Analysis of The Fairness of Child Health Services In China 2010-2019

Background: The imbalance of child health services caused by the huge income gap between urban and rural residents and uncoordinated regional development has become increasingly prominent. This article analyzes the basic situation and equity of child care services in China from 2010 to 2019. Methods: Evaluate the equity of child health services by concentration index. Results: From 2010 to 2019, neonatal visit rate and system management rate of under-three children in Chinese child health service projects showed an upward trend, and the perinatal mortality rate decreased. The perinatal mortality rate is the highest in the western region, and the level of child health services in the central region is lower than the national average, but the gap between regions has gradually decreased. Child health services concentrate in provinces with high economic levels, and the perinatal mortality rate is the most unfair. Conclusion: The decline in the mortality rate of under-ve children is related to the improvement in the child health services. We should improve the health services of perinatal infants and pay attention to the health of children aged 1 to 4 years. The fairness of child health service is affected by the two-child policy. We should rationally allocate resources and strengthen support for the central and western regions.


Background
Implementing program of national basic public health services is one of the ve major contents of Chinese New Medical Reform. It is of great signi cance for the transformation of the health service model from disease-centric to health-centric, implementation of the prevention-oriented working policy and "Healthy China" Strategy 1 . As an important part of Chinese basic public health services, child health services can reduce children's morbidity and mortality and improve the health level of all society. Since child health services were provided in China, the level of children's health has improved signi cantly.
However, the imbalance caused by the large income gap between urban and rural residents has gradually become prominent.
This article analyzes the basic situation and fairness of China child health services from 2010 to 2019, and its correlation with the under-ve mortality rate, and nds problems in comprehensive comparisons and put forward targeted suggestions to provide reference to improve the fairness of child health service. Methods

Data sources and evaluation indicators
The article collects relevant data on the economic level and child health of 31 provinces (No statistics on Hong Kong, Macao and Taiwan regions) in the China Statistical Yearbook, China Health Statistics Yearbook and China Health and Family Planning Statistical Yearbook from 2011 to 2020. After processing and sorting, the data needed is obtained (see Additional le 1). The article uses per capita GDP as a measure of the economic level of each province, uses neonatal visit rate, perinatal mortality rate, and system management rate of under-three children as indicators to evaluate child health services 2 , and uses the mortality rate of under-ve children as a result indicator of child health services.
According to the classi cation in the China Health Statistics Yearbook, the article divides Chinese 31 provinces into three regions-eastern, central and western region, in order to compare the differences of child health services in different regions 3 .

Evaluation method
Concentration index (CI), one of measurement methods of the fairness, is often applied to the fairness study of health service utilization in the health eld 4  The value range of CI is [-1,1]. A positive result indicates that child health services concentrate in provinces with high economic levels with an unfair tendency towards high-income groups. A negative result indicates that child health services concentrate in provinces with low economic levels with an unfair tendency towards low-income groups. The greater CI absolute value, the greater the unfairness of child health services. The closer CI absolute value is to 0, the more equitable child health services are 6 .
The indicators in the eastern, central, and western regions are averaged after weighted by the number of live births in each province.  Table 1 and Fig. 1, neonatal visit rate and system management rate of under-three children have increased signi cantly, but growth slowed or declined from 2015 to 2018.The perinatal mortality rate and mortality rate of under-ve children showed a downward trend, with the largest decline from 2011 to 2013. The perinatal mortality rate increased from 2015 to 2016.  Figure 2, Figure 3 and Figure 4, the neonatal visit rate and system management rate of under-three children showed an upward trend, and the perinatal mortality rate decreased. The neonatal visit rate and system management rate of under-three children in the central and western region increased signi cantly. The perinatal mortality rates in the three regions all have decreased signi cantly. The perinatal mortality rate of the western region and the eastern region is at a low level while that of the central region is at a high level in the country. The other two indicators of the central region are below the national level, while those of the western region and the eastern region are above the national level. The gap between regions has been narrowing and gradually approaching the national level, but there is still a certain gap between the central and western regions and the eastern region. From Table 3 and Figure 5, it can be seen that CI of neonatal visit rate in China from 2010 to 2019 is 0.007 ~ 0.04, and CI of system management rate of under-three children is 0.01 ~ 0.07, indicating that neonatal visit and system management rate of under-three children concentrated in provinces with high economic level. CI of perinatal mortality rate was -0.07 ~ -0.13, which was negative, indicating that perinatal mortality concentrated in provinces with low economic level. From the perspective of vertical development trend, CI of neonatal visit rate and system management rate of under-three children generally decreased, but slightly increased from 2016 to 2018. The absolute value of CI of perinatal mortality rate showed a uctuating downward trend from 2010 to 2014, but it increased signi cantly from 2014 to 2015, and then decreased slightly. In addition, through the horizontal comparison of the absolute values of these three indicators, it is found that CI of perinatal mortality rate is the highest, and CI of neonatal visit rate is the lowest, indicating that health services for perinatal infants are the most unfair, and the fairness of neonatal visit rate is the best. Discussions From 2010 to 2019, neonatal visit rate and system management rate of under-three children increase generally, and perinatal mortality rate decreases generally, indicating that child health services are gradually improving. Neonatal visit is the regular health check of the newborns by community medical staff, early detection of abnormalities and diseases, and popularization of scienti c parenting knowledge to the mothers and their families during the visits. According to the case of each newborn and parturient, individualized guidance is given to the parturient to do well in newborn feeding, nursing and disease prevention, which has a positive effect on reducing the morbidity and mortality of the newborn and promoting the healthy growth of the newborn 7,8 . System management of under-three children is that under-three children receive growth testing or physical examination, common disease prevention and other health management systems, which promotes the early intelligent physical development and reduce common diseases 9 . Perinatal death refers to stillbirths and neonatal deaths from 28 weeks of pregnancy to the 7th day after birth 10 . According to Fig. 1, it can be found that the mortality rate of under-ve children declines slower than that of the perinatal infants. This suggests that the reduction in the deaths of children under 5 in China is more due to the decrease in children aged 1 to 4, and there is still a large room for perinatal deaths to decline. Therefore, vigorously conduct neonatal visit and child system management services to reduce perinatal mortality can reduce the mortality rate of under-ve children.
Previous studies 11 have found that the death of perinatal infants is closely related to perinatal health care, the quality of obstetrics and pediatric diagnosis and treatment services, regional economic levels, social and cultural background, and geographical transportation. The perinatal health care system in the western region is imperfect, and the economic level has affected the accessibility of maternal health services, resulting in a low proportion of pregnant women receiving prenatal education and prenatal examinations. Pregnant women in these areas have higher pregnancy risks and lack of health care awareness, which affects the safety of mothers and babies. The reduction of perinatal mortality is closely related to the development of maternal health services, which requires relevant departments to improve maternal health care, and strengthen the screening and management of high-risk pregnant women and birth defects 12  indicating that the fairness of child health services continues to improve. This is related to policy of increasing capital and human input and promoting the equalization of basic public health services. However, the index increased slightly from 2014 to 2019, and the absolute value of CI of perinatal mortality rate in 2017 even reached the highest value in a decade, indicating that the fairness of child health services from 2014 to 2019 has not been further improved. This is related to the implementation of the separate two-child policy in 2013 and the implementation of the comprehensive two-child policy in 2015 13 .The two-child policy has increased the number of children the demand for child health services. However, nowadays resources of child care health are insu cient and high-quality resources are inclined to developed areas, resulting in inequality 14 . After the implementation of the two-child policy, the incidence of high-risk pregnant women has increased signi cantly in both developed areas and undeveloped areas 15 , which puts forward higher requirements for child health services. Developed areas have abundant medical service resources, which can still cushion the impact of the two-child policy, but undeveloped areas lack medical resources, and the contradiction between supply and demand brought about by the two-child policy is more prominent, which lead to increased unfairness of child health services between regions. Therefore, government should allocate health resources based on the needs of maternal and child health care, and appropriately tilt to the central and western regions. It is also found that the unfairness of perinatal mortality is the highest. The reason is that the perinatal mortality rate will be affected by the quality of maternal health care services, and the in uencing factors are di cult to control, such as birth defects and preterm birth factors, will lead to death of the perinatal infant. One of the keys to preventing perinatal death lies in the level of diagnosis and treatment technology in obstetrics and pediatrics. Areas with high economic levels have high medical standards and effective prevention and treatment, which keeps the perinatal mortality rate at a low level, while areas with low economic levels are just the opposite, which further highlights the unfairness of perinatal mortality.

Conclusions
The decline in the mortality rate of under-ve children is related to the improvement of child health services. The perinatal mortality rate in the western region is the highest, and the level of child health services in the central region is lower than the national average, but the gap between regions has gradually decreased Child health services concentrate in provinces with high economic levels, and fairness is affected by the two-child policy. Among them, the unfairness of perinatal mortality is the highest.

Abbreviations
Concentration index -CI

Declarations
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