| It is a momentous objective for the entire human race to continuously improve the health status of women and children. From this perspective, to improve the health and nutrition status of women and children is not only to meet the essential rights of human beings to survival and good health, but also a necessary means to advance civilization of the society, and to realize social fairness and justice. The delivery of essential health and nutrition services for women and children will effectively improve the overall population quality of the nation, advance human resource development, as well as promote a well-balanced and coordinated social and economic development of the nation. Against the backdrop of ongoing health sector reform in China, the primary role of financing and governance for the delivery of public health and essential clinical services is gradually clarified to be government accountability. With safe, effective, convenient and affordable essential health and nutrition services for women and children being important components of the public health and essential clinical services, delivery of these services should be guaranteed and secured by the government. At current stage, the Government should further clarify its due roles and responsibilities in securingessential health and nutrition services for women and children, to adopt practical and effective policy measures and to raise sufficient funds, so as to meet the basic needs of women and children, to promote the health status of the citizens, and to realize health equity.After the People's Republic of China was founded, particularly since the economic reforms, tremendous improvementshave been achieved in health and nutrition status for women and children. The health and nutrition status, however, is yet to meet the requirements posed by economic and social development, as well as the actual needs of the people. Currently the government is not providing essential health and nutrition services for women and children in a systematic and comprehensive manner. Inadequate public financing and under-delivery ofcertain essential services results in high level of out-of-pocket payment by women and children in need, which is the root cause for inequity in service utilization and health outcomes. It is of paramount importance to define what services should be included in an essential package of health and nutrition services for women and children that the Government should secure at the current stage. Meanwhile, a number of questions remain unanswered:how the government should lead and reform the financing for the services, how to allocate the fund among different tiers of governments, how to choose provider payment schemes, and how to optimize public sector governance, so as to not only improve the overall health for women and children, but also to improve health equity among different socio-economic groups. The dissertation attempts to answer these questions, and provide proposals and recommendations in resolving the issues through both theoretical and practical analyses.The first chapter of the dissertation provides an overview on the research scope, methodologies, innovations and prospects. In the second chapter, it analyses the theoretical framework for the government to secure the delivery of essential health and nutritionservices for women and children. It discusses why these essential services should be secured by the government, how it fits the social fairness theory that the State should meet the needsfor women and children, including the most vulnerable ones, in their claims foressential health and nutrition services, the conceptual models for financing and governance of health and nutrition services for women and children, the theoretical framework for accountability of service delivery, etc.Chapterâ…¢offers a comprehensive analysis of the status quo forwomen and children's health and nutrition in China, with an emphasis on the existing challenges. Currently the status for woman and child health, measured mainly by maternal and child mortalities, is predominantly featured by the following two characteristics:(1)Evident room for improvement is still seen in maternal and childhealth:maternal and child mortality ratios are still to be further reduced; (2)Large disparities exist across geographical regions and amongst socioeconomic population groups:the mortality ratios are found to be negativelyrelated with the local GDP per capita, i.e. Significant geographic inequity in health outcome. In the area of maternal and child nutrition, due to the lack of comprehensive public interventions to address malnutrition, the overall situation is worrying, i.e., predominant child malnutrition still prevails in least developed rural regions, whilst the disparities increase over years between better off and less off regions. In general, a series of simple, inexpensive but effective nutrition interventionshave not been delivered, leaving manymaternal women and children unprotected from malnutrition and bad health risks, and inequity prevails. This problem of lack of available public services also leads to over-dependence on out of pocket (OOP) payment in utilization of necessary health and nutrition services by women and children, which eventually results in inequitable maternal health and nutrition outcomes.Chapterâ…£probes into the public finance factors that account for the inequity in health and nutrition outcomes. The author argues, the inequitable and inefficient public resource allocation should explain for the inequitable health outcome to alarge extent. Analyses of a large amount of local spending data revealthat, the inequitable allocation of public resources widely prevail across provinces, across prefectures and counties within provinces:On the one hand, the government resources are not always allocated based on needs for health and nutrition services by the citizens, but more according to the economic development status of the localities. This worrying trend is intensifying over the past decade. On the other hand, public resources are not allocated amongst population groups equitably either. In summary, pubic finance is not playing its due role in promoting resource redistribution and equalization of essential social services under the current market economy regime. In addition to the inequity problem, the government resources are not allocated efficiently either, i.e., resources allocation disproportionally favourstertiary clinical institutions, which are located in cities mostly, whilst primary care institutions do not get sufficient resources based on cost effectiveness principle. Moreover, intergovernmental fiscal relations are problematic, in a waythat the health spending duties are greatly decentralized to local governments, and there is over-reliance on earmarked fiscal transfer as opposed to general purpose (equalization) transfers in the health sector.The dissertation then reviews the international experiences of financing and governance (including choice of provider payment schemes) for health and nutrition services for women and children. In choosing financing modes, international review suggests that, no matter developed countries or developing countries that areat comparable development stages with China, taxation financing for woman and child health and nutrition is the primary modality. Social insurance financing plays a supplementary role, mainly to meet the essential clinical needs for women and children. Waiver in premium and copayment to the poor women and children has been a common practice. Out of pocket payment could be used to cover special services needed by special groups of women and children. Its use, however, should not lead to catastrophic health spending to poor households either. In practice many countries offer waiver or deduction in OOP to such population groups as maternal women and/or children.International review of public policies and interventions on nutrition for women and children offers a good deal of useful implications for China. Recognizing how nutrition interventions could contribute to the overall improvement of citizens' health status as well as the nation's socio-economic development, China should design national planning and implementation strategies for nutrition intervention and promotion, taking into accountsboth thepractices proven cost-effectiveinternationally, and the domestic realities.The dissertation also investigates into the provider payment schemes, which directly affects the economic burden of the service users. The traditional provider payment scheme in China'health sector, i. e. fee for services, has been widely criticized for causing huge waste in the use of health resources, and imposing heavy burden on patients and service users. The choice on provider payment schemes has direct impact on the allocation efficiency of health resources, as well as the level of service utilization by citizens including women and children, and thus has equity implications. Rich experiences accumulated by various countries in provider payment schemes for various types of services (i.e. primary care, hospital services) offer good reference for China to draw from.Based on the above analyses of existing issues and investigation into the causes of the issues, as well as the rich international experiences and lessons, the dissertation draws a comprehensive policy framework for the financing and management of essential health and nutrition services for women and children.(1) Taxation should be primary source of financing for the health and nutrition services. Taxation financing is more equitable, and a better fit for China in securing services for women and children as well as the nation's development needs. Social health insurance can be a supplementary financing source for basic medical services for women and children. However, necessary waivers for premium and copayment should be granted to poor women and children. Financing by pure out of pocket payment should only be used to meet private needs for non-basic maternal and children health and nutrition services.(2) In view of the current socio-economic development stage and the public financing capacity in China, as well as the status quo of health and nutrition status for women and children, with reference to international best practices, the dissertation outlines the contents in an essential package of health and nutrition services for women and children, which includes five major categories such as maternal health and nutrition services, child health and nutrition services, maternal and new born basic medical services, health services for women at fertility ages, and general public health promotion services. (3) Thedissertation offers policy recommendations on how to address the inequitable and inefficient public resource allocation and public sector governance:enhancing governmentaccountability scheme for service delivery, reforming performance evaluation for local government in delivering services, and increasing participation of citizens particularly from women and children, etc.(4) It is then proposed that in the current reforms of provider payment schemes for health and nutrition services, different types of institutions should use different provider payment modalities to achieve respective policy goals. Local realities should be taken into serious consideration when new payment schemes are introduced, and results should be constantly monitored and evaluated to allow timely adjustments.(5) It is recommended the current maternal and children health and nutrition surveillance statistical and information system be improved and strengthened. |
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