Mortality in China: Data Sources, Trends and Patterns

Abstract

While China has continued to make impressive progress in lowering its mortality, there are few detailed studies on how has this happened, on the major characteristics of Chinese mortality in comparison to many other countries, or on the major lessons learned from China’s mortality decline. This is partly because mortality studies in China have long been overshadowed by those on fertility, and is also partly attributable to lack of knowledge and limited accessibility of some mortality data.

This chapter aims to fill some of these gaps. It starts with a systematic review of China’s major mortality data collected by different government departments, and the purposes and methods of collecting these data. It then examines mortality data gathered from different sources and evidences their differences and similarities. On the basis of this analysis, this chapter further examines China’s recent mortality decline, the differentials between urban and rural areas, and changes in major causes of death.

Concluding Remarks

During the past six decades, mortality in China has declined considerably. The progress was particularly impressive in the first 30 years of Communist rule, with the exception of famine periods. While levels of economic development and standards of living were both low, rapid improvement in population health and mortality was widely observed in the country. This experience offers valuable lessons for other less developed countries. In the 1980s and 1990s, China’s mortality decline began to slow down. There were two reasons for this. First, the country was entering a new stage of the epidemiologic transition and faced new and very different health challenges. Second, during this period, China’s profound social and economic reform led to some negative impacts on population health and longevity, and China gradually lost the relative mortality advantage gained in previous decades. The Chinese government recognized these negative impacts and made substantial efforts to overcome them. Its achievements in maintaining rapid economic growth, raising people’s standards of living, alleviating poverty, and re-establishing a nationwide medical care insurance system have been particularly notable. They have helped to speed up the improvement in mortality in recent years. China has made a major contribution to the world mortality decline by raising the life expectancy of nearly a quarter of the world’s population and by offering useful experience of lowering mortality in a less developed country.

While China has been very successful in lowering mortality, there is little detailed knowledge of how this has been achieved, and its mortality transition is still poorly documented. In comparison with the investigation into fertility changes and family planning, studies of mortality decline have not received high priority. While hundreds of papers on China’s fertility, migration, or population ageing have been published in the last decade, research on mortality changes in the country has been rather limited. This is partly because detailed mortality data are difficult to find or access. As documented in Section  11.2 of this chapter, compared with many other countries in the world, China has made considerable efforts to collect morbidity and mortality data. Some of these data are of good quality, and could become very important data sources for mortality research. A major challenge is to make these data available to researchers and to use them more efficiently. There is an urgent need to further improve mortality data collection, to extend their dissemination and use, and to enhance their quality.

China’s long-term mortality decline started nearly a century later than that of many developed countries. But its mortality transition has been faster and is an illustration of the “accelerated model” of epidemiological transition (Omran 1971).

According to United Nations estimates, by 1990 China had already narrowed its life expectancy gap with respect to more developed countries from some 20 years in the early 1950s to about 5 years. This gap was further narrowed to about 2.5 years in 2010 (UN-WPP 2012). China has already entered the stage of delayed degenerative diseases or the fourth stage of the epidemiologic transition, as suggested by Olshansky and Ault (1986). The country is now facing many unprecedented health challenges. In the next 10–20 years, China’s working-age population will decline, and this will have major impacts on the sustainability of economic growth. The number and proportion of old people will increase rapidly. This may lead to an increase in the incidence of degenerative and other diseases and in demand for medical services and care. Even though China now has medical insurance programmes that cover almost its entire population, the quality of care and the level of insurance provided by these programmes vary significantly. On average they are notably lower than those in many developed countries. In addition, the health impacts of social and income inequalities will remain a major obstacle for raising the health status and longevity of poor and disadvantaged populations. Overcoming these difficulties is of great importance if China is to write another successful chapter in the history of improving mortality.

Inset 11.1. Health System Reforms

Since 1949, China has gone through two distinct phases: the hardline socialist era, marked by a quest for social equality (1950–1970s), and the liberal era, which saw a transition toward a socialist-style market economy (1980–1990s), and during which two crucial reforms were implemented: the decollectivization of agriculture and the restructuring of state-owned enterprises. Hitherto, collective institutions had taken charge of every Chinese person from cradle to grave. By disrupting overall social organization, the dismantling of those institutions had repercussions well beyond the economic sphere. Previously, each citizen, through his or her work unit, was strictly dependent on the state in all areas of everyday life: employment, housing, health, child education, retirement, social insurance, and so on. By taking apart its collective structures, the state has, in effect, partially or totally handed over to the private sector a set of functions that it could no longer perform.

Public service, as developed by Mao Zedong in the 1950s and 1960s, was informed by the principles of egalitarianism and massification. The focus was on public health, with three main goals: rapid improvement of access to healthcare; prevention and mass campaigns; and creation of a comprehensive insurance system. Priority was assigned to training medical workers in charge of dispensing primary care, and to pharmaceutical production. This strategy enabled China to achieve remarkable progress—notably in combating infant mortality and improving life expectancy at birth. In less than three decades, rural areas were provided with infrastructure offering access to primary healthcare for all local residents. By the eve of the reforms, mass vaccination campaigns, most notably against the most lethal childhood diseases, had eradicated large-scale epidemics and the worst health scourges. A number of community initiatives, such as sewer construction, were taken to improve sanitation standards. Drawing inspiration from the Soviet system, China established centres for disease and epidemic prevention supervised by the Health Ministry in various regions.

As with birth control, the health policies implemented from the 1950s onward owe their success largely to China’s administrative organization. After the agrarian reform, collective property and central control by different echelons of government became the predominant mode of social and political organization, and the healthcare system was modelled on the administrative system. At that time, public hospitals charged for procedures and medicines, but the state-set prices were affordable for most people.

During the Cultural Revolution, which began in 1966, the role of Party leaders and the bureaucracy was reassessed. The widening disparities between urban and rural areas, between intellectuals and manual workers, and between Party leaders and the people were among the major dysfunctions denounced by Mao Zedong. In a directive of 1965, he reproached the Health Ministry for giving precedence to city-dwellers and neglecting the needs of the peasantry. In the years that followed, tens of thousands of urban healthcare workers were sent to the countryside on a permanent basis or as part of mobile medical teams. In 1975, rural areas numbered 1.6 million “barefoot doctors” who, despite their shoddy medical training, achieved a substantial improvement in health conditions and public hygiene.

A few years after Mao Zedong’s death, the Chinese experienced a decisive turning-point in their lives: the advent of economic reforms. The outstanding productivity gains that they generated have led to sizable improvements in real income, nutrition, and housing, and hence a decline in overall poverty. But it is mainly the urban populations of the eastern coastal areas that have benefited from this progress. At the national level, inequality has widened, and economic growth has not favoured an acceleration of the health transition. Once under the responsibility of people’s communes, the healthcare system is now decentralized, and has ceased to operate as a public service: patients are required to pay for treatment, while doctors and hospital managers must meet profitability criteria, making medical care unaffordable for the poorest citizens. Inequalities now exist not only in access to healthcare, but also in the quality of care.

In fact, the overall health status of the population has only improved marginally since the start of economic reform. A decline in the effectiveness of preventive and remedial care seems to have partially cancelled out the improvements brought by the general rise in living standards. Nearly everywhere, medical insurance, when it exists, covers only minor expenses, and families must pay for most of their medical costs.

Increasingly aware of the problems created by the transfer of welfare-state functions to the private sector, the government has recently conducted a major review of its health policies and introduced several embryonic reforms.

I.A.