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National and regional under-5 mortality in China in the past two decades
Comment
National and regional under-5 mortality in China in the past two decades As one of the few countries that have achieved Millennium Development Goals 4 and 5, China has had a remarkable decline in under-5 mortality rate in past three decades. 1,2 Drivers of such rapid improvement in China have been widely discussed. In The Lancet Global Health, Chunhua He and colleagues3 report a decline in under-5 mortality rate in China at the national and regional level, and the level and trend of cause-specific mortality for under-5 age groups. Results presented in this study are important for China in the Sustainable Development Goal era and are of global relevance in guiding effective interventions and evidence-based decision making in other developing countries. As shown in He and colleagues’ study, major reductions have been observed for mortality due to neonatal tetanus, diarrhoea, and pneumonia from 1996 to 2015. By contrast, the decline in mortality due to concomitant congenital malformations and complications of preterm birth was lower. There are two possible reasons for the reductions: natural reduction or disappearance of the causative agent, and deliberate interventions or improvement in socioeconomic conditions of the population under investigation. Many researchers have argued that improvements in hospital delivery rate, nutrition, sanitary conditions, and medical services in general are the main contributing factors for the decline of mortality rates caused by neonatal tetanus, diarrhoea, and pneumonia in China.4–8 The relatively slower progress made in mortality due to congenital malformations and prematurity complications might be associated with worsening environmental conditions. 9 Identification of the major risk factors for death, reduction of the pathogenic effect, and implementation of early screening and intervention for these diseases are crucial to further improve survival and reduce health disparity in children younger than 5 years in China. There is, however, inconsistency in He and colleagues’ estimation of under-5 mortality rate at the national and region level. The authors have scaled the regional under-5 mortality rate estimates based on the Maternal and Child Health Surveillance System (MCHSS) to the national level estimates provided by UN Interagency Group on Child Mortality Estimation (UN IGME).
Although data from MCHSS play an important part in the estimation of under-5 mortality rate at the national level, UN IGME does use other sources of information such as censuses and the Annual Survey on Population Change. The authors might have benefited from use of multiple sources of information on under-5 mortality rate, such as the National Disease Surveillance Point System and the new population registry, especially at the subnational level. We encourage the authors to further their research on under-5 mortality rate and cause-specific mortality in the corresponding age groups by using state-of-art data synthesis methods and multiple sources of information to arrive at a more consistent and complete picture of health of the under-5 age group in China, nationally and subnationally. China’s achievement in reducing under-5 mortality rate has been widely recognised. Reporting of what China has achieved and the contributing factors to other developing countries to achieve the SDG goals on child health is crucial. However, a high level of disparity in both level and trend of under-5 mortality rate at the regional and county level still exists in China. The reduction in all-cause mortality in the western region of China was lower than that in the eastern and central region of China. Closing such gaps in subnational units within China requires strenuous efforts and investments from all levels of government in China. China needs to further improve its MCHSS to aid such efforts, for example by adding more sites across the country, as done previously for the Disease Surveillance Point system.
Lancet Glob Health 2016 Published Online December 19, 2016 http://dx.doi.org/10.1016/ S2214-109X(16)30360-6 See Online/Articles http://dx.doi.org/10.1016/ S2214-109X(16)30334-5
*Maigeng Zhou, Haidong Wang National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Xicheng District, Beijing 100050, China (MZ); Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA (HW) [email protected] We declare no competing interests. © The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND license. 1
GBD 2015 Child Mortality Collaborators. Global, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388: 1725–74.
www.thelancet.com/lancetgh Published online December 19, 2016 http://dx.doi.org/10.1016/S2214-109X(16)30360-6
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Zhou M, Wang H, Zhu J, et al. Cause-specific mortality for 240 causes in China during 1990–2013: a systematic subnational analysis for the Global Burden of Disease Study 2013. Lancet 2016; 387: 251–72. He C, Liu L, Chu Y, et al. National and subnational all-cause and causespecific child mortality in China, 1996–2015: a systematic analysis with implications for the Sustainable Development Goals. Lancet Glob Health 2016; published online Dec 19. http://dx.doi.org/10.1016/ S2214-109X(16)30334-5. UN System in China, Ministry of Foreign Affairs People’s Republic of China. Report on China’s implementation of the Millennium Development Goals (2000–2015). New York: United Nations Development Programme, 2015. Liang J, Li X, Dai L, et al. The changes in maternal mortality in 1000 counties in mid-western China by a government-initiated intervention. PloS One 2012; 7: e37458.
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He C, Kang L, Miao L, et al. Pneumonia mortality among children under 5 in China from 1996 to 2013: an analysis from National Surveillance System. PLoS One 2015; 10: e0133620. Wang H, Yan S, Teng H, et al. Analysis the effect of maternity and child health services project on reducing the mortality and morbidity rate in the poorest areas in China. Matern Child Health Care China 2003; 18: 398 (in Chinese). Zhang Y, Dai Y, Zhang S. Impact of implementation of Integrated Management of Childhood Illness on improvement of health system in China. J Paediatr Child Health 2007; 43: 681–85. Zhang J, Mauzerall DL, Zhu T, Liang S, Ezzati M, Remais JV. Environmental health in China: progress towards clean air and safe water. Lancet 2010; 375: 1110–19.
www.thelancet.com/lancetgh Published online December 19, 2016 http://dx.doi.org/10.1016/S2214-109X(16)30360-6
National and regional under-5 mortality in China in the past two decades As one of the few countries that have achieved Millennium Development Goals 4 and 5, China has had a remarkable decline in under-5 mortality rate in past three decades. 1,2 Drivers of such rapid improvement in China have been widely discussed. In The Lancet Global Health, Chunhua He and colleagues3 report a decline in under-5 mortality rate in China at the national and regional level, and the level and trend of cause-specific mortality for under-5 age groups. Results presented in this study are important for China in the Sustainable Development Goal era and are of global relevance in guiding effective interventions and evidence-based decision making in other developing countries. As shown in He and colleagues’ study, major reductions have been observed for mortality due to neonatal tetanus, diarrhoea, and pneumonia from 1996 to 2015. By contrast, the decline in mortality due to concomitant congenital malformations and complications of preterm birth was lower. There are two possible reasons for the reductions: natural reduction or disappearance of the causative agent, and deliberate interventions or improvement in socioeconomic conditions of the population under investigation. Many researchers have argued that improvements in hospital delivery rate, nutrition, sanitary conditions, and medical services in general are the main contributing factors for the decline of mortality rates caused by neonatal tetanus, diarrhoea, and pneumonia in China.4–8 The relatively slower progress made in mortality due to congenital malformations and prematurity complications might be associated with worsening environmental conditions. 9 Identification of the major risk factors for death, reduction of the pathogenic effect, and implementation of early screening and intervention for these diseases are crucial to further improve survival and reduce health disparity in children younger than 5 years in China. There is, however, inconsistency in He and colleagues’ estimation of under-5 mortality rate at the national and region level. The authors have scaled the regional under-5 mortality rate estimates based on the Maternal and Child Health Surveillance System (MCHSS) to the national level estimates provided by UN Interagency Group on Child Mortality Estimation (UN IGME).
Although data from MCHSS play an important part in the estimation of under-5 mortality rate at the national level, UN IGME does use other sources of information such as censuses and the Annual Survey on Population Change. The authors might have benefited from use of multiple sources of information on under-5 mortality rate, such as the National Disease Surveillance Point System and the new population registry, especially at the subnational level. We encourage the authors to further their research on under-5 mortality rate and cause-specific mortality in the corresponding age groups by using state-of-art data synthesis methods and multiple sources of information to arrive at a more consistent and complete picture of health of the under-5 age group in China, nationally and subnationally. China’s achievement in reducing under-5 mortality rate has been widely recognised. Reporting of what China has achieved and the contributing factors to other developing countries to achieve the SDG goals on child health is crucial. However, a high level of disparity in both level and trend of under-5 mortality rate at the regional and county level still exists in China. The reduction in all-cause mortality in the western region of China was lower than that in the eastern and central region of China. Closing such gaps in subnational units within China requires strenuous efforts and investments from all levels of government in China. China needs to further improve its MCHSS to aid such efforts, for example by adding more sites across the country, as done previously for the Disease Surveillance Point system.
Lancet Glob Health 2016 Published Online December 19, 2016 http://dx.doi.org/10.1016/ S2214-109X(16)30360-6 See Online/Articles http://dx.doi.org/10.1016/ S2214-109X(16)30334-5
*Maigeng Zhou, Haidong Wang National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Xicheng District, Beijing 100050, China (MZ); Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA (HW) [email protected] We declare no competing interests. © The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND license. 1
GBD 2015 Child Mortality Collaborators. Global, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388: 1725–74.
www.thelancet.com/lancetgh Published online December 19, 2016 http://dx.doi.org/10.1016/S2214-109X(16)30360-6
1
Comment
2
3
4
5
2
Zhou M, Wang H, Zhu J, et al. Cause-specific mortality for 240 causes in China during 1990–2013: a systematic subnational analysis for the Global Burden of Disease Study 2013. Lancet 2016; 387: 251–72. He C, Liu L, Chu Y, et al. National and subnational all-cause and causespecific child mortality in China, 1996–2015: a systematic analysis with implications for the Sustainable Development Goals. Lancet Glob Health 2016; published online Dec 19. http://dx.doi.org/10.1016/ S2214-109X(16)30334-5. UN System in China, Ministry of Foreign Affairs People’s Republic of China. Report on China’s implementation of the Millennium Development Goals (2000–2015). New York: United Nations Development Programme, 2015. Liang J, Li X, Dai L, et al. The changes in maternal mortality in 1000 counties in mid-western China by a government-initiated intervention. PloS One 2012; 7: e37458.
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He C, Kang L, Miao L, et al. Pneumonia mortality among children under 5 in China from 1996 to 2013: an analysis from National Surveillance System. PLoS One 2015; 10: e0133620. Wang H, Yan S, Teng H, et al. Analysis the effect of maternity and child health services project on reducing the mortality and morbidity rate in the poorest areas in China. Matern Child Health Care China 2003; 18: 398 (in Chinese). Zhang Y, Dai Y, Zhang S. Impact of implementation of Integrated Management of Childhood Illness on improvement of health system in China. J Paediatr Child Health 2007; 43: 681–85. Zhang J, Mauzerall DL, Zhu T, Liang S, Ezzati M, Remais JV. Environmental health in China: progress towards clean air and safe water. Lancet 2010; 375: 1110–19.
www.thelancet.com/lancetgh Published online December 19, 2016 http://dx.doi.org/10.1016/S2214-109X(16)30360-6