Policy Implications of Migration for Immunization of Chinese Children in Hong Kong and Shenzhen

Introduction: The repatriation of Hong Kong to The People's Republic of China in 1997 alongside the designation of Shenzhen in 1980 as a major Special Economic Zone in China has led to significant increases in migration in the Hong Kong-Shenzhen border region. The complex nature of migration under the fundamental principle of "One Country, Two Systems", has drastically changed the way populations are seeking and utilizing health care systems. Migrant Chinese children, especially, are affected. There are implications for the development of future health policy and systems on either side of the border.;General objective: This research uses immunization as a proxy to study the effect of migration and socioeconomic status on health service utilization of Chinese children at community health clinics in Hong Kong and Shenzhen. Under a conceptual policy framework focusing on the perspectives of Policy and Legislation, Health Systems, and Individual Needs, the thesis comprises background literature, analysis of population data, and caregiver surveys in community health clinics in Hong Kong (HK) and Shenzhen (SZ).;Methods: Background consisted of a review of policy and immunization in HK and SZ and two literature reviews. Our three main studies included: (1) A retrospective analysis of the HK Child Health Service System for immunization completion and timeliness among migrant children attending HK Maternal and Child Health Centres (MCHC) (2) A survey of caregiver attitudes, perceived access, and perceived barriers towards childhood immunization at HK MCHC (3) A survey of caregiver attitudes, perceived access, and perceived barriers towards childhood immunization in SZ Community Health Centers (CHC). Policy implications were then discussed based on study findings.;Results: Analysis of CHSS electronic records showed that nearly half of children attending HK MCHC's for immunization were migrant children, meaning a child of at least one non-eligible parent (NEP). Migrant children were less likely than local children to have received recommended immunizations on time at 3 and 12 months and more likely to have delayed receipt of specific immunizations. It was difficult to assess true immunization uptake because of incomplete immunization records and missing residence data.;Caregiver surveys at Fanling and Lek Yuen MCHC's showed that most migrant children immunized at MCHC were cross border attendees residing in mainland China. They comprised half the sample. Families of cross border migrant children were better educated and relatively more affluent than local families. They showed high motivation, taking extra measures for their children to attend HK MCHC for immunization. Whether a child was a cross boundary migrant had little significance on caregiver answers. However, length of time the child's mother had lived in mainland, mother's place of birth, and mother's hukou status were found to be factors for caregiver attitudes and awareness towards immunization. Children of non-eligible (NEP) mothers were more likely to have received delayed immunization than local children, suggesting some difficulties in caregiver access. A mother's experience is a significant factor in attaining immunization for the child.;In Shenzhen, the majority of children immunized at SZ CHC's were umegistered migrant children who had lower socioeconomic status than local children. Caregivers at CHC's with more migrants attending were overall poorer and less educated than caregivers at CHC's with more local children. Significant findings were that caregivers experienced service inconsistencies in CHC's based on geographic location alone, especially in CHC's with more migrants and poorer households attending. Migrant status of the child based on registered residence status had little effect on caregiver attitudes or access towards immunization, although caregivers of migrant children were more likely to find price a disincentive for immunization. Children whose mothers had lived in SZ for less time were found to have received immunization on time more than children with local mothers. Education of mother was a significant factor for immunization delay and poorer self reported health of caregiver was found to affect perception of immunization importance.;Conclusion: Our studies show that there are different narratives of migration taking place on either side of the border. In HK, there is a new growing population of cross border migrants, many of whom are from affluent and well-educated mainland families seeking advantage of HK citizenship for their children. In SZ, migration is not new and community health services have much potential but migrants are characteristically poorer; their socioeconomic difficulties are aggravated by limitations of the hukou system and inconsistency of health services. Development of future policy and goals to strengthen health care systems therefore requires us to consider the unique needs of migrant subgroups with caution.;Future health policy and legislation for cross border populations in HK will need to consider political implications of The Basic Law as the HK and mainland border becomes more transparent. Considerations for policy makers include the long-term effects of HK government regulation of births to mainland mothers on the health system, the rights of mainland mothers of HK children, and gender equity. From a health system perspective, health care authorities should consider current burden on state-funded obstetric services as preface to what is to come; and how to finance and expand health services including information systems to respond to the health needs of cross border migrants with HK citizenship. Health providers need to consider the individual needs of cross boundary populations including better organizational support and accessible information for NEP mothers.;In SZ, our studies suggest that immunization in CHC's are accessible for migrant families. This is in no small part due to backing by national policy and commitment by local authorities. There is a need now for local health authorities to prioritize, and for Beijing to support, the provision of basic health services to all children through the widely accessible community health system, despite registered hukou. The socioeconomic status of caregivers of migrant children is significant, and cost is a barrier, so health services should understand the role of the education of mothers and health status of caregivers in shaping child health services. Moving forward, Shenzhen needs also to focus on service inconsistencies in CHC's and develop health planning that monitors and evaluates quality and consistency of care---especially in communities with larger number of migrants of lower socioeconomic status.