS policy implementation: reversing the HIV/AIDS epidemic by 2015. Int J Epidemiol. 2010;39 (suppl 2):ii1–3. Strand MA, Duan X, Johnson R, Li Y. Social determinants of delayed diagnosis of tuberculosis in a north China urban setting. Int Q Community Health Educ. 2010;31:279–90. China Ministry of Health. A Joint Assessment of HIV/AIDS Prevention, Treatment and Care in China. Beijing, China: State Council AIDS Working Committee Office, UNAIDS, WHO, 2007. Yang H, Wu Z, Duan S, Li Z, Li X, Shen M, et al. Living environment and schooling of children with HIV-infected parents in southwest China. AIDS Care. 2006;18:647–55. Zhao G, Li X, Kaljee L, Zhang L, Fang X, Zhao J, et al. Psychosocial consequences for children experiencing parental loss due to HIV/AIDS in central China. AIDS Care. 2009;21:769–74. Li L, Duanmu HJ. [The epidemic of childhood tuberculosis in China]. Zhonghua Yi Xue Za Zhi. 2004;84:1678–80. Cao H, Zhou Y, Brauer F. Estimates of tuberculosis progression rate of children in China. Journal of Biological Dynamics. 2012;6:663–73. China contributes hugely to MDG in access to safe drinking water: UN officials. People’s Daily Online, 2010. Available from: http://english.peopledaily.com.cn/90001/90776/90883/ 6926993.html Jiang Y. China’s water scarcity. J Environ Manag. 2009;90:3185–96. Bloom G, Tang SL. Rural health prepayment schemes in China: towards a more active role for government. Soc Sci Med. 1999;48:951–60.
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34 China Ministry of Water. 2006 China Water Resources Bulletin. China Water Resources and Hydropower Press: China Ministry of Water Resources, 2007. 35 Shannon MA, Bohn PW, Elimelech M, Georgiadis JG, Marinas BJ, Mayes AM. Science and technology for water purification in the coming decades. Nature. 2008;452:301– 10. 36 Moyo D. Dead Aid. New York: Farrar, Straus and Giroux, 2009. 37 UNICEF. Narrowing the Gaps to Meet the Goals. New York: UNICEF, 2010. 38 Chen X, Hu T-W, Lin Z. The rise and decline of the Cooperative Medical System in rural China. Int J Health Services. 1993;23:731–42. 39 Yip W, Hsiao WC. The Chinese Health System At A Crossroads. Health Affairs. 2008;27:460–8.
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40 World Health Organization. Macroeconomics and Health: Investing in Health for Economic Development. Geneva: WHO Commission on Macroeconomics and Health, 2001. 41 Sachs JD. The End of Poverty: Economic Possibilities for our Time. New York: Penguin, 2005. 42 Easterly W. The White Man’s Burden: How the West’s Efforts to Aid the Rest Have Done So Much Ill and So Little Good. NY: Penguin, 2006. 43 Ministry of Health and Family Planning. 2000 China Health Statistical Digest, Beijing, China: China Ministry of Health; 2000. Available from: http://www.moh.gov.cn/zwgkzt/ptjty/ 200805/35308.shtml. 44 Ministry of Health and Family Planning. 2010 China Health Statistical Digest, Beijing, China. China Ministry of Health, 2010. Available from: http://www.moh.gov.cn/htmlfiles/zwgkzt/ ptjty/digest2010/index.html.
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An appraisal of China’s progress toward the Millennium Development Goals as they relate to children Mark A. Strand1, Philip R. Fischer2 1
Pharmacy Practice, Master of Public Health Program, North Dakota State University, Fargo, North Dakota, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
2
Since their inception in 2000, the Millennium Development Goals (MDGs) have improved understanding of the global development process. Although the goals will not be significantly achieved on a global scale, each country has had accomplishments deserving of attention and analysis. With regard to the MDGs as they relate to children, China has made significant achievements, the deeper understanding of which might help in the process of refreshing the MDGs beyond 2015. China’s accomplishments in economic development and human welfare, and the benefits this has brought to its children potentially teach lessons that can be modelled by other countries moving from low- to middle-income status. Keywords: Paediatrics, China, Development, Global health, Millennium Development Goals
Introduction
Methods
In 2003, China filed their first report on progress toward the Millennium Development Goals.1 In only 3 years they were confident of their ability to reach most of the targets. In the 2010 United Nations report on the Millennium Development Goals, China had become something of an outlier for her success.2 On many of the East Asia and the Pacific indicators, such as ‘eradicate extreme hunger and poverty,’ China was excluded from analyses.3 For one thing, much of the global progress, and certainly progress in Eastern Asia, was attributable to China’s success alone. Thus, China’s success skewed the data so that other countries’ successes were dwarfed, and failures less evident. Furthermore, it was difficult for MDG officials to know what to make of China’s apparent success. Should they be excluded from analyses, or should they be set up as an example, and their success and its methods looked to as a model for other countries? China’s progress toward the 2015 MDG deadline merits deeper analysis. Uncertainty about how to deal with China’s success stems from lack of a cultural-historical understanding of China and her development. This article is meant to fill that gap in understanding and report on some key indicators from the Millennium Development Goals (Table 1).
This narrative review set out to find reliable, official data on issues deemed by the authors to be crucial with regard to China and the Millenium Development Goals. The review relied on data available from the People’s Republic of China official government websites, including the Ministry of Health, Ministry of Education, Ministry of Water and the Ministry of Health and Family Planning Commission, UNICEF and the World Health Organization, as cited in the references section. Additionally, to enrich the explanatory power of the paper, peer-reviewed publications were selected to provide data on issues not addressed in the official websites.
Correspondence to: M A Strand, Pharmacy Practice, Master of Public Health Program, North Dakota State University, Fargo, ND, USA. Email: [email protected]
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Report on China’s Progress toward MDGs Related to Children MDG1: Eradicate extreme poverty and hunger Poverty. Reduction of the poverty rate in China has been one of its more remarkable achievements since the start of the era of openness and reform in the early 1980s. More than 500 million people have been lifted out of poverty between 1990 and 2008 (using the $1.25 a day poverty line).4 This has meant reducing the proportion of people who are income-poor from 60.2% in 1990 to 13.1% in 2008.5 As a Confucian society, family income is directly invested back into the family, so this reduction in poverty has been an essential feature of improved welfare of children in China. Underweight. In 1990, the prevalence of underweight children (defined as ,-2 SD weight-for-age
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NCHS) was 7.1 and 21.2% in urban and rural areas, respectively,6 dropping to 2 and 9% by 2010,3 which suggests that underweight is a significant problem in rural China. Therefore, continued attention to underweight children in China should focus primarily on rural areas, and those provinces with particularly high rates of underweight. Using a cross-sectional study of rural areas in 10 provinces of China, with a total of 84,009 children under aged 5, Zhang et al. reported the prevalence of stunting, underweight and wasting to be 14.59%, 7.19% and 3.07%, respectively.7 Stunting and underweight occur mostly before 2 years of age. Intervention strategies and programmes should be developed to target preventable risk factors such as rural residence and non-Han Chinese ethnicity. Two provinces have significantly worse rates of undernutrition, Guizhou and Guangxi, with prevalences of stunting among children under 5 years of 38.3% and 20–30%, respectively. Both these provinces have nonHan Chinese populations of over 40%. Breastfeeding and micronutrients. Exclusive breastfeeding at 4 months ranged from 23% in Chongqing to 85% in Shenzhen.8 Following changes introduced in the 1990s, such as the Baby Friendly Hospital
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initiative, and the efforts of the Maternal and Child Health (MCH) stations, the breastfeeding rate in China increased. Since the mid-1990s, ‘any breastfeeding’ rates in the majority of cities and provinces, including minority areas, have been above 80% at 4 months,8 but most cities and provinces did not reach the national target of 80% ‘exclusive breastfeeding’. The mean duration of ‘any breastfeeding’ in the majority of cities or provinces was between 7 and 9 months. ‘Exclusive breastfeeding’ rates in minority areas were relatively lower than in comparable inland provinces. Common reasons for ceasing breastfeeding before 4 months were perceived breast-milk insufficiency, mother going to work, maternal and child illness and breast problems, such as inverted or sore nipples.8 China’s MCH stations have been very successful in carrying out public health interventions for mothers and children. At different times, and with great regional disparity, workers have been involved in micronutrient supplementation programmes. In northern China, which has a high prevalence of rickets, vitamin D and calcium supplementation has been commonly implemented for children in the 1st year of
Table 1 Progress in China toward Key Millennium Development Goals as they relate to children Goals and targets Goal 1: Eradicate extreme poverty and hunger Target 1A: Between 1990 and 2015, halve the proportion of people whose income is ,$1/day Target 1C: between 1990 and 2015, halve the proportion of people who suffer from hunger Goal 2: Achieve universal primary education Target 2A: Ensure that by 2015 children everywhere boys and girls alike will be able to complete a full course of primary schooling Goal 3: Promote gender equality and empower women Target 3A: Eliminate gender disparity in primary and secondary education, preferably by 2005, and in all levels of education no later than 2015 Goal 4: Reduce child mortality Target 4A: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate Goal 5: Improve maternal health Target 5A: Between 1990 and 2015, reduce maternal mortality by three-quarters Goal 6: Combat HIV/AIDS, malaria and other diseases Target 6C: By 2015, to halt and have begun to reverse the incidence of malaria and other major diseases
Goal 7: Ensure environmental sustainability Target 7C: By 2015, halve the number without sustainable access to safe drinking water and basic sanitation Goal 8: Develop a global partnership for development Target 8A: Further develop an open, rule-based, predictable, non-discriminatory trading and financial system. Includes a commitment to good governance, development and poverty reduction, nationally and internationally.
China’s progress
Proportion of people who are income-poor declined from 60.2% in 1990 to 13.1% in 2008 Prevalence of underweight children in 1990 was 7.1% and 21.2% in urban and rural areas, respectively, and in 2010 2% and 9% in urban and rural areas School-age children enrollment rates of 97.8% in 1990 and 99.8% in 2011.
In 1991, 98.7% and 96.9% of boys and girls were enrolled in school in China, rising to over 99% for both genders by 2011
Mortality rate of children under 5 years declined from 13.8 and 45.7 (per 1000 live births) in urban and rural areas in 2000 to 7.1 and 19.1% in 2011. Maternal mortality rate declined from 29.3 and 69.6 (per 100,000 live births) in urban and rural areas in 2000 to 25.2 and 26.5 in 2011. By 2005–2011, 96% of births attended by skilled health personnel. Malaria incidence decreased by .75% from 2000–2011. Incidence of HIV/AIDS among all persons rose from 1 to 1.53/100,000 from 2000 to 2010. Measles immunization coverage of children in China rose from 84 to 99% between 2000 and 2010. 89% of the population has access to drinking-water from improved sources, up from 67% in 1990. General government expenditure on health as % of total government expenditure increased from 10.9–12.1% during 2000–2010.44,45 Basic healthcare coverage increased from 15% in 2000 to 95% in 2010.
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life. In poorer regions, zinc and vitamin A supplementation programmes have been used occasionally, depending on the UNICEF funding cycle, but rarely sustained under local funding. Anaemia remains a particular problem in rural elementary schools in poor provinces such as Shaanxi, where 21.5% of schoolchildren were found to have anaemia using a cut-off of 11.5 g/dl.9 Therefore, an increased intake of animal protein needs to be ensured through school cafeterias. Distribution of micronutrient supplements should continue, but to targeted at-risk populations.
MDG2: Achieve universal primary education
Figure 1 Change in under-5 mortality rate in China Since the introduction of the MDGs
The enrollment rate of all school-age children in China in 1990 was 97.8%. A drive for universal primary education was launched in 1996. It has been successful in significantly developing rural education and reducing inequalities in rural education,10 so that from 2000 to 2011 the enrollment rate of all schoolage children rose even further, from 99.1% to 99.8%. In 2004, 9 years of education was made compulsory in China, and school fees were eliminated in 2007. But in recent years urban migration has reduced village populations by nearly half, so that many villages can no longer sustain an elementary school, much less a middle school. Therefore, many village children have to travel considerable distances to attend school, including boarding for most rural middle- and high-school students. However, there is concern that the cost and inconvenience, including the difficulty for these commuting or boarding rural children to fit in with their new classmates, is significant. Additionally, as young teachers aspire to better working conditions, some are unwilling to accept postings to more rural schools. This leaves many schools with a severe shortage of teachers, and sometimes they have to employ unqualified teachers to fill the gap. This compromises the quality of education and contributes to the growing urban/rural economic and social divide.
2011. In the early years of the MDGs, under-5 mortality rates declined rapidly in rural areas and gradually in urban ones (Fig. 1). Since the mid-2000s both have plateaued. This is because in some areas the challenges of extreme poverty and absence of medical services make it impossible to achieve further reduction of child mortality rates. This highlights the significant rural/urban disparity that remains in many areas of China. China has successfully reduced child mortality with a combination of system-wide implementation of broad maternal and child health initiatives, as well as targeted interventions in diseases which contribute significantly to child mortality, e.g. diarrhoeal disease, pneumonia and neonatal tetanus.13 China has had a well organized immunization programme with substantial government subsidization. Measles immunization coverage was 98% in 1990, 84% in 2000 and 99% in 2010.14 Coverage with DTP3 and HepB3 were both 99% in 2010. The Chinese government has used some progressive policies, such as strategic planning every 10 years when they revise their Maternal and Child Health guidelines document nn中国妇女发展纲要、中国儿童 发展纲要2011–2020mm. Each province also has a 10year plan with details specific to their region. The purpose is to ensure that at every level the government is implementing policies that are in the best interests of women and children. This long-range plan contributes to reducing under-5 mortality.
MDG3: Promote gender equality and empower women In 1991, 98.7% of boys and 96.9% of girls were enrolled in school in China, with a gender disparity of 0.98.11 Official government reports show that by 2011 female students stood at 46.23% of all primary school students, 47.13 of middle school students, 49.98% of high school students, 50.40% of university baccalaureate students, 50.8% of master’s degrees and 36.13% of doctor’s degrees.12 So, parity in education has clearly been achieved.
MDG5: Improve maternal health Maternal health among Chinese women has improved as the fertility rate has declined and medical services have improved. Total fertility rate was six children per woman in 1970. While China’s one-child policy has been restrictive, it has increased the rate of contraception use to 85%14 and has reduced the total fertility rate to 1.6 per woman in 2010.14 With the one-child policy, families invest more heavily in antenatal care for the pregnant mother and preventive care for her only child. The MCH stations
MDG4: Reduce child mortality The mortality rate of children under 5 years declined from 13.8 and 45.7 (per 1000 live births) in urban and rural areas, respectively, in 2000 to 7.1 and 19.1 in
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Figure 2 Change in maternal mortality rate in China since introduction of the MDGs
and some hospitals have developed antenatal care, with coverage of 93.7% in 2011. This has been particularly so in rural areas where government funding of MCH stations has improved community-level antenatal care, and rural hospitals have received training in safe delivery.15 This resulted in the World Health Organization pronouncing China free of maternal and neonatal tetanus as of 30 October 2012 after a monthlong validation exercise. Skilled health personnel attend 95% of births; usually, they are modestly trained, but highly experienced midwives.14 One area of concern is the high rate of Caesarean section (46%).16 While China is on track to achieve national Millennium Development Goal targets for maternal and child health, women and children in western provinces suffer from substantial health inequities in access to antenatal and skilled birth and post-partum care.17 This is a result of the ten-fold difference in average provincial GDP between the richest and poorest provinces in China.18 This is one of the problems of the MDGs being aggregated at national level. Furthermore, this inequality has contributed to migration from rural to urban areas, which frequently puts migrant workers in cities at even greater risk because they do not enjoy privileges because of their migrant status.19 The maternal mortality rate declined from 29.3 and 69.6 (per 100,000 live births), respectively, in urban and rural areas in 2000 to 25.2 and 26.5 in 2011 (Fig. 2). This is a sign of more equality in health care. However, if the data are further disaggregated, great disparities are seen by region and province in China. As a participant in the ‘Evidence for Policy and Implementation project (EPI4)’, China hopes to make development more localized, reduce inequalities of health care, and to report disaggregated data more thoroughly to ensure accountability of low-performing regions.20
MDG 6: Combat HIV/AIDS, malaria and other diseases With the exception of Yunnan Province and Hainan Island, China is considered a low-risk country for
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malaria, with good control, as assessed by the World Health Organization. Furthermore, malaria case incidence decreased by more than 75% between 2000 and 2011.21 The nationwide incidence of HIV/AIDS in China increased from one to 1.53 per 100,000 between 2000 and 2011, with an AIDS mortality rate of 0.688 per 00,000.22 Antiretroviral therapy coverage among people with advanced HIV infection was 32% in 2010,14 yet China’s HIV/AIDS epidemic is not as severe as was once predicted, partly because of China’s political resolve after 2003 to tackle HIV/ AIDS seriously.23 Since then, China has participated in 267 collaborative international projects to arrest the HIV/AIDS epidemic.24 HIV/AIDS health knowledge is greater than for TB which is a far more prevalent problem.25 Despite that success, as of 2007, approximately 700,000 people in China were living with HIV/AIDS.26 Each of these individuals represents a family and possibly children who are affected by the epidemic. Most children of HIV-infected parents are in households of low economic status with family anxiety and shame. Strangely, non-orphans and their families were less likely than orphans to receive social support from the community.27 A great deal of work is needed to prevent these children from growing up as double victims of their parents’ disease and social discrimination. Implications for intervention programmes include the need for psychological support and special counselling services, greater public education in accurate knowledge of HIV/AIDS to decrease stigma and discrimination, and financial programmes to decrease the economic and care-giving burden on these children.28 China implemented universal bacillus CalmetteGue´rin (BCG) vaccination against tuberculosis in the early 1930s. Despite the fact that the BCG vaccine is known to confer immunity inconsistently, it is essential in a country such as China with a high prevalence of TB. TB prevalence rates in children did not decrease between 1979 and 2000.29 For infants, the TB progression rate decreases exponentially from birth to the age of 2 years.30 Cases of TB in children this young result from community or family transmission. Therefore, prevention and health-care efforts in areas with a high prevalence of TB such as China should be aimed at patients younger than one as well as those with extrapulmonary disease and severe TB. Maternal and child health workers as well as clinicians within the local Centers for Disease Control, who are responsible for managing infectious diseases, need to pay particular attention to children living with adults with active TB.
MDG 7: Ensure environmental sustainability United Nations officials report that 89% of China’s population has access to drinking-water from
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improved sources, up from 67% in 1990.31 China’s geology falls along a north–south divide, with southern provinces experiencing perennial floods, and northern China in perpetual drought. It is expected that by 2030 the volume of water used overall in China will have increased by 16%, with a 21% increase in the north, where there is the greatest lack of water.32 There is also a rural–urban divide in inequality in the availability of clean water and access to sanitary latrines. Even amongst the most modest urban residents, a higher proportion enjoy clean water and sanitary toilets than do the wealthiest rural ones.33 As important as volume of water is its cleanliness. Many water sources have been polluted by industry and agriculture. Only 58.3% of the riverways, 49.7% of lakes, 79.5% of reservoirs and 38.7% of groundwater wells met the quality criteria for water source.34 A growing number of toxins harmful to humans are found in water sources, including heavy metals, organic pollutants and emerging micro-pollutants.35 Many water sources in China have high fluoride levels that are not controlled before delivery to the public.2 Better treatment technology is needed. Air pollution in China continues to be a major contributor to elevated rates of asthma in children. While the government has worked hard to reduce the burning of fossil fuels in cities, the increased use of automobiles threatens to reverse improvements in air quality. Poor air quality contributes to the significant burden of respiratory disease at all ages.
beyond dependence on foreign aid. In the early years, China received aid from global bilateral agencies. The model was that recipient countries would be subsidized to do the work laid out by the donor organization or nation, such as training in safe deliveries in rural clinics, or health education for safe sex to prevent the spread of HIV. As China has established its own development plan and source of funding, it has had greater empowerment and capacity to design and implement its own development agenda. Furthermore, with economic growth, it is able to expand the sources of revenue to include domestic tax. Therefore, as they have achieved upper middle economy status and ceased to be eligible for foreign aid, they have been able to maintain their development. This development pathway is one which many countries in the world could learn from, and should be shared more broadly through international conferences and partnerships.
Lessons Learned from China’s Experience of the MDG process The importance of health equity There is evidence that focusing on equality to improve the lives of the most disenfranchised is the best way to achieve the UN MDGs.37 This involves transferring capital to remote and needy areas to build the infrastructure and basic services required for primary health care. China ranks 101st out of 168 UN member nations on the Human Development Index, and they still have large pockets of poverty, so there remains a long way to go.5 As a whole, they have striven to build a stable infrastructure in geographic areas of greatest need to meet the most pressing issues. This is an approach that needs to be emulated in low-income countries. Of course this is very difficult to do because by definition nations in greatest need lack adequate national revenue to make such allocations. One of China’s greatest accomplishments has been making training an essential part of the development process. This training component has accomplished the dual purpose of adding rigour to the projects being carried out, and increasing the capacity of the grassroots healthcare workers for the longer term. This is key to achieving the MDGs and an essential underpinning of sustainable development. A testimony to this process is the panic in China during SARS, and then their relatively straightforward response to similar outbreaks since, such as the avian flu outbreak in 2008 and the H7N9 outbreak in 2013. At all levels in China, people now know the protocols to follow, and have the capacity to make sound decisions at their level of responsibility.
MDG 8: Develop a global partnership for development In the 1980s and ‘90s, as China was implementing a policy of openness and reform, they benefitted from large World Bank loans and grants from UNICEF and the World Health Organization for health and development. These grants were used primarily for training and the establishment of systems needed to address pressing population-wide needs such as maternal and child health and infectious disease. China received many UNICEF grants in the 1990s, during which time they grew their maternal and child health system in line with UNICEF programmes such as Baby Friendly Hospitals, the establishment of MCH stations, micronutrient supplementation and safe deliveries. China used the money well and was able to repay these loans, so that, as their economy grew, they were able to move forward without dependence on foreign aid. This is a lesson for other lower- and lower-middle-income countries. As has been argued by Moyo, reliance on foreign aid is not sustainable and can be an impediment to sustainable development.36 The support provided in the early years of China’s era of openness and reform was essential, but the country eventually demonstrated that it is possible to move
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The risk of an excessive market approach to health care In 1985, China abandoned their low-cost but extensive primary health-care system in pursuit of a highly
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medicalized market approach.23,28 The result was a medical system that increased the level of technical expertise in large tertiary hospitals, but left 80% of the population largely beyond reach of medical services, either geographically or financially. This short-sighted approach came to a head in 2003 with the SARS pandemic which revealed the absence of a basic public or primary health care system. This precipitated China’s health-care reform debate, resulting in the reinstatement in 2007 of a system of broad coverage and primary health care of modest cost. Cost-effective investments such as immunization and antenatal care bring greater population-wide returns than expensive, high-tech investments which benefit only the few who can afford them. From a nationwide perspective, the former bring a greater return on investment. The political will after 2003 to provide affordable care to more people changed the course of China’s health-care system. Beginning in 2007 in urban areas and in 2009 in rural ones, China implemented a Basic Public Health plan in order to establish community health centres in close proximity to the people. These centres are responsible for establishing medical records for all residents, screening for chronic diseases and delivering vaccination and basic well-child care. The government has funded these programmes. The skill of workers in these health centres is limited, so progress is slow, but the infrastructure on which to build a sustainable public and primary health-care system is being put in place.
Political will As China’s economy has grown, the government has provided minimal, but sufficient and steadily increasing funding for health care. The concept of government support for necessary social services was encapsulated in the ‘Harmonious Society’ doctrine established by then President Hu Jintao in 2006. The doctrine enshrined the belief that, for a society to develop in a harmonious way, equality in basic service provisions was essential. From 2000 to 2009, total expenditure on health as a percentage of gross domestic product increased from only 8.3 to 8.4%, but general government expenditure on health as a percentage of total government expenditure increased from 10.9 to 12.1%. This increasing commitment to health care was also demonstrated by expenditure on health as a percentage of total government expenditure increasing from 38.3 to 52.5%. The government has shouldered a steadily increasing portion of the healthcare expenditure. This is also reflected in the decline of out-of-pocket expenditure as a percentage of private expenditure on health from 95.6 to 78.9%.14 Private expenditure on health care and health insurance is not reimbursed by the government. Out-of-pocket costs
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are those that are not reimbursed by an insurance company or other health-care financing source, including non-reimbursable expenses, defined individual contributions to some charges such as services or pharmaceuticals (co-payments) and deductibles. The financial investment was mainly in building sustainable primary health-care systems. The Community Health Service programme described previously provides 95% of all Chinese with some kind of health care, up from just 15% in 2000. Although it is still somewhat rudimentary, a primary health-care system framework is being established, the quality and value of which can be increased over time.39 It is likely that China’s successes in achieving MDGs are owing to prioritization of health-care rather than simply disease treatment.
The role of economic development China is already the second largest economy in the world and will be the largest within this generation. The economy has grown at 9.3% annually even since the economic downtown which began in 2007.40 This has resulted in a steady flow of federal revenue which the government can then use to fund social services and other domestic programmes. This is a reminder that economic growth is essential to human development in general.41 If one imagines a cycle with three components – economics, health and education – one would quickly see that each is dependent on the other. Economic development depends on a healthy and well educated populace. For people to be able to receive education, funding is needed, and the people need to be healthy enough to learn from the education they receive. Finally, improved health depends on access to educational opportunities and the economic benefits it brings. The mutual interdependence of these components is clear. While open to debate, it is hard to deny that on a global scale economic development has been the critical and essential element in human development, from which flow education and improved health. Therefore, sustainable economic development as the engine for and not at the expense of education and health care is a model to be emulated globally.
The limitations of global goals Global goals in the aggregate must be analyzed carefully. Consider, for example, the global success in MDG 1 to eradicate extreme poverty and hunger. This so-called global success is mainly owing to a drop in China’s poverty rate from 60.2% in 1990 to 13.1% in 2008. Because China and India have such large populations, changes to the world’s poverty rate depend heavily on their performance. Therefore, this global goal does not give smaller countries much incentive to address poverty because by doing nothing they can still celebrate global success.
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Serious consideration needs to be given to the best and most sustainable model for global development. The Sachs model advocates transfer of money from donor to recipient nations so that they can provide essential services.42 This is the basis of the Millennium Development Goals. Goals are established by global expert committees and participating nations are then given various types of support to achieve them. By establishing clear targets, national leaders are better able to design simple development agendas, particularly important as public health in many countries falls far behind GDP growth in national priorities. But it is essential that national leaders are actively engaged in the process of establishing these goals so that they have a stake in their realization. In terms of funding, the Sachs model might lead to significant short-term gains, but such successes rarely outlive the funding cycle. Aid should be seen either as relief funding to address a current challenge without which lives would be lost, or as development funding which brings with it the need for sustainability at the end of the funding cycle. Achieving sustainable economic and human development in countries currently dependent on foreign aid remains a serious global conundrum. It is essential to consider how the global community can work together towards improving the lives of people in the developing world. An alternative model is what might be called the community-up approach, advocated by Easterly and others.43 This model assumes that every country has what Easterly calls ‘searchers’ who identify local problems and use local expertise and resources to address them. The Millennium Development Goals would do well to seek such searchers around the world who might then become the agents of change and development in their own countries.
The Millennium Development Goals were adopted by countries around the world as an add-on or a reprioritization of existing development goals. In fact, each country was in the process of development at that time, with both strengths and weaknesses. In the case of China, successful development leading to health improvements for children preceded the year 2000. China’s success in achieving the MDGs is because they had a ‘running start’. In fact, the majority of their success towards the goals happened before the advent of the millennium. In summary, China is prepared to achieve the majority of the Millennium Development Goals by 2015 (Table 1). Key accomplishments have been reducing the rate of poverty and providing equal universal education for all children. Poor rural areas and ethnic minority regions have experienced improvement, but continue to lag behind others in all categories. From China the world can learn that the key trigger of improvement in social services is economic development. Additionally, the Chinese government’s consistent and increasing investment in health and education, with a primary focus on infrastructure and workforce development, has driven this economic growth to improve public welfare. Lingering shortcomings include environmental challenges such as reducing air pollution and ensuring sufficient amounts of clean water for all. Additionally, China is still in the process of establishing global partnerships for development.
Lessons Learned About Global Development Since 2000 The Millennium Declaration was meant to be a promise by developing countries to re-focus on primary care and basic development issues in exchange for funding from global friends. This has been accomplished to some extent: global donors have now been able to combine their funding rather than duplicate efforts. But real partnership of equals remains elusive. Perhaps the last MDG, which deals with ‘global partnership’, should be the first and a prerequisite to all the others. Development of a nation is a function of strong central government, and is only moderately responsive to the pressures of other countries or global organizations. One of the key roles of any government is to transcend tribal or caste divisions. China has made tremendous progress in this regard, and ethnic minorities are given unique privilege in some areas such as educational opportunities, but overall and not inconsistent with the situation in many resource-rich nations, minority people still experience health disparities compared with the majority Han population. A collectivist social ethic, as is seen in East Asian countries, is also a contributor to public health because people are more inclined to sacrifice individual rights in exchange for the public good.
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The Millennium Development Goals after 2015 The Millennium Development Goals have been met to varying degrees around the world. As the 2015 deadline looms, it is time to consider how to build on lessons learned since the inception of the goals in 2000. Degree of development and areas of need vary from country to country. To foster more equal collaborative progress, country goals should be weighted so that each country has to work equally hard to reach their targets, and, where, countries are weighted to ensure that the contribution of each country is balanced. Countries could choose from a basket of MDG goals, focusing on areas in which progress is most crucial in their own country and which will make the largest contribution to global goals. Self-determinism and clear incentives to development at national level are essential in a country taking development seriously. Global partnership requires that every country be at the table as an equal partner, and each country is able to make unique contributions to the global good.
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If these are global goals, then every well meaning country should participate. Using the formula described above, the United States would then participate on a relatively equal footing with every other country. This might motivate all nations to work toward these goals in earnest. Furthermore, lines of accountability for the achievement of the goals need to be clarified. Sustainable primary health-care systems, not isolated funding agencies built around disease-related groups, are the greatest health-care need globally. Therefore the MDGs should be biased to reward countries for an overall integrated and balanced program that favorably impacts healthy behaviors, disease prevention, and disease management. This would meet the MDGs in a more sustainable way. The MDGs have followed a global development pattern that defines ‘global partnership’ in terms of transfer of funds from donor to recipient nations.42 While the MDGs have clarified the targets, one has to wonder how much the funding formula has contributed to the accomplishment of these goals. This issue needs robust dialogue in 2015 so that the MDGs can be extended meaningfully. China is on the way to significant achievement of many of the Millennium Development Goals related to children (Table 1). While each country’s developmental trajectory is different, inter-country comparison can reveal important lessons learned. China’s accomplishments in economic development and human welfare since the 1980s have been remarkable, and potentially have lessons for other countries moving from low income to middle income status. The Millennium Development Goals have helped the world to better understand and track the development process. In order for these noble goals to be meaningful after 2015, they need to be refreshed and updated. Analyzing the real experience of member countries is the best method of revitalizing the Millennium Development Goals so that they achieve yet greater accomplishments in the future.
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