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Harnessing the opportunity to achieve health equity in China

December 2021
The Lancet Public Health 6(12):e867-e868

December 2021
6(12):e867-e868

DOI:10.1016/S2468-2667(21)00211-5

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www.thelancet.com/public-health Vol 6 December 2021

e867

Harnessing the opportunity to achieve health equity in

China

The Chinese Government has transformed its

development paradigm in the past 4 years. It has

gradually shifted its goal from the eﬃciency-orientation

model towards one which prioritises social equity

and sustainability. Indeed, it has reported having

eliminated absolute poverty by 2020,1 and stated in

the Central Financial and Economic Aﬀairs Commission

of the Chinese Communist Party, that the need for

income redistribution should be emphasised, and

that highly proﬁtable enterprises should make greater

contributions to address social disparity in China, to

boost social justice and equity.2

As a pivotal component of social equity, health equity

is the equal opportunity to attain full health potential

regardless of one’s socioeconomic position. Therefore,

the shift of the focus of the macropolicy towards social

equity might also indicate the need to promote health

equity in China. The social determinants of health are

the structural and systemic factors that inﬂuence health.

Thus, it is crucial to address the social determinants

of health to achieve health equity, which will not only

improve the health status of vulnerable populations, but

also reﬁne social structure and boost social equity.

Health equity is a multidimensional concept, and

in respect of the widely acknowledged PROGRESS

framework,3 health inequities can be reﬂected in

multiple dimensions, such as geographical region,

race or ethnicity, occupation, level of education, and

economic status. For instance, geographical and ethnic

disparities in maternal and under-5 child mortality

rates have been reported for China.4–6 Substantial

regional variability in the levels and trends of maternal

and child mortality has also been reported between

counties in China.4,5 Children younger than 5 years of

ethnic minorities were found to be lagging behind

in service coverage, with higher odds of mortality

and lower access to child health-care services than

Han children.6 Population-based observational or

surveillance studies in China seldomly report their

ﬁndings by social determinants of health features, and

thus only the status quo is presented, without further

insight of health status across subgroups. Additionally,

as appealed by Sustainable Development Goal 17,7 the

importance of collecting data on social determinants of

health to generate disaggregated health data has been

further emphasised, especially in the COVID-19 era.8 The

current policy designation in China also does not contain

a clear description of the concept of health equity, with

only a limited focus on urban–rural disparities in health.

There is clearly a gap in health equity in China, and we

need a more systematic and comprehensive monitoring

framework for the social determinants of health in both

academic and policy environments.

There have been extensive eﬀorts by the Chinese

Government to alleviate absolute poverty over the past

8 years. A variety of poverty-reduction health policies

and programmes have been launched in impoverished

areas, and it has substantially improved the general

wellbeing of the poorest with some success.9 However,

there remains no operationalised deﬁnition of health

equity with regards to health policies. For example,

there was no clear plan or action to monitor health

equity, particularly in populations with diﬀerent

socioeconomic positions. As per the Healthy China

Action plan,10 the goal to achieve health equity by 2030

has been stated, and more than 100 health indicators

have been proposed to improve health behaviours and

outcomes. However, the indicators were all related to

the measurement of aggregated health status, and

thus there seems to be inadequate attention to the

distribution of health indicators in populations with

diﬀerent socioeconomic status. This could potentially

undermine the eﬀorts by the Chinese Government to

alleviate poverty, because the absence of a monitoring

framework for health equity is like a missing piece of the

puzzle in the big picture of health equity.

Therefore, in light of the high-level political

commitment to strengthen social equity that is already

in place, we call for more operationalised policies to

improve the current situation of health inequity in China

and to address the health equity problem in a more

systematic way. Chinese health departments should

take advantage of China’s development paradigm shift

to emphasise health equity in Healthy China 2030, and

should identify the main connotations of health equity,

monitor the development of relevant health indicators

Comment

e868

www.thelancet.com/public-health Vol 6 December 2021

and health equity, and make con tinuous eﬀorts to

achieve better health and health equity by 2030.

We declare no competing interests.

Access article under the CC BY-NC-ND 4.0 license.

*Zhicheng Wang†, Ge Yang†, *Yan Guo

wanzc61@gmail.com; guoyan@bjmu.edu.cn

†Contributed equally

Vanke School of Public Health (ZW) and Research Center for Public Health,

School of Medicine (ZW), Tsinghua University, Beijing, China; Department of

Neonatology, Guangzhou Women and Children’s Medical Center, Guangzhou,

Guangdong, China (GY); Department of Health Policy and Management, School

of Public Health, Peking University, Beijing, China (YG)

1 CGTN. Zero poverty: China eliminates absolute poverty one month before

self-imposed deadline. Nov 23, 2020. https://news.cgtn.com/

news/2020-11-23/China-eliminates-absolute-poverty-one-month-before-

schedule-VEp8VAJJS0/index.html (accessed Aug 25, 2021).

2 Financial Times. China’s Xi calls for wealth redistribution and clampdown

on high incomes. Aug 17, 2021. https://www.ft.com/content/87c3aa02-

f970-48c8-b795-82768c9f7634. (accessed Aug 25, 2021).

3 O’Neill J, Tabish H, Welch V, et al. Applying an equity lens to interventions:

using PROGRESS ensures consideration of socially stratifying factors to

illuminate inequities in health. J Clin Epidemiol 2014; 67: 56–64.

4 Wang Y, Li X, Zhou M, et al. Under-5 mortality in 2851 Chinese counties,

1996–2012: a subnational assessment of achieving MDG 4 goals in China.

Lancet 2016; 387: 273–83.

5 Liang J, Li X, Kang C, et al. Maternal mortality ratios in 2852 Chinese

counties, 1996–2015, and achievement of Millennium Development Goal

5 in China: a subnational analysis of the Global Burden of Disease Study

2016. Lancet 2019; 393: 241–52.

6 Huang Y, Shallcross D, Pi L, et al. Ethnicity and maternal and child health

outcomes and service coverage in western China: a systematic review and

meta-analysis. Lancet Glob Health 2018; 6: e39–56.

7 UN Department of Economic and Social Aﬀairs. Sustainable Development

Goal 17: Strengthen the means of implementation and revitalize the global

partnership for sustainable development. 2021. https://sdgs.un.org/goals/

goal17 (accessed Aug 25, 2021).

8 Khalatbari-Soltani S, Cumming RC, Delpierre C, Kelly-Irving M. Importance

of collecting data on socioeconomic determinants from the early stage of

the COVID-19 outbreak onwards. J Epidemiol Community Health 2020;

74: 620–23.

9 CGTN. Poverty alleviation via healthcare. Oct 17, 2019. https://news.cgtn.

com/news/2019-10-17/Poverty-alleviation-via-healthcare-KQ2aiQGjiE/

index.html (accessed Aug 25, 2021).

10 Chinese Government. Healthy China Action (2019–2030). July 15, 2019.

http://www.gov.cn/xinwen/2019-07/15/content_5409694.htm (accessed

Aug 25, 2021).

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( Lancet . 2019;393:241–252) Mortality for both mother and child have been falling at impressive rates in China over the past 2 decades. Nationwide, maternal mortality dropped from 111.0 per 100,000 livebirths in 1990 to 21.8 per 100,000 livebirths in 2015. However, child mortality has varied substantially among counties and maternal mortality might also vary widely among counties. Identifying counties experiencing less progress could help guide the Chinese government in allocating extra resources as needed to meet the Millennium Development Goal 5 (MDG 5) of decreasing the maternal mortality rate by 75% between 1990 and 2015. This study aimed to estimate the maternal mortality ratio in 2852 counties in China between 1996 and 2015 and determine the effects of key factors such as economic development and maternal education on maternal mortality.

Under-5 mortality in 2851 Chinese counties, 1996-2012: A subnational assessment of achieving MDG 4 goals in China

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Background: In the past two decades, the under-5 mortality rate in China has fallen substantially, but progress with regards to the Millennium Development Goal (MDG) 4 at the subnational level has not been quantified. We aimed to estimate under-5 mortality rates in mainland China for the years 1970 to 2012. Methods: We estimated the under-5 mortality rate for 31 provinces in mainland China between 1970 and 2013 with data from censuses, surveys, surveillance sites, and disease surveillance points. We estimated under-5 mortality rates for 2851 counties in China from 1996 to 2012 with the reported child mortality numbers from the Annual Report System on Maternal and Child Health. We used a small area mortality estimation model, spatiotemporal smoothing, and Gaussian process regression to synthesise data and generate consistent provincial and county-level estimates. We compared progress at the county level with what was expected on the basis of income and educational attainment using an econometric model. We computed Gini coefficients to study the inequality of under-5 mortality rates across counties. Findings: In 2012, the lowest provincial level under-5 mortality rate in China was about five per 1000 livebirths, lower than in Canada, New Zealand, and the USA. The highest provincial level under-5 mortality rate in China was higher than that of Bangladesh. 29 provinces achieved a decrease in under-5 mortality rates twice as fast as the MDG 4 target rate; only two provinces will not achieve MDG 4 by 2015. Although some counties in China have under-5 mortality rates similar to those in the most developed nations in 2012, some have similar rates to those recorded in Burkina Faso and Cameroon. Despite wide differences, the inter-county Gini coefficient has been decreasing. Improvement in maternal education and the economic boom have contributed to the fall in child mortality; more than 60% of the counties in China had rates of decline in under-5 mortality rates significantly faster than expected. Fast reduction in under-5 mortality rates have been recorded not only in the Han population, the dominant ethnic majority in China, but also in the minority populations. All top ten minority groups in terms of population sizes have experienced annual reductions in under-5 mortality rates faster than the MDG 4 target at 4·4%. Interpretation: The reduction of under-5 mortality rates in China at the country, provincial, and county level is an extraordinary success story. Reductions of under-5 mortality rates faster than 8·8% (twice MDG 4 pace) are possible. Extremely rapid declines seem to be related to public policy in addition to socioeconomic progress. Lessons from successful counties should prove valuable for China to intensify efforts for those with unacceptably high under-5 mortality rates. Funding: National "Twelfth Five-Year" Plan for Science and Technology Support, National Health and Family Planning Commission of The People's Republic of China, Program for Changjiang Scholars and Innovative Research Team in University, the National Institute on Aging, and the Bill & Melinda Gates Foundation.

a subnational assessment of achieving MDG 4 goals in China

Jan 1996
LANCET
273-283

Y Wang
X Li
M Zhou

Wang Y, Li X, Zhou M, et al. Under-5 mortality in 2851 Chinese counties, 1996-2012: a subnational assessment of achieving MDG 4 goals in China. Lancet 2016; 387: 273-83.