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Abstract
Objectives To analyse annual trends of the under-five mortality rate (U5MR) and main cause-specific U5MR in China from 1996 to 2020 and to assess the potential correlation of the healthcare system and health expenditure with the U5MR in China.
Design A retrospective observational study using national data from 1996 to 2020. Joinpoint regression was employed to model U5MR trends and Pearson correlation analysis was conducted to examine the relationship between healthcare system factors, health expenditure and U5MR.
Setting Nationwide study covering both rural and urban populations across China over a 25-year period.
Results The U5MR in China experienced a three-stage decline from 1996 to 2020 with an average annual percentage rate change (AAPC) of −7.27 (p<0.001). The AAPC of the rural U5MR (−7.07, p<0.001) was higher than that in urban areas (−5.57, p<0.001). Among the five main causes, the decrease in pneumonia-caused U5MR was the fastest while the decreases in congenital heart disease and accidental asphyxia were relatively slow. The rates of hospital delivery (r=−0.981, p<0.001), neonatal visits (r=−0.848, p<0.001) and systematic health management (r=−0.893, p<0.001) correlated negatively with U5MR. The proportion of government health expenditure in the total health expenditure (THE) correlated negatively with the national U5MR (r=−0.892, p<0.001) while the proportion of out-of-pocket health expenditure in THE correlated positively (r=0.902, p<0.001).
Conclusion China made significant advances in reducing U5MR from 1996 to 2020. The rural–urban gap in U5MR has narrowed, though rural areas remain a key concern. To further reduce U5MR, China should focus on rural areas, pay more attention to congenital heart disease and accidental asphyxia, further improve its health policies, and continue to increase the government health expenditure.
- public health
- paediatrics
- health policy
Data availability statement
Data are available in a public, open access repository.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Strengths and limitations of this study
The study covered the annual trends of the under-five mortality rate (U5MR) in China from 1996 to 2020 providing a long-term perspective for analysis.
Joinpoint regression was used to model the annual trends of mortality rate over time.
Due to the limited availability of public data, we were unable to collect case-specific information on deceased children including basic characteristics and medical treatments.
The study lacks predictive analysis for future trends in U5MR or early warning analysis of risk factors.
Introduction
As a core indicator reflecting child health and economic development, the under-five mortality rate (U5MR) was listed in the United Nations Millennium Development Goals and the Sustainable Development Goals.1 2 U5MR refers to the total number of deaths of children under the age of 5 years divided by the total number of live births in the same time interval and is generally expressed as deaths per 1000 live births.2 According to data from the Health Statistics Yearbooks of China,3 in the period between 1996 and 2020, the U5MR in China has decreased from 45.0 to 7.5 deaths per 1000 live births. although details of the annual changes have not been described systematically.
The rapid decrease in the U5MR in China between 1996 and 2020 can be accounted for by the alleviation of social deprivation through the development of the economy and society.4–8 The main influencing factors include but are not limited to: Improvement of the healthcare system, optimisation of wealth distribution, increase of health expenditure, development of medical technology and improvement of education.4–8
As important components of the children’s healthcare system in China, neonatal visits and child system management encompass a wide array of services including postnatal consultations for newborns, comprehensive health evaluations, nutritional counselling, disease prevention strategies and the mandatory establishment of health records.9 10 They also involve systematic regular check-ups, vaccinations and the provision of health education and guidance.9 10 The total health expenditure (THE) in China has kept increasing over the past two decades.11 As a well-accepted health status indicator of a country,12 THE comprises three parts: Government health expenditure (GHE), social health expenditure (SHE) and out-of-pocket health expenditure (OOPHE). In 2020, the THE in China was 7.1% of the gross domestic product (GDP)11 which was higher than the average for developing countries as reported by the WHO.
Joinpoint regression is a novel analytical method used to analyse trends and changes in datasets. By establishing segmented regression based on the time characteristics of rate change trends, this method provides a detailed evaluation of rate changes within different intervals across an entire period.13 14
In this study, we used Joinpoint regression to systematically analyse the annual changes in the national, urban and rural U5MRs in China between 1996 and 2020. Our research aimed to provide a clearer understanding of these trends and to explore potential associations between U5MR and various factors including the rates of neonatal visits, systematic health management for children under the age of 3 years and hospital deliveries. Additionally, we examined the relationships between U5MR and THE as well as its components. The objective of this study is to provide evidence-based insights that can inform policymaking and guide intervention strategies aimed at further improving child health and survival rates in China.
Methods
Definitions
A live birth is defined as a fetus born after 28 weeks of gestation (or with a birth weight>1000 g) with at least one of the following vital signs: Heartbeat, breathing, pulsation of the umbilical cord or contraction of voluntary muscle.15 U5MR refers to the total number of deaths of children aged under 5 years divided by the total number of live births in the same time interval and is generally expressed as deaths per 1000 live births.2
Neonatal visits refer to regular health check-ups and follow-up of newborns conducted by medical staff, usually doctors, nurses or other professional medical personnel within a certain period of time after birth.9 At these visits, growth and development, feeding, sleep, vaccination and the home environment of newborns are evaluated and relevant health guidance and advice are provided to parents. These visits are crucial for monitoring the growth of newborns and early detection of potential health issues. The neonatal visit rate is defined as the ratio of the number of newborns receiving one visit and petitioning visits to the number of live births annually in a particular jurisdiction.
Systematic management is an important aspect of the child healthcare system in China.9 Government policy stipulates that the Child Health Department is required to conduct regular visits, monitor feeding, conduct physical examinations, implement management of high-risk cases and promote early physical exercise as part of the comprehensive health management of children aged under 7 years. The systematic health management rate for children aged under 3 years is defined as the ratio of the total number of children aged under 3 years who receive growth monitoring in accordance with the age requirement during the statistical year to the number of children aged under 3 years during the same period.
The THE refers to the total amount of money spent by a country or region on medical and healthcare services over a certain period of time. The GHE refers to the governmental finance allocation for healthcare services including public healthcare service funds and public medical expenses. The SHE refers to the expenditure on social medical security, commercial health insurance, social medical enterprises and social donations. The OOPHE refers to the expenses borne directly by individuals or families when residents receive medical and health services. Per total health expenditure (PTHE) is defined as the average healthcare spending per person.11 12 16
Data sources
The following data were obtained from the China Health Statistics Yearbooks:3 The U5MR, the main causes of under-five deaths, the national neonatal visit rate and the systematic management rate of children aged under 3 years. Data for the following indicators were collected from the National Bureau of Statistics of China:17 THE, GDP, GHE, OOPE, SHE and PTHE.
In terms of ethical considerations, all mortality data analysed in this study were collected from the China Health Statistical Yearbooks with strict adherence to confidentiality principles to ensure that personal information is not disclosed or misused.
Patient and public involvement
None.
Statistical analysis
Details of the trends in the U5MR, the main causes of under-five deaths and the health management indexes were analysed using the Joinpoint Regression Program, V.5.0.2.14 Using this method, the annual percentage rate change (APC) and the average annual percentage rate change (AAPC) were determined. An APC value>0 indicates an upward trend in mortality over time and vice versa.13 An APC equal to the AAPC indicates an overall upward or downward trend in mortality.13 In Joinpoint regression, ‘change points’, also known as ‘joinpoints’, are points that indicate significant changes in trend such as shifts from increasing to decreasing trends or changes in the rate of growth. This analysis helps identify these points to better understand trend changes in time series data.14
To evaluate the statistical significance of differences in trends of urban and rural data over time, pairwise comparisons were conducted using coincidence and parallelism tests with the Joinpoint Regression Program. Pearson correlation analysis was performed with SPSS V.25.0 software to assess the associations between the national U5MR and the total health financing composition in China. A two-tailed p value<0.05 was considered to indicate statistical significance.
Results
Annual changes in the U5MR of China between 1996 and 2020
Between 1996 and 2020, the national U5MR decreased from 45.0 to 7.5 per 1000 live births. The urban and rural U5MRs showed a continual decrease during this period, although the latter rate was consistently higher than the former. For instance, the rural U5MRs were 3.04 and 2.02 times greater than the urban U5MRs in 1996 and 2020, respectively. The largest gap (3.34 times) between the rural and urban U5MRs occurred in 1999. We used Joinpoint regression to analyse the trends in the annual changes in the U5MR between 1996 and 2020 (figure 1 and table 1). The national and urban U5MRs showed a three-stage decline during this period, with AAPCs of −7.27% (p<0.001) and −5.57% (p<0.001), respectively, while the rural U5MR showed a four-stage decline, with an AAPC of −7.07% (p<0.001). The most rapid declines in the national, urban and rural U5MRs occurred during 2002–2005, 2003–2006 and 2000–2006, respectively. In addition, pairwise comparisons showed that the rate of decline in the rural U5MR was significantly different from that of urban U5MR over the past 20 years (p<0.001).
Joinpoint regression model for China’s U5MR from 1996 to 2020. The national, urban and rural U5MR in China from 1996 to 2020 were analysed using the Joinpoint Regression Program. The numbers of Joinpoints and corresponding annual percentage rate change (APC) were indicated. *p<0.05. U5MR, under-five mortality rate.
Annual changes in U5MR of China from 1996 to 2020
Annual changes in the main causes of under-five deaths in China from 1996 to 2020
The main causes of under-five deaths include preterm birth/low birth weight, birth asphyxia, pneumonia, congenital heart disease and accidental asphyxia. From 1996 to 2020, the national, urban and rural mortality due to these causes declined with significant decreases in the first three causes while the magnitudes of the decline in the latter two were relatively small (figure 2).
Changing trends of five main cause-specific mortalities of children under 5 years old in China from 1996 to 2020. National (A), urban (B) and rural mortality (C) due to the following five main causes were shown: Preterm birth/low birth weight, birth asphyxia, pneumonia, congenital heart disease and accidental asphyxia.
Joinpoint regression analysis of the annual changes in the five main causes of under-five deaths (table 2, online supplemental figures 1–5) revealed that pneumonia showed the largest decline with an AAPC of −10.77 (p<0.001) while a relatively minimal decrease in congenital heart disease was observed (AAPC=−3.25%, p<0.001). Different numbers of change points were observed for the five causes of the national U5MR. Similar trends were observed for rural U5MR while differences were observed for the trends in urban areas. Specifically, the urban U5MR due to birth asphyxia showed the largest decline (AAPC=−8.36, p<0.001) while the U5MR due to accidental asphyxia exhibited a minimal decrease (AAPC=−1.70, p<0.001). Furthermore, pairwise comparisons revealed significant differences in the patterns of change in the rural and urban U5MRs due to the following causes between 1996 and 2020: Preterm birth/low birth weight (p=0.001), pneumonia (p<0.001), congenital heart disease (p<0.001) and accidental asphyxia (p=0.003).
Supplemental material
Annual changes in the main causes of under-five deaths of China from 1996 to 2020
Correlation of the national U5MR with the main health management indexes and health financing composition
We next investigated the correlation between the decline in the U5MR and improvements in the healthcare indexes (online supplemental table S1). As important indicators of the health management system for children, continuous growth was observed in both the national neonatal visit rate and the systematic management rate for children aged under 3 years. Specifically, from 1996 to 2020, the former index increased from 81.40% to 95.50%, while the latter increased from 61.40% to 92.90%. Moreover, the hospital delivery rate also rose continuously during this period. All three indicators were found to be negatively correlated with the national U5MR (online supplemental table S1).
Furthermore, the associations between national U5MR and the health expenditure compositions were evaluated by conducting Pearson correlation analysis (online supplemental table S1). The results showed that the national U5MR was negatively correlated with the absolute values of the THE (r=−0.819, p<0.001), GHE (r=−0.820, p<0.001), SHE (r=−0.790, p<0.001), OOPE (r=−0.860, p<0.001) and PTHE (r=−0.826, p<0.001). The national U5MR was also negatively correlated with the proportion of the THE in the GDP (r=−0.793, p<0.001), the proportion of the GHE in the THE (r=−0.892, p<0.001) and the proportion of the SHE in THE (r=−0.842, p<0.001). In contrast, a positive correlation was observed between the national U5MR and the proportion of the OOPE in the THE (r=0.902, p<0.001).
Discussion
Between 1996 and 2020, the U5MR in China exhibited a three-stage decline, decreasing from 45.0 to 7.5 per 1000 live births. The rural and urban U5MRs showed roughly similar patterns (figure 1 and table 1). The most rapid decline in the national U5MR occurred between 2002 and 2005. This significant decline can be attributed to the interplay of multiple factors. From the perspective of social deprivation, economic growth, improvements in healthcare services, advancements in education and support from social security policies all played pivotal roles.1 4 5 8
Over the past two decades, significant economic growth has drastically reduced the levels of poverty in China and positively impacted children’s living conditions, health and survival rates.4 8 Economic growth has also promoted an increase in health expenditure (online supplemental table S1). Additionally, China has increased its healthcare investment, especially in maternal and child care in less affluent regions, to improve essential healthcare services, nutrition and access to vaccination.4 8 18 These changes have been accompanied by continuous increases in the rates of neonatal visits, hospital delivery and systematic management for children aged under 3 years (online supplemental table S1). Furthermore, the education system in China has undergone substantial improvements over the past 20 years.19 The expansion and equalisation of educational opportunities have enhanced general health awareness, contributing indirectly to a decrease in child mortality rates.20 China has also implemented policies to tackle social deprivation, introducing healthcare schemes, living allowances and nutrition programmes for women and children, further improving child health and reducing illness and malnutrition-related deaths.1 6 7
Despite the continued narrowing of the gap between rural and urban U5MRs, the former has remained higher than the latter (figures 1 and 2). Significantly, the rural and national U5MRs exhibited similar patterns of decline. To date, the rural U5MR remains the U5MR determining factor in China. The main reasons underlying the difference in U5MR between urban and rural areas are disparities in social deprivation, including but not limited to the following: Economic and educational inequalities, unequal distribution of healthcare resources and inadequate infrastructure in rural areas.6 7 18 Although the overall economy has grown rapidly, the issue of uneven wealth distribution still exists in China.6 7 Addressing these issues requires sustained investment in rural healthcare services, infrastructure, education and economic empowerment.
In 1996, the three leading causes of death in children aged under 5 years were pneumonia, premature birth/low birth weight and birth asphyxia (figure 2 and table 2). From 1996 to 2020, mortality rates due to the three leading causes have all decreased rapidly with the fastest decrease observed for pneumonia (figure 2 and online supplemental figure S3). At the beginning of the 21st century, China implemented standard case management for acute respiratory infections in children which significantly reduced the pneumonia-caused mortality rates of children.21 Mortality rates caused by premature birth/low birth weight and birth asphyxia have also undergone a rapid decline (figure 2 and online supplemental figure S1) due to improvements in maternal and newborn healthcare services and advances in the technology applied to treat preterm infants.22 23 Multiple strategies are needed to control the rising premature birth rate in China among which the public health education is important, for instance, raising public awareness of premature birth caused by secondhand smoke.24
In 2020, the ranking of the three leading causes of death shifted to premature birth/low birth weight, birth asphyxia and pneumonia. In contrast, the decline in the rates of mortality caused by congenital heart disease and accidental asphyxia were relatively slow, especially in rural areas (figure 2). Interestingly, due to the improved diagnostic rate,25 26 the mortality rate caused by congenital heart disease exhibited significant increases from 1996 to 2000 (online supplemental figure S4). Sustained efforts are required to address these issues in China. For instance, early screening, diagnosis and treatments for congenital heart disease should be further strengthened and first aid skill training to aid children with accidental suffocation should be consistently popularised.
According to data from the World Bank,27 the U5MR has also declined in other developing countries over the past two decades, although the pace and magnitude of the declines are relatively smaller compared with that in China. For example, the U5MR in Brazil fell from 45 to 14.7 deaths per 1000 live births during the period from 1996 to 2020. India’s U5MR decreased from 106 to 32.4 deaths per 1000 live births. In contrast, Nigeria faces a particularly severe situation, with its U5MR still alarmingly high at about 113.8 deaths per 1000 live births in 2020. These disparities can be attributed mainly to differences in the rate and quality of national economic growth, the effectiveness of public health strategies implemented by the state and the degree of enhancement in healthcare infrastructure.2 28 Nonetheless, according to the World Bank, the U5MR in China still lags significantly behind those of developed countries. For instance, Japan and Sweden boasted exceptionally low U5MRs in 2020, at 2.4 and 2.5 deaths per 1000 live births, respectively. Significantly, there are clear distinctions in the causes of the U5MR between developed and developing countries.2 In the former, child deaths are more often associated with non-communicable diseases and accidents, such as congenital anomalies, low birth weight/prematurity and accidental suffocation. In developing countries, children more frequently die from preventable and treatable infectious diseases or malnutrition.2
It should be noted that although the proportion of both the GHE and SHE in the THE have been increasing in China and the proportion of OOPE has undergone a reduction (online supplemental table S1), there are still significant gaps in these indexes compared with those of developed countries. First, we noticed that the proportion of GHE in the THE has broadly remained static since 2011 (online supplemental table S1). The data in 2020 was 30.4%, which was far lower than that of the USA, Japan, Canada and Italy (all>40%).12 Second, in 2020, the proportion of OOPE in the THE in China (27.65%) greatly exceeded 20%, the international experience upper limit for eliminating catastrophic health expenditure in households.29 In fact, China still has one of the highest OOPHE rates in Asia.30 Therefore, further efforts are needed to rationalise the composition of China’s healthcare expenditure.
This study has several limitations. First, the limited availability of public data restricted our ability to gather detailed information on individual cases of child mortality thus limiting our analysis of specific factors contributing to mortality, such as developmental status, living environments and healthcare access. Second, while we can propose potential factors contributing to the reduction in U5MR, this study does not establish a definitive causal relationship. Lastly, our research does not extend to predictive analyses of U5MR trends or to an early warning system for identifying risk factors.
Conclusion
Significant advances in reducing the U5MR have been achieved in China over the past two decades, although there is still room for progress compared with developed countries. Our study reveals the need for further reduction in the national U5MR in China based on continuous optimisation of its healthcare systems with a focus on building comprehensive child healthcare services, particularly in rural areas. In addition, effective solutions should be actively explored to reduce mortality caused by congenital heart disease and accidental asphyxia and rationalise the national health expenditure composition.
Data availability statement
Data are available in a public, open access repository.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Acknowledgments
The authors thank all the editors of the China Health Statistics Yearbooks (1997–2021) and thank the open platform of National Bureau of Statistics of China.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors Q-RF and J-ML collected data and performed statistical analysis. QM and J-ML wrote the manuscript. QM and H-XL designed the study and revised the manuscript. NC, X-NH, JZ and Y-FT analysed data. J-ML is responsible for the overall content as the guarantor. All authors read and approved the final manuscript.
Funding This work was supported by the Natural Science Foundation of Shaanxi Province (grant number 2024JC-YBMS-736), and the Xi’an Science and Technology Plan Project (grant number 23YXYJ0122).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.