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Abstract
Objectives To inform the impacts of health programmes which aimed at preventing women and children from being trapped in or returning to poverty because of illness in Yunnan, the main battlefield against poverty in China.
Design The longitudinal comparative evaluation design.
Data collection and analysis National and Yunnan policy documents related to maternal and child health programmes for poverty alleviation during 2015–2020 were analysed. The changes in disparities in maternal and child health system inputs, service coverage, and health outcomes between poor and non-poor areas, as well as out-of-pocket payments between poor and non-poor populations were assessed before and after 2017.
Results In total 12 policies and 15 programmes related to poverty alleviation for poor women and children in Yunnan were summarised. As a result of health system strengthening in Yunnan, the densities of licensed doctors, nurses, obstetricians, midwives, township health workers and female village doctors had been increased substantially in poor areas, with the annual rates of 14.3%, 22.5%, 21.8%, 23.9%, 14.1% and 7.1% separately. Although disparities existed in some of service coverage between poor and non-poor areas, the health programmes had narrowed the gaps in utilisation of facility birth, caesarean section, prenatal screening and newborn screening across Yunnan (p<0.01). The out-of-pocket payments for inpatient care for serious illnesses among women and children with poverty registration had been considerably decreased to 10.0%. Paralleling the universal coverage, maternal deaths per 100 000 livebirths and child deaths per 1000 livebirths had further declined in both poor and non-poor areas, and the impacts of health programmes on closing the gaps in child survivals across Yunnan were significant (p<0.01).
Conclusions Remarkable progress in equitable maternal and child survival has been achieved in Yunnan. The practices in Yunnan have shown the Chinese model in ending poverty by strengthening health system and implementing universal coverage with firm commitment, determined leadership, detailed blueprint and social participation.
- health policy
- health economics
- public health
Data availability statement
Data are available in a public, open access repository. Data used in this study are available in Yunnan Maternal and Child Health Routine Reporting System, Yunnan Health Statistical Yearbooks, Yunnan Statistical Yearbooks and Yunnan Social Medical Insurance Reimbursement Datasets.
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
This study examined the impacts of implementing maternal and child health (MCH) programmes on various outcomes, including health system inputs, service coverage, health outcomes and out-of-pocket payments in Yunnan Province, China, to provide empirical evidence supporting the importance of health programmes in breaking the vicious cycle of poverty and illness among vulnerable populations.
This study employed a difference-in-difference design, which compared outcomes in poor and non-poor areas before and after the intensive implementation of MCH programmes in 2017, and found significant improvements in many indicators of service coverage and health outcome following the interventions.
The effects of MCH programmes were mainly estimated with secondary data at county/township level in this study, which lacked the considerations of some key variables such as maternal literacy and household income and veiled the differences at individual level.
Introduction
Maternal and child health (MCH) affects economic growth and social development globally. Reducing maternal and child mortality is continually featured in the United Nations post-2015 Sustainable Development Goals (SDGs) and requires global supports.1 China has made impressive progress in maternal and child survivals in recent decades. Between 1990 and 2015, maternal mortality rate (MMR) fell from 89 to 22 deaths per 100 000 livebirths and same decrease trend was seen in under-5 mortality rate, falling from 54 to 11 deaths per 1000 livebirths in China.2 3 However, disparities remained in western China where the maternal and child survivals were lagging behind in 2015, typically in rural and remote areas of Yunnan Province which is economically deprived and overwhelmingly concentrated by ethnic minorities.4 Due to poor nutrition, little health knowledge and lack of access to proper sanitation and healthcare services, poor and remote pregnant women and children were vulnerable populations at high risk of severe illness and death, which was the tough challenge facing in China.4 5 Particularly, both of MMR and under-5 mortality rate were twice as high for ethnic minorities than for their Han counterparts in western China according to a meta-analysis published in 2017.6 Except for economic and educational disadvantages, traditional beliefs, mountainous topography and poor quality of care were important barriers to seeking MCH care.7 Maternal and child deaths not only decreased household income but also took a substantial share of national labour productivity loss.8 Moreover, the treatment cost of disease or long-term complication might trap women and their families in poverty especially when large out-of-pocket expenditures were paid.9
To break the vicious cycle of poverty and illness, the China’s Government has introduced the Health Programme for Poverty Alleviation Strategy which is an important measure to win the battle against poverty by targeting the poor and remote population precisely and reducing the heath disparities across regions and population groups.10 In response to this, efforts have been made to ensure that the poor seldom fall ill, but can access and afford healthcare services when falling ill, as they can expect help from national public services, severe illness insurance and government funds which will cover the remaining cost after the relevant reimbursements to protect these people’s right to health and prevent them from being trapped in or returning to poverty because of illness.11 12 Promising to leave no one behind, as the main battlefield against extreme poverty in China, the Yunnan has launched the Thirty Health Actions for Poverty Alleviation in 2017, which includes a series of MCH programmes under Targeted Poverty Alleviation Strategy (hereinafter referred to as MCH-PA programmes) to address the specific challenges when seeking MCH healthcare services, reduce deaths of pregnant women, newborns and children under 5 years old, and avoid catastrophic health expenditures happened to those remote women and children as well as the ethnic minorities in poor rural Yunnan.13 The MCH-PA programmes which include specific interventions in poor rural areas from strengthening emergency obstetric and newborn care to preventing birth defects, improving child nutrition, supplementing folic acid, breast and cervical cancer screening as well as affordable medical services, also echo the goal of guaranteeing the Healthy China 2030 and Healthy Yunnan 2030 Initiatives and the Strategy of Rural Revitalisation to achieve moderate prosperity in all respects after ending absolute poverty.13
We present a systematic assessment in Yunnan to inform the impacts of the MCH-PA programmes which aimed at preventing women and children from being trapped in or returning to poverty because of illness, moreover improving MCH equity across Yunnan. This article discussed the lessons learnt with regard to health-related poverty alleviation in Yunnan, which may provide special reference to those still remaining impoverished by illness. These improvements may not only benefit Yunnan and people living there, but also serve as excellent demonstrations to other places and populations on how things can change, for the better.
Methods
Study setting
Yunnan Province of China, a mountain and plateau region on the country’s southwestern frontier, covers an area of 394 100 km2 with altitudes varying from the mountain peaks to river valleys by as much as 6000 metres. The total population of Yunnan was 47.2 million in 2020, which includes 11.3 million women of childbearing age (23.9%) and 3.1 million children under 5 years old (6.6%).14 Yunnan is noted for a very high level of ethnic diversity and owns the highest number of ethnic groups and autonomous regions in China, accounting for 33.1% of its total population.14 As one of the least developed provinces in China, more than 8.8 million rural residents in Yunnan were living in poverty in 2012, based on national poverty line CNY2300 (about US$364.5) per capita net income of rural residents.15 Some of the most entrenched poverty in Yunnan was found in regions inhabited by 11 smaller ethnic groups who practised relatively primitive ways of life.15 In 2014, the China’s Government released a list of 832 impoverished counties according to poverty headcount ratio. Yunnan had 88 such counties including 8502 impoverished villages when the list was released, more than any other provinces of China.16 After 6-year efforts under China’s Targeted Poverty Alleviation Strategy, as the main battlefield in China’s war against poverty, Yunnan announced that all 88 counties designated by the government as poverty-stricken (accumulatively 7.6 million population including 2.3 million women of childbearing age and 0.3 million children under 5 years old) have shrugged off absolute poverty and all of its impoverished rural residents have been lifted above the current poverty line by December 2020.17
Overview of study designs
We applied the WHO Health System Building Blocks as the evaluation framework which assesses the improved MCH outcomes through an analysis of MCH systems inputs, MCH services coverage and quality, and geographical disparity (see online supplemental appendix figure 1).4 18 19 We started by reviewing the National and Yunnan provincial policy documents since 2015 to summarise the key MCH programmes for poverty alleviation in Yunnan. The timeline of MCH-PA programmes disaggregated into four aspects by health system inputs was drawn by an iterative process during a series of workshops with a multidisciplinary team of maternal health and health systems experts. As the Yunnan intensively launched MCH-PA programmes in 2017 and aimed at reaching women and children in poor rural areas, we described the variations in MCH system inputs, services coverage and health outcomes between 88 poor rural counties and 41 non-poor rural counties/urban districts before (in 2015) and after (in 2020) MCH-PA programmes. The changes from 2015 to 2020 were calculated for areas with and without MCH-PA programmes. The ratios of poor to non-poor were used to show the differences between areas in 2015 and 2020. In order to assess the impact of MCH-PA programmes more precisely, the township-level data were adopted to estimate the changes in those MCH indicators brought about by MCH-PA programmes in poor areas after 2017, compared with non-poor areas. A total of 912 rural townships from 88 impoverished counties of Yunnan were categorised into the group ‘poor areas with MCH-PA programmes’; the remaining 295 rural townships and 109 urban streets from 41 non-poor counties/districts as well as 102 urban streets from impoverished counties were clustered into the group ‘non-poor areas without MCH-PA programmes’ (506 rural townships/urban streets in total) (see online supplemental appendix figure 2). The effects of MCH-PA programmes on out-of-pocket payments were assessed at individual level, between populations with and without poverty registration.
Supplemental material
Data sources
First, we extracted data on MCH outcomes (the number of live births, maternal deaths, neonatal deaths, infant deaths, under-5 deaths, birth defects, low-weight births, underweight children, stunted children, wasted children, overweight children, obese children, anaemic children and anaemic pregnant women) and MCH services (the number of high-risk pregnancies, antenatal visits, prenatal screening, facility deliveries, caesarean sections, postnatal visits, newborn visits and newborn diseases screening) between 2015 and 2020 at both county level and township level, and data on MCH system inputs (the number of obstetricians, midwives and facilities providing delivery services or caesarean sections) between 2017 and 2020 at county level from Yunnan Maternal and Child Health Routine Reporting System. This system reports the annual number of MCH outcomes and service coverage for all 129 rural counties/urban districts including 1418 rural townships/urban streets of Yunnan and data are reliable because rigorous quality control mechanisms including data quality audit process and standardisation of data collection were introduced from 1997 onward. But data on MCH system inputs were added from 2017 onward. Second, data on the number of licensed doctors, licensed nurses, public MCH programme personnel at township level, female village doctors, and hospital beds for all health facilities and the number of beds in the department of gynaecology and obstetrics and in the department of neonatology and paediatrics in 129 rural counties/urban districts across Yunnan between 2015 and 2020 were extracted from Yunnan Health Statistical Yearbooks. Third, we obtained county-level data on total resident population, per capita gross domestic product (GDP), per capita disposable income of rural residents, and land area between 2015 and 2020 from Yunnan Statistical Yearbooks. The density of MCH health resources per 1000 population or per 1000 livebirths were calculated. Fourth, the individual data on total medical expenditures and out-of-pocket payments for the treatment of breast cancer and cervical cancer among women, and the treatment of congenital heart disease and pneumonia among children under 5 years old across Yunnan were extracted from Yunnan Social Medical Insurance Reimbursement Datasets. Medical expenditures of both outpatient care and inpatient care were collected. Finally, policy data related to MCH-PA programmes were provided by Office for Poverty Alleviation People’s Government of Yunnan Province, Office for Women and Children Health Commission of Yunnan Province, and Yunnan Provincial Maternal and Child Health Care Hospital.
Statistical analysis
We adapted the longitudinal comparative evaluation design and the difference-in-difference (DID) technique to assess the changes in disparities in MCH service coverage and health outcomes between poor and non-poor areas at township level before and after MCH-PA programmes.20 We constructed two dummy variables 
and 
. If i is a poor area/person with MCH-PA programmes, the value of 
is 1 (the treatment group); opposite, the value of 
is 0, if i is a non-poor area/person without MCH-PA programmes (the control group). 
is a time dummy variable and it is assigned 1 after the implementation of MCH-PA programmes (2018–2020), 0 before the MCH-PA programmes (2015–2017). Based on the DID technique, the theoretical model to estimate the treatment effects comparing the pretreatment and post-treatment differences in the outcome of a treatment and a control group can be expressed as:
(1)
E is the mathematical expectation in the equation. 
is the observations if i area/person participated MCH-PA programmes. 
represents the area/person which did not participate in MCH-PA programmes. 
shows the difference before and after MCH-PA programmes implementation. To estimate the impact of MCH-PA programmes, the equation (1) could be designed as follows:
(2)
Then the coefficient of interaction δ in equation (2) measures the effects of MCH-PA programmes:
(3)
So we used the following multivariate linear regression model to examine if MCH-PA programmes contributed to the changes in MCH indicators:
(4)
is any of MCH indicators and data normalisation will be adopted when necessary. 
is poor area dummy indicating poor rural townships where the MCH-PA programmes has implemented. 
is time dummy indicating years after the implementation of MCH-PA programmes. 
indicates the confounding variables including per capita GDP, the number of live births or the density of maternal health personnel. α indicates intercept. 
is residual. The fixed effect of year, which could account for all time-invariant unobserved confounding for two groups, was also included as a covariate. The parallel trends assumption for DID analysis that pretreatment trends in outcomes were same between two groups was verified by regressing each MCH indicator on an interaction term between the binary treatment status and a continuous variable representing years before 2017. The models for continuous outcomes used ordinary least squares, categorical outcomes used logistic, and binary outcomes (such as incidence or mortality) used Poisson. No significant coefficients on the interaction terms were detected, which suggested that the parallel trends assumption was not to be violated and the DID estimators were unbiased. In order to avoid heteroscedasticity and serial correlation of residual, we clustered residual to the county level. All estimates were reported with 95% CIs where relevant. Statistically significant change was defined as change for which the 95% CIs did not overlap zero. All analyses were done with STATA V.15.0.
Patient and public involvement
Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.
Results
In total of 69 policy documents related to the national and provincial MCH-PA programmes had been reviewed. Finally, 6 national policies and another 6 policies and 15 MCH-PA programmes of Yunnan were list in figure 1. The Chinese government has maintained a strong focus on MCH through a series of national general and specific Plans of Actions for Women and Children. The guidance on the Implementation of Health Programme for Poverty Alleviation provided a complete legal and policy framework for breaking the vicious cycle of poverty and illness among vulnerable populations, such as poor pregnant women and children, which echoed the Healthy China 2030 initiative. As shown, Yunnan provincial policies and plans of actions were made under the national guidance which specified clear targets and tasks. The Yunnan Thirty Health Actions for Poverty Alleviation and Yunnan Actions for Wining Tough Battle against Poverty which were formulated in 2017 and 2019, respectively, emphasised the main objectives to ensure that the MMR and infant mortality rate in Yunnan are, respectively, lower than 20 per 10 000 livebirths and 10 per 1000 livebirths by the end of 2020. Specific strategies in four aspects of financing, infrastructure building/drugs/equipment/medical suppliers, services provision and health human resources have been designed and realised through the implementations of a series of MCH-PA programmes.
Timeline of Maternal and Child Health Policies and Programmes for Poverty Alleviation during 2015–2020 in Yunnan, China.
A total amount of CNY1.3 billion (about US$201.8 million) was transferred from central and provincial governments to the specific MCH-PA programmes in Yunnan from 2017 to 2019. The government’s expenses on social basic medical insurance reimbursements for ill women and children were not included in the number mentioned above. Otherwise, another CNY449.1 million (about US$69.5 million) was especially invested in infrastructure building for MCH system strengthening in poor rural areas in Yunnan. A total of 128 emergency obstetric care centres and 112 emergency newborn care centres have been built until 2020, which nearly covered all the poor counties of Yunnan. For further improving level of and equity in maternal and child survivals in Yunnan, besides the regular free MCH services such as antenatal and postnatal care, the free services including prepregnancy check-up, prenatal screening, newborn diseases screening, child nutrition package, folic acid supplement, breast and cervical cancer screening, and female common disease screening had been provided which had expanded MCH health service coverage to woman and child in poor rural areas. Birth companion and waiting room services in the department of obstetrics had been available for pregnant women at high risk in remote and poor areas since 2013. Meanwhile, counterpart assistance programmes and special training had been conducted. Specialists from Shanghai, Guangzhou and Fujian (the most developed provinces from the Eastern China) and nine tertiary hospitals of Yunnan were assigned to the poor counties or townships and had worked in the department of obstetrics or the department of paediatrics there for 2 years. The capacity-building series training had been given to obstetricians and other medical staff at primary level. Otherwise, a three-tiered financial protection strategy has been made to ensure that medical services would be affordable (out-of-pocket payments at 10%) with basic medical insurance, serious illness insurance, and medical financial assistance schemes among the Households with Poverty Registration. For some extremely poor households, out-of-pocket health expenditure was completely covered by the governmental financial protection strategy.
Poor areas where the MCH-PA programmes have been implemented are home to half of the total population in Yunnan. But population densities in most poor areas were much lower than those in non-poor areas. Between 2015 and 2020, there was a sign that people moved from poor areas to non-poor areas. Although disparities persisted between areas, the per capita GDP and per capita disposable income of rural residents in poor areas had increased at the annual rates of 19.8% and 11.5% respectively, which exceeded those in non-poor areas (14.9% and 11.4%). The decrease trend was seen in the number of live births across Yunnan, but which was not statistically significant (table 1).
Socioeconomic characteristics and health system inputs of areas with and without MCH-PA programmes at county-level in Yunnan, China
As a result of capacity strengthening of MCH system in Yunnan, health workforce and facilities had been growing steadily in poor areas. Not only the numbers of licensed doctors (from 1.1 to 1.9) and nurses (from 1.1 to 2.6) per 1000 population, but also the numbers of obstetricians (from 10.1 to 15.7) and midwives (from 10.9 to 21.6) per 1000 livebirths had been increased substantially in poor areas, with the annual rates of 14.3%, 22.5%, 21.8% and 23.9% separately. Moreover, the numbers of township MCH workers and female village doctors in poor areas had been increased largely, who participated in MCH programme implementation and service provision at primary- level (the township level and village level). Disparities existed in most indicators of MCH human resources between poor and non-poor areas, but the gap in the density of obstetricians per 1000 livebirths had become smaller (from 0.83 to 0.76) in 2020. Oppositely, the gaps in densities of township MCH workers and female village doctors per 1000 livebirths had grown larger between areas at the same time period and there were more health staff working for MCH at both township level (p=0.04) and village level (p=0.05) in poor areas, compared with those in non-poor areas. Meanwhile, the percentages of township MCH workers with bachelor degree (3.7% vs 3.6%) and female village doctors with high school degree (2.7% vs 1.5%) had grown faster in poor areas than non-poor areas. Besides, the densities of hospital beds in the department of gynaecology and obstetrics and the department of neonatology and paediatrics per 1000 livebirths and the densities of facilities providing delivery services and caesarean sections per 1000 livebirths had increased in poor areas, with the annual rates of 10.2%, 18.5%, 10.9% and 8.6%. (table 1).
Although more than 99% of pregnant women gave birth in health facilities across Yunnan in 2015, the determined efforts to expanding MCH services to every woman and child had resulted in a continuous rise in proportions of births in health facilities in 2020 (from 99.2% to 99.9% in poor areas and from 99.9% to 100.0% in non-poor areas). Both crude (0.49, p<0.01) and adjusted (0.52, p<0.01) DID estimators showed the MCH-PA programmes had effectively encouraged facility births in Yunnan. Paralleling the universal coverage in health facility births, the median caesarean section rates had been increased to 24.5% in poor areas and 34.8% in non-poor areas, with the annual rates of 1.6% and 1.1%, respectively. The adjusted (1.62, p=0.04) DID estimator showed the MCH-PA programmes had narrowed the gaps in proportions of caesarean section between areas in Yunnan. Proportions of antenatal visits, postnatal visits and newborn visits had showed decrease trend between 2015 and 2020 in poor areas, however, those in non-poor areas followed similar trends. In order to prevent and control birth defects, prenatal screening for fetal abnormalities and newborn screening for hearing, phenylketonuria (PKU) and congenital hypothyroidism (CH) had been provided free of charge to pregnant women and newborns in poor areas. The annual rates of increase in attendances of fetal abnormalities (12.9% vs 9.6%) and hearing (2.7% vs 1.5%) screening were all faster in poor areas than those in non-poor areas. Ratios of poor to non-poor in newborn screening for PKU and CH were around 1 in both 2015 and 2020 and there were no significant difference between areas (p>0.05). Compared with non-poor areas, the MCH-PA programmes had promoted the attendances of prenatal screening (crude DID estimator 9.08, p<0.05; adjusted DID estimator 13.46, p<0.01) and newborn hearing screening (crude DID estimator 4.68, p<0.01; adjusted DID estimator 4.74, p<0.01) in poor rural areas of Yunnan (table 2).
The impact of MCH-PA programmes on service coverage and health outcomes across Yunnan, China
In addition, the out-of-pocket payments for serious illnesses among women and children with poverty registration had been considerably decreased by the three-tiered financial protection strategy. After MCH-PA programmes had launched, the registered poor women only paid 10.0% of total medical expenses for inpatient care for both cervical cancer and breast cancer, which was much less than those (30.0% and 27.2%) paid by populations without poverty registration (p<0.01). Except for inpatient care, the registered poor women paid for outpatient care much less from their own pockets compared with the non-poor women for treating cervical cancer (50.0% vs 60.0%) and breast cancer (50.0% vs 62.7%) (p<0.01). Same trend had been seen among children under 5 years old and the households with registered registration paid less for both inpatient and outpatient care for children with congenital heart disease (10.0% vs 43.1%, 65.0% vs 75.0%) or pneumonia (10.0% vs 46.0%, 50.0% vs 60.0%), compared with their counterparts (p<0.01). Moreover, for those without poverty registration, the out-of-pocket payments for inpatient care for cervical cancer (from 35.0% to 30.0%), breast cancer (from 30.0% to 27.2%) and pneumonia (from 48.0% to 46.0%) had declined after the MCH-PA programmes had launched, whereas the out-of-pocket payments for outpatient care had only declined in the treatment of pneumonia (from 77.2% to 60.0%) among children under 5 years old (p<0.01) (table 3).
The impact of MCH-PA programmes on out-of-pocket payments by specific medical treatments in Yunnan, China
As a result, maternal deaths per 100 000 livebirths and child deaths (including neonatal, infant and under-5 deaths) per 1000 livebirths had declined substantially between 2015 and 2020 in both poor and non-poor areas. The median MMR per 100 000 livebirths declined from 17.8 to no death in poor areas and from 16.3 to no death in non-poor areas. Difference in MMR between areas had not been found, however, the impact of MCH-PA programmes on maternal survivals was not significant and the gap between poor and non-poor areas had not gone closer with the estimated change trend of MMR from 2015 to 2020 (table 2, figure 2A).
Estimated change trend of MMR (A), NMR (B), IMR (C) and U5MR (D) among all areas and areas with and without MCH-PA programmes from 2015 to 2020 in Yunnan, China. IMR, infant mortalityrate; MCH-PA, Maternal and Child Health Policies and Programmes for Poverty Alleviation; MMR, maternal mortality rate; NMR, neonatal mortality rate; U5MR, under-5 mortality rate.
The median neonatal mortality rate (NMR) varied 1.59 times (p<0.01) between poor and non-poor areas of Yunnan in 2015 and 1.43 times (p<0.01) in 2020, whereas the median IMR varied 1.50 times (p<0.01) and 1.54 times (p<0.01), and the median U5MR varied 1.53 times (p<0.01) and 1.37 times (p<0.01), respectively. All the NMR (−11.1% vs −10.8%), IMR (−9.4% vs −9.3%) and U5MR (−7.8% vs −7.7%) per 1000 livebirths had decreased faster in poor areas than those in non-poor areas. Although disparities remained between areas, the impacts of MCH-PA programmes on closing the gaps in child survivals across Yunnan were significant (p<0.01) (table 2) which were showed obviously with the estimated change trend of NMR, IMR and U5MR from 2015 to 2020 (figure 2).
Between 2015 and 2020, the prevalence rate of child underweight had significantly decreased in both poor areas (from 1.8% to 1.3%) and non-poor areas (from 2.0% to 1.5%), however, the prevalence rate of child stunted had only decreased in non-poor areas (from 1.9% to 1.4%). Oppositely, the percentages of children who were either overweight (from 0.4% to 0.5%) or obese (from 0.2% to 0.3%) had increased in poor areas at an annual rate of 0.1%, whereas there were no significant changes in non-poor areas. But children in non-poor areas were more likely to be stunted, overweight or obese, compared with their counterparts in poor areas (p<0.01). Moreover, the proportions of anaemic children had decreased from 25.3% to 18.2% (annual rate of decline −1.2%) in poor areas of Yunnan during the same time period (table 2).
Discussions
Ending poverty in all its forms is the first goal of UN SDGs.1 Nearly 20 million people in China were victims of poverty or had returned to poverty because of illness in 2015, which accounted for 44.1% of the total number of poor population.11 The poverty headcount ratio in rural China was 5.7% in 2015,21 whereas the prevalence rates of poverty among women of childbearing age (15–59 years) and children under 5 years in rural Yunnan in the same year were 7.83% and 5.92%. The poverty headcount ratios among women and child being higher than the national average level indicated a greater impact of poverty on women and children in Yunnan. Our systematic assessment in Yunnan provides evidence of the positive effects of launching health programmes on preventing households from being trapped in or returning to poverty by decreasing maternal and child mortality and morbidity, as well as avoiding the catastrophic medical expenses because of illness, which is an important feature of China’s poverty alleviation efforts and an useful measure to win the battle against poverty for whole China.
Remarkable progress in equitable maternal and child survival has been achieved in Yunnan, which is not only an outcome, but an essential component of poverty reduction. The MMR fell to 12.42 deaths per 100 000 livebirths and under-5 mortality rate fell to 6.89 deaths per 1000 livebirths in 2020 in Yunnan, which had been below the national average for three consecutive years.22 While the inequality in maternal mortality between poor areas and non-poor areas has disappeared, the gaps in child mortalities (including neonatal, infant and under-5 child) across Yunnan have also been closing. The proportions of maternal deaths due to obstetric haemorrhage, neonatal and infant deaths due to preterm birth and low birth weight, and the preventable maternal deaths had decreased in poor areas between 2015 and 2020. China’s efforts to improve maternal and child survival have been extraordinary and coherent. The progress presented by this research is not only past-depended but also boosted by China’s Targeted Poverty Alleviation Strategy. Yunnan, as one of the most underdeveloped provinces in China, owned the most impoverished counties in 2014.16 The mountainous environment, cultural diversity and weak service delivery at primary level of Yunnan made people living in poor areas face a range of interrelated cultural, financial, geographical and institutional barriers in seeking formal healthcare.7 To defeat the vicious cycle of poverty and illness, especially among vulnerable populations like poor women and children, a series of MCH-PA programmes have been introduced in Yunnan to strengthen MCH system in poor rural areas by building infrastructures, improving human resources, expanding service coverage and providing financial protection.13
The huge investments in the constructions of emergency obstetric care centre and emergency newborn care centre with the referral pathway across provincial, prefecture and county levels in Yunnan have guaranteed the timely rescue service providing to the pregnant and newborn in risk. To identify the high-risk pregnancy as early as possible, counterpart assistance programmes and special training had been conducted at primary level for MCH human resource capacity building in rural Yunnan.23 Hence, the densities of licensed doctors, nurses, obstetricians and midwives, as well as township MCH workers and female village doctors had been increased substantially in poor areas between 2015 and 2020. The gaps had been narrowed not only in the quantity of health staff but also in the quality of them. There are now more township MCH workers with bachelor degree and female village doctors with high school degree in poor areas than those in non-poor areas. Township MCH workers and female village doctors play very important roles in MCH system who mainly participate in MCH programme implementation at primary level and special service provision such as birth companion and waiting room services for pregnant women at high risk in remote and poor areas.24 With the increase of both quantity and quality of MCH human resources, our DID statistical models showed the positive effect of MCH-PA programmes on expanding MCH service coverage in poor areas. Except for the proportions of facility birth, caesarean section, antenatal visit and postnatal visit which had achieved the national average,22 the proportions of prenatal screening and newborn diseases screening had increased in both poor and non-poor areas to prevent birth defects, but much faster in poor areas. Otherwise, MCH-PA programme such as nutrition improvement for poor children, folic acid supplementation for poor pregnant women, and cervical and breast cancer screening for rural women at childbearing age had been delivered and enlarged in poor areas to prevent diseases or identify diseases at an early stage, thus improving health among targeted populations.25 26 The percentages of underweight children and anaemic children in poor areas of Yunnan had been decreased significantly between 2015 and 2020. Accessibility to essential health services is also improved by providing health insurance and financial assistance schemes.27 With supports from MCH-PA programmes, all registered poor women and children are covered by a three-tiered financial protection strategy. The out-of-pocket payments for inpatient care for poor women and children with cancer or heart disease had been considerably decreased to 10% of total medical expenses which may greatly help them access high-quality treatments and avoid catastrophic medical expenses.28
Despite impressive progress in maternal and child survival has been made in Yunnan, the current research points out that insufficient MCH system inputs, unmet needs and poor health outcomes still remain in small parts of poor areas in Yunnan. To maintain what have been achieved, the current MCH-PA programmes should be continued and enhanced for a sustainable improvement in accessibility to and affordability of high-quality MCH services, which may be one of the main focus areas of rural revitalisation after Chines government announced that all 98.99 million impoverished rural residents have been lifted from absolute poverty according to the current poverty line by 25 February 2021.29 In this study, we found while the proportion of underweight children had decreased, the proportions of overweight (0.5%) and obese (0.3%) children had increased in poor areas in Yunnan. Although there was not a change, the proportions of overweight (1.4%) and obese (0.7%) children in non-poor areas were much higher than those in poor areas. Childhood obesity often start children on the path to health problems like diabetes, high blood pressure and high cholesterol.30 Living in a healthy lifestyle including enough activity and limited calories from food and drinks is what parents and children should be told through health education campaigns to prevent childhood obesity.31
Some interesting facts were found in this study. While the numbers of live births increased in some areas mainly because of the universal two-child policy after 2015, there was a slight decrease trend in the numbers of live births in more areas between 2015 and 2020. To earn a living and shrug off poverty, there were more and more young rural–urban migrants in Yunnan, which could be an explanation of less babies born during the same period.32 The next step towards rural revitalisation will involve upgrading economic activities and creating new jobs for young people in rural areas, which will be a long-term mechanism for stable poverty elimination.33 Otherwise, we found the decrease trends in the numbers of facilities providing delivery services and caesarean sections in non-poor areas between 2015 and 2020. The Amended MCH Services Policy of Yunnan Province issued 31 July 2019 re-emphasise that only the qualified health facility and staff can provide MCH services, with a legal permit.34 To ensure the safeties of pregnant women and newborns, some of the health facilities at primary level had to strengthen their capacities to provide obstetric services.4
Our assessment was comprehensive and systematic, but the study design might have some limitations. First, mortality estimates were mainly based on the data from Yunnan Maternal and Child Health Routine Reporting System, which was possible for under-reporting of maternal and child deaths.4 Especially, the deaths which had been missed were more likely to occur in the poor areas far away from health facilities, where people might die at home without recording. Second, the statistical standards had been changed in some of the indicators of MCH service coverage in 2018, such as the proportions of five and more antenatal visits, first trimester antenatal visits, postnatal visits and newborn visits. The updated statistical standards strictly require the timely full coverage, which means that only the MCH service provided in a specific time period can be counted.35 Third, due to lack of some key variables at county level or township level such as maternal illiteracy rates which are related with both poverty and health,36 37 some potential confounders were not controlled to adjust for DID estimations of MCH-PA programmes. Otherwise, MCH programmes which were ended before 2017 could have underscored the effect of the MCH-PA programmes implemented after 2017. Thus, caution is needed in the interpretation of the effects of MCH-PA programmes on MCH indicators mentioned above across Yunnan between 2015 and 2020 provided by this study.
Yunnan Province, as the main battlefield against poverty in China, has achieved remarkable progress in equitable MCH, which is an essential component of great success in poverty alleviation in China. The practices in Yunnan have showed the Chinese model in ending poverty with health programmes, which may be summarised as firm commitment and determined leadership from the government at all levels, people-centred and problem-oriented health system strengthening, detailed and long-term health strategy blueprint, and social mobilisation and participation. China has its own poverty alleviation policies, derived from theory to practice and based on its own national conditions, which can provide new perspectives and useful references for other countries and regions in their battle against poverty.33
Data availability statement
Data are available in a public, open access repository. Data used in this study are available in Yunnan Maternal and Child Health Routine Reporting System, Yunnan Health Statistical Yearbooks, Yunnan Statistical Yearbooks and Yunnan Social Medical Insurance Reimbursement Datasets.
Ethics statements
Patient consent for publication
Ethics approval
This study does not involve human participants and ethical approval was not required.
Acknowledgments
We are grateful to the members of the Chinese Peasants and Workers Democratic Party, the People’s Government of Yunnan Province and the Health Commission of Yunnan Province for data collection.
Supplementary materials
Supplementary Data
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Footnotes
Contributors YH designed the research protocol, constructed the database, developed the DID statistical model, interpreted the results and drafted the article. XX and YW assisted with protocol design and development, data extraction and synthesis, results interpretation, and article revision. QY, ZY, LX, SC, HL, FW, YC and DZ were involved in compiling database, doing data analysis and producing tables and graphs. QZ, JZ and GG assessed the database, reviewed results and revised article. YL is the guarantor of this article who proposed the study and oversaw database construction, models establishment, results interpretation and article revision. All authors reviewed and approved the final submitted version.
Funding This work is supported by Kunming Medical University (2021YNPHXT02).
Disclaimer The views expressed are those of the authors and do not necessarily reflect the views of the Chinese Peasants and Workers Democratic Party or the People’s Government of Yunnan Province.
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.