Introduction
After the founding of the People’s Republic of China in 1949, maternal and child health (MCH) was within a few years put on the agenda of the Chinese Government. In the early 1970s, family planning programs were launched throughout the country. Since the early 1980s, “to implement family planning, control population growth and improve the life quality of the population” became a basic state policy, which was enshrined in the Constitution promulgated in 1982. Since the 1970s, the two national networks of MCH and Family Planning have long addressed sexual and reproductive health services, through joint or complementary actions, in collaboration with other agencies (Information Office of the State Council, 1995).
Prior to the mid-1990s, China harshly implemented a strict population control policy. A top- down approach focused on controlling the birth-rate and emphasised the quantitative demographic goals and birth quotes. A system of “one-vote veto” was initiated and the performance of the local ‘head’ of the Party and the government would be voted against if they failed to meet their population control targets. During the high tides of the family planning campaign, local family planning staff resorted to violence, coercion and other abuses, including forced abortions, sterilisation, IUD insertion, and even tearing down houses or confiscations in some places in the countryside (Xie and Tang, 2008:6).
Not surprisingly, equality, quality and accountability (EQA) in sexual and reproductive health and rights (SRHR) has seldom been considered seriously. For instance, every expectant mother needed a birth permit, otherwise her child was not entitled to state preferential medical, food, housing and educational benefits, and extra allocations of land in rural areas (Conly and Camp, 1992:23). In rural areas, married women were regularly inspected to check if they were pregnant, even well into their 40s and 50s. To achieve demographic targets, local family planning staff developed some measures such as to insert IUDs for couples who had had their first child and to perform sterilisation for those who had had a second child. A woman who had given birth to unlicensed children might suffer forced abortions, even late-term abortions, and sterilisations as well as escalating financial penalties known as the “social compensation/upbringing fee” (Conly and Camp, 1992: 8-9; Xie, 2011: 6). The priority of population control apparently often overrode respect for women’s and men’s needs, rights, and dignity (Xie and Tang, 2008: 2-3).
Following the International Conference on Population and Development (ICPD) in 1994 and its path-breaking outcome document, Program of Action (PoA), which was described as a “paradigm shift” in population policy because of its overarching human rights frame and emphasis on the interconnections of sexual and reproductive health, gender equality, women’s empowerment, and poverty reduction; China gradually started to reform population and development polices. Led by the State Family Planning Commission established in 1984, a holistic approach to addressing SRHR was strengthened. The quality of care (QOC) campaign became a catalyst to translate some new international concepts into practices.
Despite great progress over the past 25 years, gaps in SRHR between the most advantaged and least advantaged populations remain. The convergence of globalisation, urbanisation, large- scale migration, along with the influences of mass media, have reshaped the demographic landscape, as well as opportunities and perils for sexual and reproductive health among Chinese people, particularly marginalised groups.2 So far, a large percentage of the population remains vulnerable and excluded from access to quality sexual and reproductive health services. They include the left-behind women in poor rural areas, rural-urban migrants, and particularly sexually active young people.3
Since the early 1990s, China has actively engaged in global health governance. The Chinese Government has aligned its 13th Five-Year Plan with the 2030 Sustainable Development Goals (SDGs). Health has become an explicit priority with the approval of the Healthy China 2030 Planning Outline launched in October 2016. This strategic plan, with its focus on social equity and justice, offers a rare opportunity to make a difference in promoting a healthy life for all. It demonstrates the Government’s tremendous political will in investing in health and fulfilling the SDGs.
Meanwhile, the Chinese Government kicked off the two-child policy nationwide at the end of 2015. More women of advanced age have been seeking to have their second child, which is associated with a range of adverse pregnancy outcomes. As indicated by official data, there was an increase in the maternal mortality rate in rural areas, which rose from 20 per 100,000 live births in 2016 to 21.1 per 100,000 live births in 2017 (National Bureau of Statistics, 2018). In 2017, the number of live births born in the hospital was 17.58 million, and the percentage of second child accounted for 51% (National Health Commission, 2018). In 2016, pregnant women with high risks accounted for 24.7% (National Commission on Health and Family Planning and China Population and Development Research Center, 2018:253). Safe motherhood and postpartum contraception thus became a new challenge for improving availability, accessibility and quality of reproductive health care.
It is timely to take account of EQA in monitoring the progress, identifying gaps and improving the delivery of services. However, there has been little scholarly literature linking these three dimensions in SRHR. We know even less about their intersections in the real world.
Reproductive health policies and practices urgently require a thorough analysis of these key factors.
This case study seeks to fill the gap by examining the state of EQA in SRHR in China. It tries to answer the following three questions applying EQA framework: (1) What have been the changes in SRHR related laws and policies over time? (2) What has been achieved and what are the major challenges? and (3) How can China deal with the gaps? Drawing on available official statistics, population-based studies and academic work, this case study scrutinises the realities of EQA in China since the mid-1990s beyond the political rhetoric.
This case study primarily focuses on maternal and child health and family planning policies and practice in China, the two priority issues that have topped the government agenda. There is adequate data and evidence for the in-depth analysis.
2 Since the 1980s China has experienced rapid urbanisation, with the proportion of urban residents increasing from 21.1 per cent in 1982 to 59.6 percent in 2018 (National Bureau of Statistics, 2019). Along with urbanisation, China has witnessed a large-scale internal migration from rural to urban areas, from the western and central to the eastern regions over the past four decades. By end of 2017, there were a total of 287 million rural migrants, accounting for more than one-fifth of the total population, with migrant women accounting for more than one third (34.4%) of them. Notably, more than half of them (50.5%) were the new generation of migrant workers born after 1980(National Bureau of Statistics, 2018a)
3 According to China’s sixth census in 2010, China has approximately 300 million young people aged 10-24, more than one fifth of the total population. An increasing number of vulnerable youth population is exposed to a variety of reproductive health risks, including unsafe sex, unplanned pregnancies, sexually transmitted infections including HIV/AIDS, and gender-based violence. Severe inequalities have been embedded also in the shortage and unequal distribution of human and financial resources for their reproductive health.