Under-5 mortality in 2851 Chinese counties, 1996-2012: a subnational assessment of achieving MDG 4 goals in China.
BACKGROUND
In the past two decades, the under-5 mortality rate in China has fallen substantially, but progress with regards to the Millennium Development Goal (MDG) 4 at the subnational level has not been quantified. We aimed to estimate under-5 mortality rates in mainland China for the years 1970 to 2012.


METHODS
We estimated the under-5 mortality rate for 31 provinces in mainland China between 1970 and 2013 with data from censuses, surveys, surveillance sites, and disease surveillance points. We estimated under-5 mortality rates for 2851 counties in China from 1996 to 2012 with the reported child mortality numbers from the Annual Report System on Maternal and Child Health. We used a small area mortality estimation model, spatiotemporal smoothing, and Gaussian process regression to synthesise data and generate consistent provincial and county-level estimates. We compared progress at the county level with what was expected on the basis of income and educational attainment using an econometric model. We computed Gini coefficients to study the inequality of under-5 mortality rates across counties.


RESULTS
In 2012, the lowest provincial level under-5 mortality rate in China was about five per 1000 livebirths, lower than in Canada, New Zealand, and the USA. The highest provincial level under-5 mortality rate in China was higher than that of Bangladesh. 29 provinces achieved a decrease in under-5 mortality rates twice as fast as the MDG 4 target rate; only two provinces will not achieve MDG 4 by 2015. Although some counties in China have under-5 mortality rates similar to those in the most developed nations in 2012, some have similar rates to those recorded in Burkina Faso and Cameroon. Despite wide differences, the inter-county Gini coefficient has been decreasing. Improvement in maternal education and the economic boom have contributed to the fall in child mortality; more than 60% of the counties in China had rates of decline in under-5 mortality rates significantly faster than expected. Fast reduction in under-5 mortality rates have been recorded not only in the Han population, the dominant ethnic majority in China, but also in the minority populations. All top ten minority groups in terms of population sizes have experienced annual reductions in under-5 mortality rates faster than the MDG 4 target at 4.4%.


CONCLUSIONS
The reduction of under-5 mortality rates in China at the country, provincial, and county level is an extraordinary success story. Reductions of under-5 mortality rates faster than 8.8% (twice MDG 4 pace) are possible. Extremely rapid declines seem to be related to public policy in addition to socioeconomic progress. Lessons from successful counties should prove valuable for China to intensify efforts for those with unacceptably high under-5 mortality rates.


BACKGROUND
National "Twelfth Five-Year" Plan for Science and Technology Support, National Health and Family Planning Commission of The People's Republic of China, Program for Changjiang Scholars and Innovative Research Team in University, the National Institute on Aging, and the Bill & Melinda Gates Foundation.
National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
Yanping
Y
Wang
National Center for Birth Defect Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China.
Xiaohong
X
Li
National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
Maigeng
M
Zhou
Office for National Maternal and Child Health Statistics of China, School of Public Health, Peking University Health Science Center, Beijing, China; Department of Child, Adolescent and Women's Health, School of Public Health, Peking University Health Science Center, Beijing, China.
Shusheng
S
Luo
National Office for Maternal and Child Health Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Juan
J
Liang
Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
Chelsea A
CA
Liddell
Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
Matthew M
MM
Coates
Office for National Maternal and Child Health Statistics of China, School of Public Health, Peking University Health Science Center, Beijing, China; Department of Child, Adolescent and Women's Health, School of Public Health, Peking University Health Science Center, Beijing, China.
Yanqiu
Y
Gao
National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
Linhong
L
Wang
National Office for Maternal and Child Health Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Chunhua
C
He
Office for National Maternal and Child Health Statistics of China, School of Public Health, Peking University Health Science Center, Beijing, China; Department of Child, Adolescent and Women's Health, School of Public Health, Peking University Health Science Center, Beijing, China.
Chuyun
C
Kang
National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
Shiwei
S
Liu
National Office for Maternal and Child Health Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Li
L
Dai
Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
Austin E
AE
Schumacher
Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
Maya S
MS
Fraser
Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
Timothy M
TM
Wolock
Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
Amanda
A
Pain
Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
Carly E
CE
Levitz
Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
Lavanya
L
Singh
Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
Megan
M
Coggeshall
Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
Margaret
M
Lind
National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
Yichong
Y
Li
National Office for Maternal and Child Health Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Qi
Q
Li
National Office for Maternal and Child Health Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Kui
K
Deng
National Office for Maternal and Child Health Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Yi
Y
Mu
National Office for Maternal and Child Health Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Changfei
C
Deng
National Office for Maternal and Child Health Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Ling
L
Yi
National Office for Maternal and Child Health Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Zheng
Z
Liu
National Office for Maternal and Child Health Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Xia
X
Ma
Office for National Maternal and Child Health Statistics of China, School of Public Health, Peking University Health Science Center, Beijing, China.
Hongtian
H
Li
National Office for Maternal and Child Health Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Dezhi
D
Mu
National Office for Maternal and Child Health Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China; National Center for Birth Defect Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China. Electronic address: zhujun028@163.com.
Jun
J
Zhu
Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA. Electronic address: cjlm@uw.edu.
Christopher J L
CJ
Murray
Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
Haidong
H
Wang
D000367:Age Factors; D046688:Child Mortality / Q000266:history; D002675:Child, Preschool; D002681:China / Q000453:epidemiology; D040361:Healthy People Programs / Q000706:statistics & numerical data; D049673:History, 20th Century; D049674:History, 21st Century; D006801:Humans; D007223:Infant; D007226:Infant Mortality / Q000266:history; D007231:Infant, Newborn; D017059:Models, Econometric; D012959:Socioeconomic Factors